Smoke-free hospitals in Greece: Personnel perceptions, compliance and smoking habit

Smoke-free environments in Greece are scarce. Despite existent legislation that forbids smoking in all health care service centers, smoking is still evident. Using a random sample of hospital personnel from a large university hospital in Greece, we evaluated their smoking habits, perceptions and compliance towards hospital smoking regulations. 57.8% of the nursing personnel and 34.5% of medical/research staff were found to be current smokers (p < 0.05). Although 66% of the staff does not oppose the complete hospital smoking ban, 95% responded that they would prefer it to be partial. The above findings warrant the necessity for nurturing efforts to reduce smoking and increase the health professionals' awareness of their position as a role model to both patients and the society

Evaluation of Inflammatory Markers in a Large Sample of Obstructive Sleep Apnea Patients without Comorbidities

Systemic inflammation is important in obstructive sleep apnea (OSA) pathophysiology and its comorbidity. We aimed to assess the levels of inflammatory biomarkers in a large sample of OSA patients and to investigate any correlation between these biomarkers with clinical and polysomnographic (PSG) parameters. This was a cross-sectional study in which 2983 patients who had undergone a polysomnography for OSA diagnosis were recruited. Patients with known comorbidities were excluded. Included patients (n=1053) were grouped according to apnea-hypopnea index (AHI) as mild, moderate, and severe. Patients with AHI < 5 served as controls. Demographics, PSG data, and levels of high-sensitivity C-reactive protein (hs-CRP), fibrinogen, erythrocyte sedimentation rate (ESR), and uric acid (UA) were measured and compared between groups. A significant difference was found between groups in hs-CRP, fibrinogen, and UA. All biomarkers were independently associated with OSA severity and gender (p<0.05). Females had increased levels of hs-CRP, fibrinogen, and ESR (p<0.001) compared to men. In contrast, UA levels were higher in men (p<0.001). Our results suggest that inflammatory markers significantly increase in patients with OSA without known comorbidities and correlate with OSA severity. These findings may have important implications regarding OSA diagnosis, monitoring, treatment, and prognosis. This trial is registered with ClinicalTrials.gov number NCT03070769

Maintained Smoking Cessation for 6 Months Equilibrates the Percentage of Sputum CD8+ Lymphocyte Cells with That of Nonsmokers

Little is known about the longitudinal effects of smoking cessation on sputum inflammatory cells. We aimed to investigate the changes in sputum inflammatory cells and T-lymphocyte subpopulations after 6 and 12 months smoking cessation. Induced sputum was obtained from 68 healthy smokers before and after 6 months (n = 21) and 1 year (n = 14) smoking cessation and from ten healthy never-smokers. Inflammatory cells were identified by morphology and T-lymphocyte subpopulations by flow cytometry. Sputum macrophages were decreased after 12 months of smoking cessation in comparison to baseline, while neutrophils increased. Moreover, CD8+ T-cells were decreased in smokers before smoking cessation compared to never-smokers and increased in smokers after 6 months of smoking cessation in comparison to baseline; result that was maintained after 1 year of smoking cessation. These novel findings indicate that smoking cessation can equilibrate certain inflammatory cells of smokers with those of nonsmokers, within 6 months of smoking cessation

Differences between rural and urban primary care practices in asthma and allergic rhinitis control: the Greek experience

Introduction: Limited data exist on allergic rhinitis and asthma control in rural primary care. Therefore, the aim of our study was to assess asthma and comorbid allergic rhinitis control in patients attending primary care in both urban and rural settings in Greece. Additionally, we aimed to identify potential factors associated with the control of asthma and comorbid allergic rhinitis. Methods: In this cross-sectional study, patients with asthma and comorbid allergic rhinitis completed questionnaires assessing demographic, co-morbidities and treatment status. Symptom control was evaluated by the Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ) and Control of Allergic Rhinitis/Asthma Test (CARAT). Multivariate logistic regression analysis was applied to identify associated factors of asthma and comorbid allergic rhinitis control after adjusting for age, gender, smoking status and comorbidities. Results: Out of 121 subjects with asthma and comorbid allergic rhinitis 75 (62%) resided in rural areas. A significant percentage of participants reported suboptimal asthma control using the ACT (54%) and ACQ (67%). Moreover, 88% of participants had not-well-controlled asthma and comorbid allergic rhinitis based on CARAT. Females (odds ratio (OR)=4.1, 95% confidence interval (CI) 0.8-19.9, p=0.043) and patients living in rural areas (OR=3.8, 95%CI 1.34-10.5, p=0.010) were more likely to report well-controlled asthma and allergic rhinitis based on CARAT score (&gt;24). Patients reporting intranasal steroid use (OR=3.6, 95%CI 1.1-121, p=0.035) were more likely to have well-controlled asthma based on ACT score. Analysis also indicated a trend towards significance for the association between short-acting beta-agonist use and not-well-controlled asthma based on the ACT (score&amp;le;19) (OR=5, 95%CI 0.9-10, p=0.066) and partially and not-well-controlled asthma based on the ACQ (score&gt;0.75) (OR=5, 95%CI 0.9-10, p=0.066). Conclusion: Our results suggest that asthma and allergic rhinitis control remain suboptimal in a large proportion of patients in primary care. Area of residence, female gender and medications emerged as significant associated factors that must be taken into account in order to effectively improve asthma and comorbid allergic rhinitis outcomes

