Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

Context Despite decades of accumulated observational evidence, the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain Objective To assess the major health benefits and risks of the most commonly used combined hormone preparation in the United States Design Estrogen plus progestin component of the Women's Health Initiative, a randomized controlled primary prevention trial (planned duration, 85 years) in which 16608 postmenopausal women aged 50-79 years with an intact uterus at baseline were recruited by 40 US clinical centers in 1993-1998 Interventions Participants received conjugated equine estrogens, 0625 mg/d, plus medroxyprogesterone acetate, 25 mg/d, in 1 tablet (n = 8506) or placebo (n = 8102) Main outcomes measures The primary outcome was coronary heart disease (CHD) (nonfatal myocardial infarction and CHD death), with invasive breast cancer as the primary adverse outcome A global index summarizing the balance of risks and benefits included the 2 primary outcomes plus stroke, pulmonary embolism (PE), endometrial cancer, colorectal cancer, hip fracture, and death due to other causes Results On May 31, 2002, after a mean of 52 years of follow-up, the data and safety monitoring board recommended stopping the trial of estrogen plus progestin vs placebo because the test statistic for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits This report includes data on the major clinical outcomes through April 30, 2002 Estimated hazard ratios (HRs) (nominal 95% confidence intervals [CIs]) were as follows: CHD, 129 (102-163) with 286 cases; breast cancer, 126 (100-159) with 290 cases; stroke, 141 (107-185) with 212 cases; PE, 213 (139-325) with 101 cases; colorectal cancer, 063 (043-092) with 112 cases; endometrial cancer, 083 (047-147) with 47 cases; hip fracture, 066 (045-098) with 106 cases; and death due to other causes, 092 (074-114) with 331 cases Corresponding HRs (nominal 95% CIs) for composite outcomes were 122 (109-136) for total cardiovascular disease (arterial and venous disease), 103 (090-117) for total cancer, 076 (069-085) for combined fractures, 098 (082-118) for total mortality, and 115 (103-128) for the global index Absolute excess risks per 10 000 person-years attributable to estrogen plus progestin were 7 more CHD events, 8 more strokes, 8 more PEs, and 8 more invasive breast cancers, while absolute risk reductions per 10 000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures The absolute excess risk of events included in the global index was 19 per 10 000 person-years Conclusions Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 52-year follow-up among healthy postmenopausal US women All-cause mortality was not affected during the trial The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases, and the results indicate that this regimen should not be initiated or continued for primary prevention of CHD

