Patient-Reported Outcome Measures in Atopic Dermatitis and Chronic Urticaria are Underused in Clinical Practice

BACKGROUND

Patient-reported outcome measures (PROMs) are validated and standardized tools that complement physician evaluations and guide treatment decisions. PROMs are crucial for monitoring atopic dermatitis (AD) and chronic urticaria (CU) in clinical practice, but there are unmet needs and knowledge gaps regarding their use in clinical practice.

OBJECTIVE

We investigated the global real-world use of AD and CU PROMs in allergology and dermatology clinics as well as their associated local and regional networks.

METHODS

Across 72 specialized allergy and dermatology centers and their local and regional networks, 2,534 physicians in 73 countries completed a 53-item questionnaire on the use of PROMs for AD and CU.

RESULTS

Of 2,534 physicians, 1,308 were aware of PROMs. Of these, 14% and 15% used PROMs for AD and CU, respectively. Half of physicians who use PROMs do so only "rarely" or "sometimes". AD and CU PROM usage is associated with being female, younger, and a dermatologist. POSCORAD and UAS were the most utilized PROMs for AD and CU, respectively. Monitoring disease control and activity are the main drivers of the use of PROMs. Time constraints were the primary obstacle to using PROMs, followed by the impression that patients dislike PROMs. AD and CU PROM users would like training in selecting the proper PROM.

CONCLUSION

Even though PROMs offer several benefits, their use in routine practice is suboptimal, and physicians perceive barriers to their use. It is essential to attain higher levels of PROM implementation in accordance with national and international standards.

Core Outcome Set for IgE-mediated food allergy clinical trials and observational studies of interventions: International Delphi consensus study 'COMFA'

BACKGROUND

IgE-mediated food allergy (FA) is a global health concern with substantial individual and societal implications. While diverse intervention strategies have been researched, inconsistencies in reported outcomes limit evaluations of FA treatments. To streamline evaluations and promote consistent reporting, the Core Outcome Measures for Food Allergy (COMFA) initiative aimed to establish a Core Outcome Set (COS) for FA clinical trials and observational studies of interventions.

METHODS

The project involved a review of published clinical trials, trial protocols and qualitative literature. Outcomes found as a result of review were categorized and classified, informing a two-round online-modified Delphi process followed by hybrid consensus meeting to finalize the COS.

RESULTS

The literature review, taxonomy mapping and iterative discussions with diverse COMFA group yielded an initial list of 39 outcomes. The iterative online and in-person meetings reduced the list to 13 outcomes for voting in the formal Delphi process. One more outcome was added based on participant suggestions after the first Delphi round. A total of 778 participants from 52 countries participated, with 442 participating in both Delphi rounds. No outcome met a priori criteria for inclusion, and one was excluded as a result of the Delphi. Thirteen outcomes were brought to the hybrid consensus meeting as a result of Delphi and two outcomes, 'allergic symptoms' and 'quality of life' achieved consensus for inclusion as 'core' outcomes.

CONCLUSION

In addition to the mandatory reporting of adverse events for FA clinical trials or observational studies of interventions, allergic symptoms and quality of life should be measured as core outcomes. Future work by COMFA will define how best to measure these core outcomes.

Recognition of COVID-19 with occupational origin: a comparison between European countries

OBJECTIVES

This study aims to present an overview of the formal recognition of COVID-19 as occupational disease (OD) or injury (OI) across Europe.

METHODS

A COVID-19 questionnaire was designed by a task group within COST-funded OMEGA-NET and sent to occupational health experts of 37 countries in WHO European region, with a last update in April 2022.

RESULTS

The questionnaire was filled out by experts from 35 countries. There are large differences between national systems regarding the recognition of OD and OI: 40% of countries have a list system, 57% a mixed system and one country an open system. In most countries, COVID-19 can be recognised as an OD (57%). In four countries, COVID-19 can be recognised as OI (11%) and in seven countries as either OD or OI (20%). In two countries, there is no recognition possible to date. Thirty-two countries (91%) recognise COVID-19 as OD/OI among healthcare workers. Working in certain jobs is considered proof of occupational exposure in 25 countries, contact with a colleague with confirmed infection in 19 countries, and contact with clients with confirmed infection in 21 countries. In most countries (57%), a positive PCR test is considered proof of disease. The three most common compensation benefits for COVID-19 as OI/OD are disability pension, treatment and rehabilitation. Long COVID is included in 26 countries.

CONCLUSIONS

COVID-19 can be recognised as OD or OI in 94% of the European countries completing this survey, across different social security and embedded occupational health systems.

Associations of burnout with job demands/resources during the pandemic in health workers from Southeast European countries

Introduction

Despite several studies assessing job demands and burnout in countries from the Southeast European (SEE) region, there is still a lack of data about the psychological impact of the pandemic on health workers (HWs).

Aims

The present study aimed to demonstrate and compare levels of burnout dimensions in HWs from SEE countries and to reveal the burnout-job demands/resources relationships in these workers during the pandemic.

Materials and methods

During the autumn of 2020, this online multicentric cross-sectional survey studied a large group (N = 4.621) of HWs working in SEE countries. The Maslach Burnout Inventory was used for the measurement of burnout dimensions. We analyzed the job demands by using the Hospital Experience Scale. Remuneration and relationships with superiors were measured using the Questionnaire sur les Ressources et Contraintes Professionnelles (English version).

Results

A series of ANOVA comparisons of means revealed the countries in which respondents showed higher mean values of emotional exhaustion (Bosnia and Herzegovina, Bulgaria, Croatia, Moldova, Montenegro, and North Macedonia) and the countries in which respondents showed lower mean values of this burnout dimension (Israel and Romania) (Welch F = 17.98, p < 0.001). We also found differences among HWs from different countries in job demands and job resources. The testing of hierarchical regression models, which have been controlled for certain confounding factors, clearly revealed that emotional exhaustion was predicted by job demands (R2 = 0.37) and job resources (R2 = 0.16).

Conclusion

Preventive measures for the improvement of mental health in HWs during the pandemic and beyond have to take into account the differences between countries regarding the country context and current scientific knowledge. A modified stress test should be implemented in hospitals regarding future shocks that might include new pandemics, terrorism, catastrophes, or border conflicts.