The asthma diagnosis jigsaw puzzle:an adaptable teaching concept to facilitate the diagnosis of asthma in adults and children presenting to primary care

The asthma diagnosis jigsaw puzzle is a clinical practice and teaching concept conceived in clinical practice and refined through an expert multidisciplinary consensus process by academics and clinicians with an interest in primary respiratory care. The concept incorporates guidance to facilitate the effective diagnosis of adults or children with asthma in primary care where misdiagnosis is common. The jigsaw puzzle metaphor teaches a problem-solving approach to diagnosis, introducing the concept of diagnosis over time and in no particular sequence. Puzzle pieces can be collected from the domains of presentation, history, symptoms and physical examination, as well as objective tests. The clinician's challenge is to complete the diagnostic jigsaw puzzle testing the likelihood of a picture which can be recognised as asthma. This approach aligns with symptom-based pattern-recognition approaches taught to primary care clinicians which gets easier and more reliable with experience. Relational continuity, or informational continuity through the patient record, is integral to the process of puzzle completion. Where non-fitting puzzle pieces are encountered, alternative or additional diagnoses should be considered and/or referral to secondary care pursued. As a metaphor, 'puzzle completion' may be used within clinical communication encounters, addressing the importance of partnership working ('completing the puzzle together'), uncertainty (deciding 'which pieces fit') and changes in symptoms over time (enabling the 'puzzle picture to become clearer'). Adaptation of this teaching concept has started through translation of educational resources, including puzzle pieces. Supporting case vignettes developed locally will contextualise the jigsaw puzzle teaching concept. The Asthma Diagnosis Jigsaw Puzzle teaching concept has been piloted in North Macedonia and is also developed for educational workshops by primary care health educators in Malaysia, India and Uganda.</p

Excessive Daytime Sleepiness in Obstructive Sleep Apnea Patients Treated With Continuous Positive Airway Pressure: Data From the European Sleep Apnea Database

Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) that resolves under treatment with continuous positive airway pressure (CPAP). In some patients, sleepiness persists despite CPAP treatment. We retrospectively analyzed data on subjective residual EDS, assessed as an Epworth Sleepiness Scale score (ESS) &gt;10, in patients from the European Sleep Apnea Database (n = 4,853, mean age ± SD 54.8 ± 11.8 years, 26.1% females), at baseline and at the first visit (median follow-up: 5 months, interquartile range 3–13). An ESS &gt; 10 occurred in 56% of patients at baseline and in 28.2% of patients at follow-up. Residual EDS was analyzed in 2,190 patients (age: 55.1 ± 12.0 years, 26.1% females) with sleep monitoring data (median follow-up: 3 months, interquartile range 1–15). Sleep studies during CPAP use were obtained in 58% of these patients; EDS was reported by 47.2% of patients at baseline and by 30.3% at follow-up. Residual OSA, defined as an apnea–hypopnea index &gt;10/h, and insufficient CPAP adherence, defined as nightly use &lt;4 h, occurred with similar frequency in patients with and without EDS at follow-up. Prevalence of residual EDS was highest (40%) in patients with a first follow-up visit at 0–3 months, then it was 13–19% in patients with a first follow-up visit after 4 months to 2 years. The change in ESS (n = 2,190) was weakly correlated with CPAP use (R2 = 0.023, p &lt; 0.0001). Logistic regression showed that an ESS score &gt;10 at the first follow-up visit was associated directly with ESS at baseline and inversely with duration of follow-up, and CPAP use (R2 of the model: 0.417). EDS showed heterogeneity in different European countries both at baseline and at the first follow-up visit, suggesting modulation by cultural and lifestyle factors. In conclusion, residual EDS in CPAP-treated OSA occurred in approximately one in four patients at follow-up; its prevalence was highest (40%) in the first 3 months of treatment and subsequently decreased. The finding of residual EDS in a significant percentage of optimally treated OSA patients suggests that wake-promoting agents may be useful, but their indication should be evaluated after at least 3 months of treatment

Sputum and nasal lavage lung-specific biomarkers before and after smoking cessation