/pdf/risks-and-benefits-of-estrogen-plus-progestin-in-healthy-4glim99n2t.pdf

Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial

ABCD
: Appropriate Blood pressure Control in Diabetes
ABI
: ankle–brachial index
ABPM
: ambulatory blood pressure monitoring
ACCESS
: Acute Candesartan Cilexetil Therapy in Stroke Survival
ACCOMPLISH
: Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension
ACCORD
: Action to Control Cardiovascular Risk in Diabetes
ACE
: angiotensin-converting enzyme
ACTIVE I
: Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events
ADVANCE
: Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation
AHEAD
: Action for HEAlth in Diabetes
ALLHAT
: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart ATtack
ALTITUDE
: ALiskiren Trial In Type 2 Diabetes Using Cardio-renal Endpoints
ANTIPAF
: ANgioTensin II Antagonist In Paroxysmal Atrial Fibrillation
APOLLO
: A Randomized Controlled Trial of Aliskiren in the Prevention of Major Cardiovascular Events in Elderly People
ARB
: angiotensin receptor blocker
ARIC
: Atherosclerosis Risk In Communities
ARR
: aldosterone renin ratio
ASCOT
: Anglo-Scandinavian Cardiac Outcomes Trial
ASCOT-LLA
: Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm
ASTRAL
: Angioplasty and STenting for Renal Artery Lesions
A-V
: atrioventricular
BB
: beta-blocker
BMI
: body mass index
BP
: blood pressure
BSA
: body surface area
CA
: calcium antagonist
CABG
: coronary artery bypass graft
CAPPP
: CAPtopril Prevention Project
CAPRAF
: CAndesartan in the Prevention of Relapsing Atrial Fibrillation
CHD
: coronary heart disease
CHHIPS
: Controlling Hypertension and Hypertension Immediately Post-Stroke
CKD
: chronic kidney disease
CKD-EPI
: Chronic Kidney Disease—EPIdemiology collaboration
CONVINCE
: Controlled ONset Verapamil INvestigation of CV Endpoints
CT
: computed tomography
CV
: cardiovascular
CVD
: cardiovascular disease
D
: diuretic
DASH
: Dietary Approaches to Stop Hypertension
DBP
: diastolic blood pressure
DCCT
: Diabetes Control and Complications Study
DIRECT
: DIabetic REtinopathy Candesartan Trials
DM
: diabetes mellitus
DPP-4
: dipeptidyl peptidase 4
EAS
: European Atherosclerosis Society
EASD
: European Association for the Study of Diabetes
ECG
: electrocardiogram
EF
: ejection fraction
eGFR
: estimated glomerular filtration rate
ELSA
: European Lacidipine Study on Atherosclerosis
ESC
: European Society of Cardiology
ESH
: European Society of Hypertension
ESRD
: end-stage renal disease
EXPLOR
: Amlodipine–Valsartan Combination Decreases Central Systolic Blood Pressure more Effectively than the Amlodipine–Atenolol Combination
FDA
: U.S. Food and Drug Administration
FEVER
: Felodipine EVent Reduction study
GISSI-AF
: Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Atrial Fibrillation
HbA1c
: glycated haemoglobin
HBPM
: home blood pressure monitoring
HOPE
: Heart Outcomes Prevention Evaluation
HOT
: Hypertension Optimal Treatment
HRT
: hormone replacement therapy
HT
: hypertension
HYVET
: HYpertension in the Very Elderly Trial
IMT
: intima-media thickness
I-PRESERVE
: Irbesartan in Heart Failure with Preserved Systolic Function
INTERHEART
: Effect of Potentially Modifiable Risk Factors associated with Myocardial Infarction in 52 Countries
INVEST
: INternational VErapamil SR/T Trandolapril
ISH
: Isolated systolic hypertension
JNC
: Joint National Committee
JUPITER
: Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin
LAVi
: left atrial volume index
LIFE
: Losartan Intervention For Endpoint Reduction in Hypertensives
LV
: left ventricle/left ventricular
LVH
: left ventricular hypertrophy
LVM
: left ventricular mass
MDRD
: Modification of Diet in Renal Disease
MRFIT
: Multiple Risk Factor Intervention Trial
MRI
: magnetic resonance imaging
NORDIL
: The Nordic Diltiazem Intervention study
OC
: oral contraceptive
OD
: organ damage
ONTARGET
: ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial
PAD
: peripheral artery disease
PATHS
: Prevention And Treatment of Hypertension Study
PCI
: percutaneous coronary intervention
PPAR
: peroxisome proliferator-activated receptor
PREVEND
: Prevention of REnal and Vascular ENdstage Disease
PROFESS
: Prevention Regimen for Effectively Avoiding Secondary Strokes
PROGRESS
: Perindopril Protection Against Recurrent Stroke Study
PWV
: pulse wave velocity
QALY
: Quality adjusted life years
RAA
: renin-angiotensin-aldosterone
RAS
: renin-angiotensin system
RCT
: randomized controlled trials
RF
: risk factor
ROADMAP
: Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention
SBP
: systolic blood pressure
SCAST
: Angiotensin-Receptor Blocker Candesartan for Treatment of Acute STroke
SCOPE
: Study on COgnition and Prognosis in the Elderly
SCORE
: Systematic COronary Risk Evaluation
SHEP
: Systolic Hypertension in the Elderly Program
STOP
: Swedish Trials in Old Patients with Hypertension
STOP-2
: The second Swedish Trial in Old Patients with Hypertension
SYSTCHINA
: SYSTolic Hypertension in the Elderly: Chinese trial
SYSTEUR
: SYSTolic Hypertension in Europe
TIA
: transient ischaemic attack
TOHP
: Trials Of Hypertension Prevention
TRANSCEND
: Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease
UKPDS
: United Kingdom Prospective Diabetes Study
VADT
: Veterans' Affairs Diabetes Trial
VALUE
: Valsartan Antihypertensive Long-term Use Evaluation
WHO
: World Health Organization

### 1.1 Principles

The 2013 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology …

/pdf/2013-esh-esc-guidelines-for-the-management-of-arterial-4ydvs5ifsx.pdf

2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).

Basics of qualitative research: Grounded theory procedures and techniques

Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide

/pdf/grade-an-emerging-consensus-on-rating-quality-of-evidence-ft3aqcsyh5.pdf

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

/pdf/hormone-replacement-therapy-and-endometrial-cancer-are-2ddhby2vlw.pdf

Hormone Replacement Therapy and Endometrial Cancer: Are Current Regimens Safe?