Prevalence and Characteristics of Chronic Obstructive Pulmonary Disease in Dairy Farmers

Objective: To assess the prevalence and characteristics of chronic obstructive pulmonary disease (COPD) in dairy farmers, and evaluate the role of job exposure and smoking as predictors for respiratory health impairment. Methods: A cross-sectional study was performed, including 83 dairy farmers (mean age: 52.6±8.7 years; mean exposure duration: 23.7±7.6 years) and 80 office workers as a control group (mean age: 52.7±8.2 years) matched for age, smoking habits, and socioeconomic status. Methods for evaluation of study participants included a questionnaire on respiratory symptoms in the last 12 months, baseline spirometry and bronchodilator reversibility testing, and diagnostic criteria for COPD. Results: The mean post-bronchodilator values of spirometric parameters are significantly lower in subjects among EG with negative bronchodilator test compared to those in CG, while the mean post-bronchodilator values of spirometric parameters are lower in dairy farmers with negative BD tests exposed more than 20 years compared to those with exposure less than 20 years, being statistically significant for FEV1/FVC%, MEF25, MEF50 and MEF75. The COPD prevalence is non-significantly higher in dairy farmers compared to controls, and is significantly associated with age over 40 years in dairy farmers (P=0.035). The risk for COPD development in dairy farmers is about 36 fold higher in subjects exposed more than 20 years (OR = 36.00 (1.21-37.77) CI 95%) compared to those with exposure duration less than 20 years, and is about 6 fold higher in dairy farmers who are current smokers (OR = 6.12 (0.95-37.77) CI 95%). COPD is significantly associated with smoking duration among smokers in both groups, while combined effect of smoking, smoking duration, and number of cigarettes smoked daily has a significant impact on COPD development in dairy farmers. According to the GOLD classification, depending on the degree of airflow limitation, mild and moderate types of COPD are detected in dairy farmers, and only mild type in controls, showing no significant difference between the two groups. Conclusion: The study findings recognized the role of farming exposure, and smoking as well, as predictors for respiratory health impairment, and furthermore confirmed their potential to be a predictive factor in the COPD development. These facts should be helpful in detection of critical points for action, indicate the need of adverse occupational exposures reduction through adequate preventive measures and regular health examinations, implementation of relevant engineering controls, smoking cessation programs, and complete and efficient respiratory health assessment.

The value of fractional exhaled nitric oxide in occupational diseases - a systematic review

Fractional exhaled nitric oxide (FeNO) is a non-invasive biomarker of respiratory tract inflammation, originally designated to identify eosinophilic airway inflammation and to predict steroid response. The main field of application of this biomarker is asthma, but FeNO has also been used for other allergic and non-allergic pulmonary disorders such as chronic obstructive pulmonary disease, hypersensitivity pneumonitis and interstitial lung disease. A substantial part of respiratory diseases are related to work, and FeNO, a safe and easy measure to conduct, is a potential valid examination in an occupational setting.

This systematic review assesses the value of measuring FeNO related to three types of airborne exposures: allergens, irritants, and respiratory particles inhaled during occupational activities. The review covers results from longitudinal and observational clinical studies, and highlights the added value of this biomarker in monitoring effects of exposure and in the diagnostic criteria of occupational diseases. This review also covers the possible significance of FeNO as an indicator of the efficacy of interventions to prevent work-related respiratory diseases.

Initially, 246 articles were identified in PUBMED and SCOPUS. Duplicates and articles which covered results from the general population, symptoms (not disease) related to work, non-occupational diseases, and case reports were excluded. Finally, 39 articles contributed to this review, which led to the following conclusions:

a) For occupational asthma there is no consensus on the significant value of FeNO for diagnosis, or on the magnitude of change needed after specific inhalation test or occupational exposure at the workplace. There is some consensus for the optimal time to measure FeNO after exposure, mainly after 24 h, and FeNO proved to be more sensitive than spirometry in measuring the result of an intervention. b) For other occupational obstructive respiratory diseases, current data suggests performing the measurement after the work shift. c) For interstitial lung disease, the evaluation of the alveolar component of NO is probably the most suitable.

Proposal of 0.5 mg of protein/100 g of processed food as threshold for voluntary declaration of food allergen traces in processed food-A first step in an initiative to better inform patients and avoid fatal allergic reactions: A GA²LEN position paper

BACKGROUND

Food anaphylaxis is commonly elicited by unintentional ingestion of foods containing the allergen above the tolerance threshold level of the individual. While labeling the 14 main allergens used as ingredients in food products is mandatory in the EU, there is no legal definition of declaring potential contaminants. Precautionary allergen labeling such as "may contain traces of" is often used. However, this is unsatisfactory for consumers as they get no information if the contamination is below their personal threshold. In discussions with the food industry and technologists, it was suggested to use a voluntary declaration indicating that all declared contaminants are below a threshold of 0.5 mg protein per 100 g of food. This concentration is known to be below the threshold of most patients, and it can be technically guaranteed in most food production. However, it was also important to assess that in case of accidental ingestion of contaminants below this threshold by highly allergic patients, no fatal anaphylactic reaction could occur. Therefore, we performed a systematic review to assess whether a fatal reaction to 5mg of protein or less has been reported, assuming that a maximum portion size of 1kg of a processed food exceeds any meal and thus gives a sufficient safety margin.

METHODS

MEDLINE and EMBASE were searched until 24 January 2021 for provocation studies and case reports in which one of the 14 major food allergens was reported to elicit fatal or life-threatening anaphylactic reactions and assessed if these occurred below the ingestion of 5mg of protein. A Delphi process was performed to obtain an expert consensus on the results.

RESULTS

In the 210 studies included, in our search, no reports of fatal anaphylactic reactions reported below 5 mg protein ingested were identified. However, in provocation studies and case reports, severe reactions below 5 mg were reported for the following allergens: eggs, fish, lupin, milk, nuts, peanuts, soy, and sesame seeds.

CONCLUSION

Based on the literature studied for this review, it can be stated that cross-contamination of the 14 major food allergens below 0.5 mg/100 g is likely not to endanger most food allergic patients when a standard portion of food is consumed. We propose to use the statement "this product contains the named allergens in the list of ingredients, it may contain traces of other contaminations (to be named, e.g. nut) at concentrations less than 0.5 mg per 100 g of this product" for a voluntary declaration on processed food packages. This level of avoidance of cross-contaminations can be achieved technically for most processed foods, and the statement would be a clear and helpful message to the consumers. However, it is clearly acknowledged that a voluntary declaration is only a first step to a legally binding solution. For this, further research on threshold levels is encouraged.