<p>Abstract</p> <p>Background</p> <p>Little is known about the effect of smoking cessation on airway inflammation. Secretory Leukocyte Protease Inhibitor (SLPI), Clara Cell protein 16 (CC16), elafin and human defensin beta-2 (HBD-2) protect human airways against inflammation and oxidative stress. In this longitudinal study we aimed to investigate changes in sputum and nasal lavage SLPI, CC16, elafin and HBD-2 levels in healthy smokers after 6 and 12 months of smoking cessation.</p> <p>Methods</p> <p>Induced sputum and nasal lavage was obtained from healthy current smokers (n = 76) before smoking cessation, after 6 months of smoking cessation (n = 29), after 1 year of smoking cessation (n = 22) and from 10 healthy never smokers. SLPI, CC16, elafin and HBD-2 levels were measured in sputum and nasal lavage supernatants by commercially available ELISA kits.</p> <p>Results</p> <p>Sputum SLPI and CC-16 levels were increased in healthy smokers before smoking cessation versus never-smokers (p = 0.005 and p = 0.08 respectively). SLPI and CC16 levels did not differ before and 6 months after smoking cessation (p = 0.118 and p = 0.543 respectively), neither before and 1 year after smoking cessation (p = 0.363 and p = 0.470 respectively). Nasal lavage SLPI was decreased 12 months after smoking cessation (p = 0.033). Nasal lavage elafin levels were increased in healthy smokers before smoking cessation versus never-smokers (p = 0.007), but there were no changes 6 months and 1 year after smoking cessation.</p> <p>Conclusions</p> <p>Only nasal lavage SLPI decrease after 1 year after smoking cessation. We may speculate that there is an ongoing inflammatory process stimulating the production of counter-regulating proteins in the airways of healthy ex-smokers.</p

Positive airway pressure (PAP) treatment reduces glycated hemoglobin (HbA1c) levels in obstructive sleep apnea patients with concomitant weight loss: Longitudinal data from the ESADA

Patients with obstructive sleep apnea (OSA) are at increased risk of developing metabolic disease such as diabetes. The effects of positive airway pressure on glycemic control are contradictory. We therefore evaluated the change in glycated hemoglobin (HbA1c) in a large cohort of OSA patients after long-term treatment with positive airway pressure. HbA1c levels were assessed in a subsample of the European Sleep Apnea Database [n=1608] at baseline and at long-term follow up with positive airway pressure therapy (mean 378.9±423.0 days). In a regression analysis, treatment response was controlled for important confounders. Overall, HbA1c decreased from 5.98±1.01% to 5.93±0.98% (p=0.001). Patient subgroups with a more pronounced HbA1c response included patients with diabetes (−0.15±1.02, p=0.019), those with severe OSA baseline (−0.10±0.68, p=0.005), those with morbid obesity (−0.20±0.81, p&lt;0.001). The strongest HbA1c reduction was observed in patients with a concomitant weight reduction &gt;5 kilos (−0.38±0.99, p&lt;0.001). In robust regression analysis, severe OSA (p=0.038) and morbid obesity (p=0.005) at baseline, and weight reduction &gt;5 kilos (p&lt;0.001) during follow up were independently associated with a reduction of HbA1c following PAP treatment. In contrast, PAP treatment alone without weight reduction was not associated with significant Hb1Ac reduction. In conclusion, positive airway pressure therapy is associated with HbA1c reduction in patients with severe OSA, in morbidly obese patients. and most obviously in those with significant weight lost during the follow-up. Our study underlines the importance to combine positive airway pressure use with adjustments in lifestyle to substantially modify metabolic complications in OSA

Arterial bicarbonate is associated with hypoxic burden and uncontrolled hypertension in obstructive sleep apnea - The ESADA cohort

Objective: Blood bicarbonate concentration plays an important role for obstructive sleep apnea (OSA) patients to maintain acid-base balance. We investigated the association between arterial standard bicarbonate ([HCO3-]) and nocturnal hypoxia as well as comorbid hypertension in OSA. Methods: A cross-sectional analysis of 3329 patients in the European Sleep Apnea Database (ESADA) was performed. Arterial blood gas analysis and lung function test were performed in conjunction with polysomnographic sleep studies. The 4% oxygen desaturation index (ODI), mean and minimum oxygen saturation (SpO2), and percentage of time with SpO2 below 90% (T90%) were used to reflect nocturnal hypoxic burden. Arterial hypertension was defined as a physician diagnosis of hypertension with ongoing antihypertensive medication. Hypertensive patients with SBP/DBP below or above 140/90 mmHg were classified as controlled-, uncontrolled hypertension, respectively. Results: The [HCO3-] level was normal in most patients (average 24.0 ± 2.5 mmol/L). ODI, T90% increased whereas mean and minimum SpO2 decreased across [HCO3-] tertiles (ANOVA, p = 0.030, &lt;0.001, &lt;0.001, and &lt;0.001, respectively). [HCO3-] was independently associated with ODI, mean SpO2, minimum SpO2, and T90% after adjusting for confounders (β value [95%CI]: 1.21 [0.88–1.54], −0.16 [-0.20 to −0.11], −0.51 [-0.64 to −0.37], 1.76 [1.48–2.04], respectively, all p &lt; 0.001). 1 mmol/L elevation of [HCO3-] was associated with a 4% increased odds of uncontrolled hypertension (OR: 1.04 [1.01–1.08], p = 0.013). Conclusion: We first demonstrated an independent association between [HCO3-] and nocturnal hypoxic burden as well as uncontrolled hypertension in OSA patients. Bicarbonate levels as an adjunctive measure provide insight into the pathophysiology of hypertension in OSA