The Cochrane Handbook for Systematic Reviews of Interventions is the official document that describes in detail the process of preparing and maintaining Cochrane systematic reviews on the effects of healthcare interventions.

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Cochrane Handbook for Systematic Reviews of Interventions

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.

The UK Biobank project is a prospective cohort study with deep genetic and phenotypic data collected on approximately 500,000 individuals from across the United Kingdom, aged between 40 and 69 at recruitment. The open resource is unique in its size and scope. A rich variety of phenotypic and health-related information is available on each participant, including biological measurements, lifestyle indicators, biomarkers in blood and urine, and imaging of the body and brain. Follow-up information is provided by linking health and medical records. Genome-wide genotype data have been collected on all participants, providing many opportunities for the discovery of new genetic associations and the genetic bases of complex traits. Here we describe the centralized analysis of the genetic data, including genotype quality, properties of population structure and relatedness of the genetic data, and efficient phasing and genotype imputation that increases the number of testable variants to around 96 million. Classical allelic variation at 11 human leukocyte antigen genes was imputed, resulting in the recovery of signals with known associations between human leukocyte antigen alleles and many diseases.

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The UK Biobank resource with deep phenotyping and genomic data

An earlier version (version 5.0.2, 2008) of the Handbook is also published by John Wiley & Sons, Ltd under “The Cochrane Book Series” Imprint, as Higgins JPT, Green S (editors), Cochrane Handbook for Systematic Reviews of Interventions (ISBN 978-0470057964) by John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England, Telephone (+44) 1243 779777; Email (for orders and customer service enquiries): cs-books@wiley.co.uk. Visit their Home Page on www.wiley.com.

Chapter 8: Assessing risk of bias in included studies

Assessing Risk of Bias in Included Studies

Dupilumab Reduces Severe Exacerbations and Improves Lung Function in Late-Onset, Uncontrolled, Moderate-to-Severe Asthma Patients Enrolled in the LIBERTY ASTHMA QUEST Study

Introduction: Severe asthma is complex and immunologically heterogenous; airways infection and innate immune dysregulation may confer inhaled corticosteroid resistance and remains clinically challenging. We hypothesise that marked airway microbiome compositional shifts in severe asthma represent a ‘treatable trait’, with dominance of pathogenic species, warranting targeted therapy. Additionally, these changes are thought to be distinct in the paucibacillary lower airway vs. heavily colonised nasopharynx. Methods: We performed Oxford Nanopore metagenomic sequencing, and RT-qPCR of induced sputum (n=67), bronchoalveolar lavage (BAL;n=71) and nasal lavage (NL;n=28 paired with sputum) samples from the Wessex Severe Asthma Cohort encompassing mild/moderate/severe asthma and health. Findings were integrated with clinical and cytokine data. Key Results: A dominant pathogenic organism (H.influenzae, S.pneumoniae,&nbsp;M.catarrhalis) was identified in sputua of 21% of patients with severe asthma and accompanied by sputum neutrophilia and elevated type-1 cytokines (including IL-1β, IL-6, IL-8, TNF;p&lt;0.01, unpaired t-test, Benjamini-Hochberg correction).&nbsp;From BAL, airways infection was identified infrequently (Severe asthma, n=1/21 H.influenzae; Mild-Moderate asthma,n=2/25 T.whipplei). Metagenomic analysis of NL demonstrated a distinct microbiome; presence of pathogenic organisms in the upper airways did not predict concurrent presence in sputum of severe asthmatics. Conclusion: Airways infection is reliably identified in sputum using metagenomic sequencing and is associated with neutrophilic inflammation. The microbiome in the upper and lower airway are distinct and ongoing work is exploring its impact on mucosal immune responses at these sites.

The Upper and Lower Airway Microbiome in Severe Asthma

Regular exposure to antimuscarinic drugs would be expected to upregulate airway muscarinic receptors and could cause a transient increase in airways obstruction if treatment was stopped or omitted. We have examined peak expiratory flow rate (PEFR) during treatment and forced expiratory flow in one second (FEV1) and airway responsiveness to three constrictor agonists (as the provocative dose of agonist causing a 20% fall in FEV1, (PD20)) following cessation of regular inhaled ipratropium bromide, in 13 subjects with mild stable asthma. Subjects inhaled placebo and ipratropium bromide, 80 microg q.i.d. for 14 days in a cross-over fashion with a 1 week run-in/wash-out period before and after each treatment period. Subjects recorded symptom scores and PEFR throughout the study, and FEV1 and PD20 to histamine, methacholine and metabisulphite were measured before and after cessation of treatment. When compared to baseline, FEV1 was lower after cessation of ipratropium than after placebo, with a significant difference 30 h after the last dose (difference 190 mL; 95% confidence interval (95% CI) 310-70 mL; p<0.02). FEV1 measured 6-10 days later, did not differ significantly. PEFR was significantly lower after cessation of ipratropium than after placebo on Day 15 (19-37 h after the last dose) (mean difference 4.6%; 95% CI 1.6-7.5%; p<0.01) but not on Day 16. There were no significant changes in PD20 histamine, methacholine and metabisulphite, symptom scores or rescue bronchodilator use after cessation of treatment. Thus, transient bronchoconstriction was found around 30 h after cessation of regular therapy with inhaled ipratropium for 2 weeks. The mechanism is unclear, as no evidence of muscarinic receptor upregulation was found. Although the changes were small and unlikely to be important for most patients, the results of this study indicate that the timing of lung function measurements relative to the last dose of ipratropium is important when interpreting the course of lung function in long-term studies.

https://erj.ersjournals.com/content/erj/9/8/1627.full.pdf

Ian D. Pavord

Papers

Dupilumab Reduces Severe Exacerbations and Improves Lung Function in Late-Onset, Uncontrolled, Moderate-to-Severe Asthma Patients Enrolled in the LIBERTY ASTHMA QUEST Study

The Upper and Lower Airway Microbiome in Severe Asthma

Effect of cessation of short-term therapy with ipratropium bromide on lung function and airway responsiveness

Responder Analysis of AQLQ in the Asthma Intervention Research (AIR) Trial

Lessons from LAVOLTA.