Occupational Asthma: The Knowledge Needs for a Better Management

The management of occupational asthma (OA) may be influenced by several factors and removal from exposure is the main tertiary prevention approach, but it is not always feasible without personal and socioeconomic consequences. Reducing the delay between the onset of suggestive symptoms of OA and the diagnosis of OA is associated with a better prognosis. Workers' education to increase awareness to trigger agents and a medical surveillance program directed especially at at-risk workers could be helpful in reducing this latency time. An early identification of workers who develop rhinitis and conjunctivitis which often precede the onset of asthma symptoms could be important for an early identification of OA. This is particularly important for cases of asthma caused by high-molecular-weight sensitizers and in the early years of employment. The availability of financial support and compensation measures for workers with OA may influence the latency time before diagnosis and, consequently, may influence the OA outcomes. In conclusion, there is a need for high-quality cohort studies that will increase knowledge about risk factor that may influence the timing of diagnosis of OA. This knowledge will be useful for implementation of future surveillance and screening programs in workplaces.

C-reactive protein and Neutrophil-Lymphocyte Ratio as predictors of clinical severity of COVID-19

COVID-19 is an infectious disease that can manifest quite differently. In this study we examined the relationship between the value of serum CRP(C-reactive protein) andneutrophil-lymphocyte ratio (NLR) as predictor factors for the development of a severe clinical manifestation in COVID19 patients. Materials and methods: We followed 95 COVID-19 positive patients who were hospitalized at the University Clinic for Eye Diseases - COVID Center. We analyzed the initial laboratory parameters of white blood cells and CRP on admission of the patients and the results of laboratory analyses performed before they left the Clinic, or the last parameters before the lethal outcome in those patients who died. Several models of logistic regression were tested to analyze the predictive value of these markers of inflammation for lethal outcome in patients hospitalized for COVID-19. Results: Bivariate analysis demonstrated that the length of hospital stay was significantly shorter in patients with lethal outcome (p=0.001). The NLR was significantly higher in patients with lethal outcome at both times (p=0.005; and p=0.017). Leukocyte’s count (p=0.046, and p<0.001) and CRP (p=0.013,and p=0.005) were also significantly higher in patients with lethal outcome at both times. The increase on the NLR scale both at hospitalization and at discharge (or the last analysis before death) leads to increase in the odds of lethal outcome (T1:40.4% increased odds; T2:36% increased odds). Conclusion: CRP and NLR are laboratory parameters that can predict the severity of the clinical manifestation in patients with COVID-19.

Lung Function Impairment in Construction Workers – Influence of Smoking and Exposure Duration

AIM: The objective of the study was to assess the influence of exposure duration and smoking on ventilatory impairment among construction workers. METHODS: A cross-sectional study was performed, including 83 construction workers aged 18–64 years, compared to equivalent number of office controls matched by age, workplace exposure duration, and smoking status. Data on chronic respiratory symptoms, work history, and smoking status were collected by standardized questionnaire, while lung functional testing of the examined subjects was performed by spirometry. RESULTS: Mean values of spirometric parameters were lower in construction workers compared to controls with statistical significance registered for maximal expiratory flow (MEF25), MEF50, and MEF75. Lung functions of construction workers have been found to decrease in relation to exposure duration but reached significance only for small airways changes. There was a significant difference in detected ventilatory impairment between exposed workers and controls for any type of ventilatory impairment, as well as obstructive and combined ventilatory pattern and obstructive ventilatory pattern in small airways. Obstructive ventilatory impairment was significantly associated with life-time smoking in construction workers, while obstructive ventilatory pattern in small airways was significantly associated with life-time smoking. The combined effect of daily smoking, life-time smoking, and number of cigarettes smoked daily was shown to have a significant influence in their development. The risk for obstructive ventilatory pattern in small airways among exposed subjects was about 4 fold higher in those exposed more than 20 years (odds ratio [OR] = 3.68 [1.01–14.59] confidence interval [CI] 95%), and about 2.5 fold higher in smokers (OR = 2.57 [0.92-7.25] CI 95%). Exposure duration, smoking and age had independent effect only on small airways changes and force expiratory volume in the 1st s/force vital capacity %. CONCLUSION: Our data suggest the importance of the joint effect of job exposure in construction and daily smoking on the development of lung function impairment and airflow limitation, being dominant, especially on small airways.

Personal Protective Equipment in Health Workers during Coronavirus Disease-19 Outbreak

BACKGROUND: Coronavirus (CoV) disease (COVID)-19 pandemic has put immense pressure on the healthcare systems worldwide. AIM: The aim of the actual study was to assess the availability of personal protective equipment (PPE) in health workers (HWs) during an outbreak. METHODS: The study was conducted in April-May 2020 using an on-line questionnaire. Completed surveys were returned by 560 HWs (297 physicians, 79 nurses/technicians, 78 dentists, 9 pharmacists, and 97 other HWs). RESULTS: High proportion of HWs was using one surgery mask for two or more times or not using it at all when contacting patients who were self-isolated (35.3%) or severe acute respiratory syndrome CoV (SARS-CoV)-2 positive (19.3%). More than 90% of participants were using surgery masks and gloves every time or almost every time while working with patients who were self-isolated or SARS-CoV-2 positive. High frequency of participants reported: No isolation zones at the workplace (61.2%), no triage of patients at the entrance (33.4%), and not attended a training course about the correct usage of PPE (72%). CONCLUSION: The data obtained can be used in the creation of specific interventions in healthcare settings aimed at providing high-quality PPE through the development of a national healthcare strategy that can lead to the prevention of COVID-19 in HWs.

Are the Obese Patients and Patients with Severe Malnutrition at Increased Risk of Severe Coronavirus Disease 2019 during Hospital Admission?