A S PRACTICING PHYSICIANS, WE HAVE OBserved that the problems associated with opioid medications for the treatment of chronic pain are growing rapidly. In primary and specialty care, chronic nonmalignant pain is common, with 20% to 40% of adults reporting chronic pain. Opioids are the most common means of treatment for chronic pain; 15% to 20% of office visits in the United States now include the prescription of an opioid, and 4 million Americans per year are prescribed a long-acting opioid. Opioids have become the most commonly prescribed drug category in the United States, and the increasing prevalence of their prescription closely parallels the increasing emphasis, which began in the mid-1990s, on treatment of chronic pain. A partial explanation of why we got to this point is that the lessons learned from the undertreatment of pain in patients with cancer were generalized to patients with chronic pain and no clear end point of cure or death. The practice of using opioids for chronic pain treatment also has been reinforced by continuing medical education classes and state regulations encouraging physicians to adequately treat pain.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=INTEMED&articleId=1105889&pdfFileName=ied15004_1426_1427.pdf

Opioids for Chronic Pain

PROMISe trial: a pilot, randomized, placebo-controlled trial of magnetic resonance guided focused ultrasound for uterine fibroids

DR REYNOLDS: Mrs W is a 60-year-old white woman who is trying to discontinue her estrogen therapy. She lives alone near Boston and teaches middle school. Her 29-year-old son lives in another state. She has managed care insurance. At the age of 40, Mrs W underwent hysterectomy and bilateral salpingo-oophorectomy to treat refractory endometriosis. After several days of severe flushes, sweats, and depression, she began taking conjugated estrogen, 0.625 mg/d. With that therapy she has felt well for the past 2 decades. Over the past few years, she became increasingly concerned about her family history of breast cancer and the health risks of postmenopausal hormone replacement therapy (HRT) after reading about it in the lay press. Mrs W asked her former physician about these risks, and he encouraged her to continue treatment. At times, she discontinued the estrogen on her own, but disabling hot flushes ensued and she restarted treatment each time. Four months ago, Mrs W visited a new primary care physician, Dr K, who encouraged her to taper the HRT. With her dose decreased to 0.3 mg/d, she didn’t feel as well as she did with the higher dose. She then stopped taking the medication according to the planned taper. She has numerous hot flushes daily, sometimes as often as every 30 minutes. The hot flushes wake Mrs W from sleep. She is not depressed, but she has a general sense of not feeling as well as when taking the hormonal therapy. Her past medical history is significant for multiple breast cysts requiring aspiration and an excisional biopsy of a left breast mass many years ago that was benign. She had atrial fibrillation treated with nodal ablation and is now in sinus rhythm. She had superficial phlebitis 1 year ago. She has never had a venous thromboembolic event. Her menarche was at age 10; her only pregnancy was at the age of 32 and was carried to term. Mrs W’s mother had rectal cancer diagnosed at the age of 70. Her maternal grandmother was in her 50s when she died of breast cancer; Mrs W’s younger sister was diagnosed as having breast cancer in her late 30s. Her father died of an abdominal aortic aneurysm. There is no family history of osteoporosis or premature coronary heart disease (CHD). Mrs W does not smoke or drink alcohol. She walks several times a week and has begun strengthening exercises. Her husband died several months ago and she reports “normal grief” and a strong support network. On physical examination, Mrs W looked younger than her age. At 5’3” she weighed 116 lb; her blood pressure was 120/60 mm Hg and her pulse was regular at 60/min. She had a left breast scar at 3-o’clock but otherwise normal breast examination findings. Her pelvic examination showed no cervical cuff and no adnexal masses. The remainder of her physical examination results were normal. Mrs W’s only medication was atenolol, 25 mg/d. Laboratory data showed a total cholesterol level of 179 mg/dL (4.6 mmol/L) and high-density lipoprotein (HDL) level of 91 mg/dL (2.4 mmol/L), measured in August 2000. Bone density testing in June 2001 showed a T score at the femoral neck of −1.68. A mammogram within the last year was unremarkable.

https://jamanetwork.com/journals/JAMA/articlepdf/194866/jxr20000.pdf

A 60-year-old woman trying to discontinue hormone replacement therapy.

The widespread implementation of electronic medical records (EMRs), stimulatedby thePatient Protection andAffordable Care Act, provides a major opportunity to conduct inexpensive pragmatic randomized trials1,2 that are embedded into the clinical practice of health care delivery. Electronicmedical recordsallowhealthsystemsto identifyparticular types of patients, deliver targeted interventions designed to improve health, and measure how those interventions impact health care delivery and health outcomes. With optimal use of EMRs, the administrative costs of a trial need not increasewith the sample size; this decouplingof costs and size facilitates large, simple, and inexpensive trials that have thepotential to transformhealthsystems intoentities that learn and continuously improve.3

Deborah Grady

Papers

Hormone Replacement Therapy and Endometrial Cancer: Are Current Regimens Safe?

Opioids for Chronic Pain

PROMISe trial: a pilot, randomized, placebo-controlled trial of magnetic resonance guided focused ultrasound for uterine fibroids

A 60-year-old woman trying to discontinue hormone replacement therapy.

Informed Consent in Randomized Quality Improvement Trials A Critical Barrier for Learning Health Systems