BACKGROUND: Recently, authorities highlighted the need for nutritional management of individuals with severe acute respiratory syndrome coronavirus 2 infection. AIM: The aim of the study was to evaluate the use of body mass index (BMI) and nutrition risk index (NRI) on hospital admission for detecting patients at risk for malnutrition and obesity and their association with patients’ outcomes (disease type, length of hospital and home stay, and inflammatory markers). METHODS: The study of 100 patients with confirmed diagnosis Coronavirus Disease-19 (COVID-19). Assessment of patients took place at City General Hospital 8th September, Skopje, transformed into main COVID-19 Center during pandemic. Primary outcomes were NRI and BMI scores, while secondary ones: length of home and hospital stay, number of symptoms, presence of co-morbidities, type of disease, serum albumin, and C-reactive protein (CRP). RESULTS: Patients were classified according to BMI and NRI scores. Increased BMI and NRI were associated with a severe type of disease. Most of the patients with severe disease were: obese (83.3%) and patients with risk for malnutrition (53.3%). Obese patients had a longer length of home stay and higher CRP levels, but the level of albumin was lower in a group with a risk for malnutrition. CONCLUSION: Future studies are needed to identify and quantify specific screening tool for nutrition deficiency in patients with COVID-19 infection.

Immunological Outcomes of Allergen-Specific Immunotherapy in Food Allergy

IgE-mediated food allergies are caused by adverse immunologic responses to food proteins. Allergic reactions may present locally in different tissues such as skin, gastrointestinal and respiratory tract and may result is systemic life-threatening reactions. During the last decades, the prevalence of food allergies has significantly increased throughout the world, and considerable efforts have been made to develop curative therapies. Food allergen immunotherapy is a promising therapeutic approach for food allergies that is based on the administration of increasing doses of culprit food extracts, or purified, and sometime modified food allergens. Different routes of administration for food allergen immunotherapy including oral, sublingual, epicutaneous and subcutaneous regimens are being evaluated. Although a wealth of data from clinical food allergen immunotherapy trials has been obtained, a lack of consistency in assessed clinical and immunological outcome measures presents a major hurdle for evaluating these new treatments. Coordinated efforts are needed to establish standardized outcome measures to be applied in food allergy immunotherapy studies, allowing for better harmonization of data and setting the standards for the future research. Several immunological parameters have been measured in food allergen immunotherapy, including allergen-specific immunoglobulin levels, basophil activation, cytokines, and other soluble biomarkers, T cell and B cell responses and skin prick tests. In this review we discuss different immunological parameters and assess their applicability as potential outcome measures for food allergen immunotherapy that may be included in such a standardized set of outcome measures.

Effects of Pleuran (β-glucan from Pleurotus ostreatus) Supplementation on Incidence and Duration of Bronchiectasis Exacerbations

BACKGROUND: Patients with non-cystic fibrosis bronchiectasis (BE) have frequent exacerbations that are causes of significant morbidity and sometimes mortality, and which it is desirable to prevent. AIM: We aimed to assess the effects of pleuran on the incidence and duration of exacerbations in patients with BE. METHODS: A prospective, observational, open-label, and active-controlled study was realized as a comparison of the frequency and duration of exacerbations between a group of patients with BE (30 patients, 14 males and 16 females, aged 44–72 years) who received a combination supplement containing pleuran 100 mg, Vitamin C 60 mg and zinc 5 mg over a 3-month period and a group of patients with BE (31 patients, 15 males and 16 females, aged 45–74 years) treated over a 3-month period with a combination supplement containing Vitamin C 60 mg and zinc 5 mg. RESULTS: Over the study period, altogether 46 exacerbations were documented (19 in the patients receiving pleuran and 27 in the patients who did not receive pleuran), nine of which required hospital treatment (four in the patients receiving pleuran [21.5%] and five in the patients who did not receive pleuran [18.6%]). The mean number of exacerbations over the study period was significantly lower in the patients receiving pleuran (0.6 ± 0.4) as compared to the mean number in the patients who did not receive pleuran (0.8 ± 0.3) (p = 0.0297). The mean duration of exacerbations, expressed in days, needed for cure or clinical improvement in the patients receiving pleuran (11.2 ± 1.7 days) was significantly shorter than that of exacerbations in the patients who did not receive pleuran (12.4 ± 1.3 days) (p = 0.0029). We found significantly lower incidence and significantly shorter duration of exacerbations in the patients with BE who received pleuran as compared to their incidence and duration in the patients with BE who did not receive pleuran. CONCLUSION: Our findings indicated a need for further investigations in this domain to define the possible role of pleuran in the prevention of BE exacerbations.

Work-related Asthma in Crop Farmers

AIM: The objective of the study was to evaluate the influence of occupational exposure on asthma development among crop farmers. METHODS: A cross-sectional study was performed, comprising 87 crop farmers, and 80 office workers, matched by gender and age. Evaluation of subjects included completion of a standard questionnaire on chronic respiratory symptoms, spirometry tests, histamine challenge, serial peak expiratory flow rates (PEFR) measurements, and skin prick tests to occupational and common inhalant allergens. RESULTS: The prevalence of chronic respiratory symptoms in the past 12 months was higher, while the mean values of spirometric parameters were lower in crop farmers. Sensitization to workplace and common inhalant allergens was similar in both groups, whereas frequencies of bronchial hyperresponsiveness (BHR) and asthma were non-significantly higher in crop farmers. The prevalence of allergic was significantly higher compared to non-allergic asthma in both groups. Asthma was registered in 8% of crop farmers and was significantly associated with atopy, and positive family history of asthma. Occupational allergic asthma (OA) was registered in 2.3% of crop farmers, while the frequency of work-aggravated asthma was 5.7%. A causal relationship between workplace and asthma, suggesting allergic OA, was documented in two crop farmers with asthma, based on serial PEFR monitoring, but specific workplace agent causing asthma in the affected subjects was not identified. CONCLUSION: The obtained results can contribute in the detection of critical points for action, and serve as a predictive factor in the development of work-related asthma, indicating the need for reduction of adverse occupational exposures through adequate preventive measures, regular health examinations, obligatory use of respiratory protective equipment, and implementation of engineering controls.

Outcomes for clinical trials of food allergy treatments

OBJECTIVE

Food allergy is a common condition that can have a significant impact on the quality of life of affected individuals and their caregivers. Recent years have witnessed an increased effort to identify new treatments for food allergy. Here, we review the need to identify core outcomes for measurement in clinical trials of food allergy treatments.

DATA SOURCES

We reviewed the literature regarding core outcome set development, the important role that these play in prioritizing patient-relevant outcomes, and the potential for core outcomes to accelerate the path to product marketing by allowing prompt and reliable evidence synthesis after trial publication.

STUDY SELECTIONS

We reviewed recent clinical trials of food allergy treatments to understand which outcomes have previously been measured, and also reviewed available core outcome set initiatives for other allergic conditions to understand which other outcomes might be explored in future trials.

RESULTS

Clinical trials of food allergy treatments have largely focused on outcomes that are relevant to investigators and commercial investors, especially the threshold of reactivity and immunologic changes. Future trials should consider addressing patient-important outcomes and should report the experiences of both adult and child participants and their caregivers.

CONCLUSION

There is a pressing need for core outcome set development for food allergy treatment trials.

Specific work activities and exposure to respiratory hazards - predictors of lung function impairment among crop farmers

OBJECTIVE: The objective of the study was to evaluate the specific work activities and occupational exposure to respiratory hazards as predictors of chronic respiratory symptoms development, lung function decline, and respiratory health impairment among crop farmers. METHODS: A cross-sectional survey was performed, including 87 crop farmers (mean age: 53.4 ± 7.8 years; and mean exposure duration: 22.9 ± 7.8 years) and 80 office workers as a control group (mean age: 52.7 ± 8.2 years) matched for age, smoking habits, and socioeconomic status. Subjects were evaluated by a questionnaire on respiratory symptoms in the past 12 months and spirometry testing. RESULTS: Crop farmers had a significantly higher prevalence of cough (41.4), phlegm (28.7%), and dyspnea (21.8%), than controls (p < 0.05). All mean baseline spirometric parameters were lower in crop farmers, but statistical significance was confirmed only for MEF25, MEF50, and MEF75 (p = 0.003, p = 0.000, and p = 0.001, respectively). Most of the respiratory symptoms were significantly associated with common work activities of crop farmers and all-day exposure to certain respiratory hazards. Age, exposure duration, and their combined effect with smoking habit had a significant effect on forced expiratory volume in one second FEV1 and FEV1/forced vital capacity. CONCLUSION: The results confirm that occupational exposure among crop farmers is associated with higher prevalence of respiratory symptoms and lung function decline and, together with specific workflow activities, may not only be a predictors of respiratory health impairment, but also a key tool in the creation of preventive strategies.

Effects of a Long-Term Use of Carbocysteine on Frequency and Duration of Exacerbations in Patients with Bronchiectasis

BACKGROUND

The failure of mucus clearance in bronchiectasis can be improved by chest physiotherapy or/and mucoactive agents.

AIM

To assess the effects of long-term use of carbocysteine on frequency and duration of exacerbations in patients with bronchiectasis.

METHODS

We performed an observational, non-randomized, open study (a real-life study) including 64 patients with bronchiectasis divided into two groups, examined group (EG) and control group (CG). All participants were treated with appropriate treatment for the stable disease, but in the study, subjects of EG two capsules 375 mg carbocysteine three times a day was added over three months. Daily diary cards realised collection of data regarding the occurrence and duration of exacerbation in all study subjects.

RESULTS

Over the study period 43 exacerbations were documented, 17 in the EG and 26 in the CG, 10 (23.4%) of which required hospital treatment (four in the EG [23.5%] and six in the CG [23.1%]). A mean number of exacerbations over the study period was significantly lower in the EG (0.5 ± 0.1) as compared to their mean number in the CG (0.8 ± 0.2) (P = 0.0000). Mean duration of exacerbations expressed in days needed for complete resolution of symptoms or return of the symptoms to their baseline severity in the EG was significantly shorter than the mean duration of exacerbations in the CG (10.1 ± 2.6 vs 12.8 ± 2.1; P = 0.0000). The frequency of adverse effects, i.e. mild gastrointestinal manifestations and headache which did not require discontinuation of the treatment, in the EG during the study period was 15.6%.

CONCLUSION

Our findings indicated positive effects of carbocysteine regarding the frequency and duration of exacerbations, as well as its good tolerability in the patients with bronchiectasis.

Enzymatic changes in orchard workers with occupational exposure to pesticides

Organophosphates (OP) and carbamates, frequently used pesticides, can cause a variety of adverse health effects, ranging from simple irritation of the skin and eyes to more severe effects. The aim of this study was to evaluate the association between chronic occupational pesticide exposure and changes in serum activities of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), acetylcholinesterase (AChE) and creatine phosphokinase (CPK) in orchard workers. In the study, 47 peach orchard workers were included, at the age from 19 to 60 years, with monthly exposure to pesticides from 5 to 20 days and 1 to 35 working years. The control group consisted of 40 healthy age-matched men, without exposure to pesticides. All orchard workers kept to safety precautions. 68% of workers reported some physical signs and symptoms. A significantly decreased AChE activity was detected in 10.6% of orchard workers and increased CPK activity in 40.4%. Very weak negative correlation was detected between AChE and ALP activities (r = -0.34, p = 0.001) and between AChE and CPK activities (r = -0.25, p = 0.02). No correlation was found between the serum AChE and day of monthly exposure, as well as years of exposure. The results have shown that orchard workers with decreased AChE activity and increased CPK activity should be monitored as workers with an increased risk for severe pesticide poisoning. These findings suggest that chronic occupational exposure to pesticides elicit mild toxic effects, as well as biochemical changes of unknown long-term consequences. Keywords: Toxic effects; Carbamates pesticide, Organophosphate pesticide, Serum enzymes, Orchard workers, Occupational exposure

Moxifloxacin in the Outpatient Treatment of Moderate Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND:

Bacterial infections are involved in more than a half of the exacerbations of chronic obstructive pulmonary disease (COPD).

AIM:

To evaluate the efficacy and safety of moxifloxacin in the outpatient treatment of moderate exacerbations of bacterial origin in the COPD patients.

METHODS:

We performed a prospective, observational study including 64 COPD patients with moderate exacerbation of bacterial origin empirically treated with moxifloxacin. In 31 of them, moxifloxacin was used as an initial antibiotic (Group 1), whereas in 33 of them moxifloxacin was used after treatment failure with another antibiotic (Group 2). All patients have treated 7 days with moxifloxacin 400 mg once daily per os, and they were followed up for 20 days, with an intermediate visit at 3, 5 and 7 days at which the duration of symptoms and the side effects of the drug were evaluated.

RESULTS:

We registered high clinical success rate, i.e. the complete resolution of the symptoms or their return to the baseline severity, similar in both groups (84.3% in all study subjects, 83.9% in the Group 1 and 84.8% in the Group 2). The mean time to complete resolution of the cardinal symptoms or their return to the baseline severity was 5.2 ± 1.1 days. Also, the mean time to complete resolution of the certain cardinal symptoms (increased dyspnea, increased sputum volume and increased sputum purulence) or their return to the baseline severity is given 4.9, 4.7 and 4.2 days, respectively. The incidence of adverse effects during the treatment with moxifloxacin in all study subjects was 10.9%, 9.6% in Group 1 and 12.1% in Group 2. There was no serious adverse effect that required discontinuation of the treatment. Relapse during a 20 days follow-up period was registered in 7.4% of the all study subjects with complete resolution of the cardinal symptoms or their return to the baseline severity, i.e. in two patients from both Group 1 and Group 2 (7.6% and 7.1%, respectively). 4

CONCLUSION:

Our findings suggest high efficacy and good tolerability of moxifloxacin in the treatment of moderate COPD exacerbations of bacterial origin.

Job Demands, Burnout, and Teamwork in Healthcare Professionals Working in a General Hospital that Was Analysed At Two Points in Time

AIM:

The purpose of the paper was to assess job demands, burnout, and teamwork in healthcare professionals (HPs) working in a general hospital that was analysed at two points in time with a time lag of three years.

METHODS:

Time 1 respondents (N = 325) were HPs who participated during the first wave of data collection (2011). Time 2 respondents (N = 197) were HPs from the same hospital who responded at Time 2 (2014). Job demands, burnout, and teamwork were measured with Hospital Experience Scale, Maslach Burnout Inventory, and Hospital Survey on Patient Safety Culture, respectively.

RESULTS:

Significantly higher scores of emotional exhaustion (21.03 vs. 15.37, t = 5.1, p < 0.001), depersonalization (4.48 vs. 2.75, t = 3.8, p < 0.001), as well as organizational (2.51 vs. 2.34, t = 2.38, p = 0.017), emotional (2.46 vs. 2.25, t = 3.68, p < 0.001), and cognitive (2.82 vs. 2.64, t = 2.68, p = 0.008) job demands were found at Time 2. Teamwork levels were similar at both points in time (Time 1 = 3.84 vs. Time 2 = 3.84, t = 0.043, p = 0.97).

CONCLUSION:

Actual longitudinal study revealed significantly higher mean values of emotional exhaustion and depersonalization in 2014 that could be explained by significantly increased job demands between analysed points in time.

Effects of Pleuran (Β-Glucan from Pleurotus Ostreatus) Supplementation on Incidence and Duration of COPD Exacerbations

BACKGROUND

1,3/1,6-β-glucans are recognised as immunomodulators in human and veterinary medicine for over 50 years.

AIM

To assess the effects of pleuran (1,3/1,6-β-glucan from Pleurotus ostreatus) on incidence and duration of bacterial exacerbations in patients with COPD.

METHODS

We performed an observational, non-randomized, open-label study including 32 COPD patients (Group D) in whom besides the recommended chronic treatment for the stable disease were administered supplement combination containing pleuran 100 mg, vitamin C 60 mg and zinc 5 mg once daily over a three month-period (Group 1). Also, an equal number of Group D COPD patients who besides the recommended treatment for stable disease received the supplement combination containing vitamin C 60 mg and zinc 5 mg once daily, matched to the study subjects of the Group 1 by sex and age served as control (Group 2).

RESULTS

Over the study period 57 exacerbations (24 in the Group 1 and 33 in the Group 2) were documented. A mean number of exacerbations over the study period was significantly lower in the Group1 (0.7 ± 0.4) as compared to their mean number in the Group 2 (1.0 ± 0.6) (P = 0.0218). Furthermore, a mean duration of exacerbations expressed in days needed for cure or clinical improvement (i.e. complete resolution of symptoms or return of the symptoms to their baseline severity) in the Group 1 (6.7 ± 0.8 days) was significantly shorter than the mean duration of exacerbations in the Group 2 (7.4 ± 1.3 days) (P = 0.0118). There was not reported any adverse effect during the study period by study subjects from both examined groups.

CONCLUSION

Our findings indicated that pleuran might impact the incidence and duration of bacterial exacerbations in patients with COPD. There is a need for further studies for more precise determination of the influence of pleuran on the course of COPD.

Burnout, Engagement, and Organizational Culture: Differences between Physicians and Nurses

BACKGROUND:

Burnout results from a prolonged response to chronic emotional and interpersonal workplace stressors. The focus of research has been widened to job engagement.

AIM:

Purpose of the study was to examine associations between burnout, job engagement, work demands, and organisational culture (OC) and to demonstrate differences between physicians and nurses working in general hospital in Skopje, Republic of Macedonia.

MATERIAL AND METHODS:

Maslach Burnout Inventory and Utrecht Work Engagement Scale were used for assessment of burnout and job engagement. Work demands and OC were measured with Hospital Experience Scale and Competing Values Framework, respectively.

RESULTS:

Higher scores of dedication, hierarchy OC, and organizational work demands were found in physicians. Nurses demonstrated higher scores of clan OC. Burnout negatively correlated with clan and market OC in physicians and nurses. Job engagement positively correlated with clan and market OC in nurses. Different work demands were related to different dimensions of burnout and/or job engagement. Our findings support job demands-resources (JD-R) model (Demerouti and Bakker).

CONCLUSIONS:

Data obtained can be used in implementation of specific organizational interventions in the hospital setting. Providing adequate JD-R interaction can lead to prevention of burnout in health professionals (HPs) and contribute positively to better job engagement in HPs and higher quality of patient care.

Stress Causing Factors Among Teachers in Elementary Schools and Their Relationship with Demographic and Job Characteristics

BACKGROUND

Once high levels of work-related stress among teachers were confirmed many studies concentrated on identifying and investigating key stress factors among school teachers. Unfortunately there are very few researches made on stress causing factors among teachers in Republic of Macedonia.

AIM

To determine the most frequent stress causing factors among teachers in elementary schools and to investigate their relationship with demographic and job characteristics.

METHODOLOGY

We performed a descriptive-analytical model of a cross-sectional study which involved 300 teachers employed in nine elementary schools. Evaluation of examined subjects included completion of a specially designed questionnaire.

RESULTS

Among six categories of factors that generate work related stress (job demands, control, relationships, role, changes and support) control and support had the highest mean scores. Within the control category the highest levels of perceived teacher's work-related stress were caused by the following factors - changes in terms and conditions without consultation and given responsibility without the authority to take decisions. 141 out of the interviewed teachers (47%) have mentioned changes in terms and conditions without consultation as very stressful, while another 50 (16.67%) have reported it as stressful. 123 out of interviewed teachers (41%) have stated given responsibility without the authority to take decisions as very stressful, with another 105 (35%) have reported it as stressful. In the category support the highest levels of perceived teacher's work-related stress were caused by stress factors - lack of funds/resources to do the job and limited or no access to training. Out of 300 interviewed teachers, 179 (59.67%) have reported lack of funds/resources to do the job as very stressful, while another 50 (16.67%) as stressful. There is no significant relationship between the stress factor limited or no access to training and demographic and job characteristics.

CONCLUSION

Our findings confirm that within the control category, the highest levels of perceived teacher's work-related stress were caused by changes in terms and conditions without consultation and given responsibility without the authority to take decisions, while in the category support, the same was true for stress factors lack of funds/resources to do the job and limited or no access to training. We have also concluded that the lower-grade school teachers, female teachers, teachers for whom this is the first job and teachers with university education perceive more often the lack of authority to take decisions as a very stressful factor than the upper-grade school teachers, male teachers, teachers previously employed in another workplace, and those with high education. The lower-grade school teachers, older teachers and teachers with university education perceive more often changes in education as a very stressful factor than the upper grade school teachers, younger teachers and those with high education.

Assessment of the Non-Cystic Fibrosis Bronchiectasis Severity: The FACED Score vs the Bronchiectasis Severity Index

INTRODUCTION

Non-cystic fibrosis bronchiectasis (NCFB) is a multidimensional disease, and no single isolated parameter is proved to have sufficient power for any overall determination of its severity and prognosis.

OBJECTIVE

To compare the results of the assessment of the NCFB severity with respect to its prognosis in the same patients by two different validated scores, i.e. the FACED score and the Bronchiectasis Severity Index (BSI).

METHODS

An observational study including 37 patients with NCFB (16 males and 21 female aged 46 to 76 years) was performed. All patients underwent evaluation of the variables incorporated in the FACED score (FEV1 % predicted, age, chronic colonization by Pseudomaonas aeruginosa, radiological extent of the disease, and dyspnea) and in the BSI (age, body mass index, FEV1 % predicted, hospitalization and exacerbations in previous year, dyspnea, chronic colonization by Pseudomaonas aeruginosa and other microrganisms, and radiological extent of the disease).

RESULTS

According to the value of the derived overall FACED score we found 17 patients (45.9%) with mild bronchiectasis, 14 patients (37.8%) with moderate bronchiectasis and 6 patients (16.2%) with severe bronchiectasis. The mean derived FACED score was 3.4 ± 1.3. In addition, according to the value of the derived overall BSI score, the frequency of patients with low, intermediate and high BSI score was 16 patients (43,2%), 14 patients (37.8%) and 7 patients (18.9%), respectively. The mean derived BSI score was 6.4 ± 2.5.

CONCLUSION

We found similar results by the assessment of the NCFB severity in regard to its prognosis by both the FACED score and the BSI. Further studies determining how these scores may impact clinical practice are needed.

Work Demands-Burnout and Job Engagement-Job Satisfaction Relationships: Teamwork as a Mediator and Moderator

BACKGROUND:

Few studies have examined teamwork as mediator and moderator of work demands-burnout and job engagement-job satisfaction relationships in healthcare workers (HCWs) in South-East Europe.

AIM:

To assess mediation and moderation effect of teamwork on the relationship between independent (work demands or job engagement) and dependent (burnout or job satisfaction) variables.

METHODS:

Work demands, burnout, job engagement, and job satisfaction were measured with Hospital Experience Scale, Maslach Burnout Inventory, Utrecht Work Engagement Scale, and Job Satisfaction Survey, respectively. Hospital Survey on Patient Safety Culture was used for assessment of teamwork. In order to examine role of teamwork as a mediating variable we fit series of regression models for burnout and job satisfaction. We also fit regression models predicting outcome (burnout or job satisfaction) from predictor (work demands or job engagement) and moderator (teamwork) variable.

RESULTS:

Teamwork was partial mediator of work demands-burnout relationship and full mediator of job engagement-job satisfaction relationship. We found that only job engagement-job satisfaction relationship was moderated by teamwork.

CONCLUSIONS:

Occupational health services should target detection of burnout in HCWs and implementation of organizational interventions in hospitals, taking into account findings that teamwork predicted reduced burnout and higher job satisfaction.

Burnout and Work Demands Predict Reduced Job Satisfaction in Health Professionals Working In a Surgery Clinic

BACKGROUND:

Burnout syndrome develops in health professionals (HPs) as a result of exposure to chronic emotional and interpersonal workplace stressors. Research demonstrates the links between burnout, work demands, and job satisfaction in hospital HPs.

AIMS:

To examine the associations between burnout, work demands and job satisfaction, and to demonstrate the mediation effect of emotional exhaustion on the relationship between work demands and job satisfaction in surgery clinic HPs.

METHODS:

Maslach Burnout Inventory was used for assessment of burnout. Work demands and job satisfaction were measured with Hospital Experience Scale and Job Satisfaction Survey, respectively. In order to examine the role of emotional exhaustion, depersonalization, and work demands, controlling for age, hospital tenure, and unit tenure, a hierarchical multiple regression models were tested for each job satisfaction factor.

RESULTS:

Job satisfaction was negatively predicted by emotional exhaustion. Certain types of work demands negatively predicted different factors of job satisfaction. Emotional exhaustion was a significant partial mediator of the relationship between work demands and job satisfaction.

CONCLUSIONS:

Adequate management of work demands, particularly excessive workload, time pressure, and lack of staff can lead to prevention of burnout and reduced job satisfaction in surgery clinic HPs, and contribute to better quality of patient care.

Efficacy and Tolerability of Eight Antimicrobial Regimens in the Outpatient Treatment of Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND: Bacterial infections are considered as the most important cause of exacerbations in patients with chronic obstructive pulmonary disease.AIM: To compare the efficacy and tolerability of eight antibiotics empirically administered for outpatient treatment of exacerbations of COPD.METHODS: We performed an observational study including 343 COPD patients with probable bacterial exacerbation (Group A and Group B COPD patients) managed in an outpatient setting. Eight antibiotic regimens each used 10 days were evaluated: amoxicillin/clavulonic acid, doxycycline, cefuroxime, cefixime, clarithromycin, roxithromycin, ciprofloxacin, and moxifloxacin. All patients were followed up for 30 days, with an intermediate visits at 5, 7 and 10 days at which the duration of symptoms and the side-effects of the drug were evaluated.RESULTS: The clinical success rate varied from 69.8% with doxycycline to 80.9% with moxifloxacin. The mean time to relief of symptoms varied from 5.6 days with moxifloxacin to 6.3 days with amoxicillin/clavulonic acid. Significant increase of the post-treatment FEV1value was registered in all treatment groups. Relapse within the first 20 days was registered in the group receiving doxycycline, clarithromycin, and ciprofloxacin. The prevalence of the adverse events was low varying from 6.7% with cefuroxime to 11.3% with ciprofloxacin.CONCLUSION: Our findings suggest high clinical success rate and high safety of all studied regimens.

Linkages between workplace stressors and quality of care from health professionals' perspective - Macedonian experience

OBJECTIVES

During last two decades, within the process of transition, the socio-economic reforms in Republic of Macedonia reflected on the national health care system. The objective of this article was to identify workplace stressors and factors that influence quality of care, from the perspective of health professionals (HPs), and to understand how they were linked in the context of such social circumstances.

METHODS

A qualitative research based on focus group (FG) methodology was conducted in a general teaching hospital. Two main topics were the subjects of discussion in FGs: workplace stressors and factors that influence quality of care, from the HPs perspective. Six FGs were conducted with a total of 56 HPs (doctors, nurses, interns, and residents) divided into two sets of three FGs for each topic separately. Two sets of data were processed with thematic analysis, and the obtained results were compared with each other.

RESULTS

By processing the data, we identified themes relating to factors that generate stress among HPs and factors that influence quality of care, from HPs' perspective. By comparing the two sets of themes, we found that many of them were identical, which means factors that increase workplace stress at the same time reduce quality of care.

CONCLUSIONS

Implementation of specific organizational interventions in the hospital setting can lead to the prevention of work-related stress and improvement in quality of care. Our research suggests that the prevention of work-related stress will impact positively on the quality of care, which may contribute to establish criteria and recommendations for the improvement in organizational culture and climate in hospitals.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Psychosocial stress at work among health professionals is often present and well studied, but relations between job stress and quality of care were rarely examined. Job demands-resources model by Demerouti, Bakker, Nachreiner and Schaufeli (2001), for assessment of job stress includes job demands (working environment, work overload, time pressures, recipient contact, shift work) and job resources (feedback, rewards, job control, participation, job security, supervisor support) was applied in different studies. There is scientific evidence that burned-out physicians have shown depersonalization from their patients, they have withdrawn from patients, demonstrated sub-optimal care, and sometimes burnout has been related to serious mistakes and patient death. Different research has shown that some workplace factors contributed to the development of work-related stress and burnout among HPs whereas others contributed protectively. What does this study add? Similar and overlapping workplace factors in hospital setting produce stress in health professionals and influence quality of care. Impact of specific socioeconomic environment in Macedonia as a country in transition and EU candidate country on job stress among health professionals and quality of care. Development of criteria and recommendations for the job stress prevention and improvement of the organizational culture and climate in hospital settings.

Respiratory and nasal symptoms, immunological changes and lung function among petroleum refinery workers

OBJECTIVE

To assess adverse respiratory effects and immunological changes among petroleum refinery workers.

METHODS

We performed a cross-sectional study including 80 subjects employed in the coking unit of a petroleum refinery (54 males and 26 females, aged 28-56 years, duration of exposure 7-28 years) and an equal number of office workers, matched by sex, age and smoking habits. Asthma and allergic rhinitis diagnosed by a physician, as well as respiratory and nasal symptoms in the last 12 months, were recorded by questionnaire. Evaluation of the subjects under study also included skin prick tests for common inhalable allergens and lung function tests.

RESULTS

We found a similar prevalence of asthma and allergic rhinitis in both examined groups. Prevalence of overall respiratory symptoms was higher among petroleum refinery workers (33.7% vs. 22.5%) with a statistically significant difference for cough (30.0% vs. 13. 7%, p = 0.018) and wheezing (21.1% vs. 8.6%, p = 0.029). Prevalence of overall nasal symptoms was higher among petrol refinery workers (36.2% vs. 23.7%) with a statistically significant difference for runny nose (28.7% vs. 12.5%, p = 0.014). We found a similar prevalence of allergic sensitization to common inhalable allergens in both examined groups. The results of lung function tests showed significantly lower value of MEF50 (61.9% vs. 67.4%, p = 0.019) and MEF75 (56.1% vs. 62.9%, p = 0.000) among petroleum refinery workers. Respiratory impairment was observed in both smoking and non-smoking petroleum refinery workers.

CONCLUSION

Our data suggest that workplace exposure among petroleum refinery workers may lead to respiratory and nasal symptoms and lung function impairment.

National survey on identifying vulnerable workers and availability of occupational health services in the Republic of Macedonia

OBJECTIVE

In order to identify vulnerable groups and high risk sectors which are at greater need of basic occupational health services, we performed a questionnaire-based study including, as key informants, different stakeholders and key players in the process of improving health and safety at work.

METHODS

The Institute of Occupational Health of Macedonia developed an specially designed questionnaire in collaboration with the WHO Regional Office for Europe. Vulnerable groups/sectors include: unemployed, female workers, workers aged under 18 years, workers aged over 55 years and workers in the informal sector, construction industry, textile industry, agriculture, and the health care workers. The Likert scale method was used to evaluate most of the questions in the questionnaire, and the study subjects were instructed to give their professional opinion in completing the questionnaire.

RESULTS

All examined groups/sectors were judged to have high risk for occupationally related health problems by over 70% of the responders. Aging workers and workers in agriculture and in the construction industry were judged to have the highest risk for such problems, as well as low health status. All examined groups/sectors were judged to have good availability of primary health care services, while agriculture, unemployed, the informal sector and young workers were judged as having poor availability of occupational health services.

CONCLUSION

The provision of Basic Occupational Health Services (BOHS) incorporated in the framework of primary health care via the public health approach was judged as a good conceptfor Macedonia.