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.

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

This article presents an introduction to the Health Belief Model (HBM). The HBM states that the perception of a personal health behavior threat is influenced by at least three factors: general health values, interest and concern about health; specific beliefs about vulnerability to a particular health threat; and beliefs about the consequences of the health problem. Once an individual perceives a threat to his health and is simultaneously cued to action, if his perceived benefits outweighs his perceived costs, then the individual is most likely to undertake the recommended preventive health action. Key words: health promotion, health belief model, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, self-efficacy. Content available only in Romanian.

Health Belief Model

BACKGROUND: Postal and electronic questionnaires are widely used for data collection in epidemiological studies but non-response reduces the effective sample size and can introduce bias. Finding ways to increase response to postal and electronic questionnaires would improve the quality of health research. OBJECTIVES: To identify effective strategies to increase response to postal and electronic questionnaires. SEARCH STRATEGY: We searched 14 electronic databases to February 2008 and manually searched the reference lists of relevant trials and reviews, and all issues of two journals. We contacted the authors of all trials or reviews to ask about unpublished trials. Where necessary, we also contacted authors to confirm methods of allocation used and to clarify results presented. We assessed the eligibility of each trial using pre-defined criteria. SELECTION CRITERIA: Randomised controlled trials of methods to increase response to postal or electronic questionnaires. DATA COLLECTION AND ANALYSIS: We extracted data on the trial participants, the intervention, the number randomised to intervention and comparison groups and allocation concealment. For each strategy, we estimated pooled odds ratios (OR) and 95% confidence intervals (CI) in a random-effects model. We assessed evidence for selection bias using Egger's weighted regression method and Begg's rank correlation test and funnel plot. We assessed heterogeneity among trial odds ratios using a Chi(2) test and the degree of inconsistency between trial results was quantified using the I(2) statistic. MAIN RESULTS: PostalWe found 481 eligible trials. The trials evaluated 110 different ways of increasing response to postal questionnaires. We found substantial heterogeneity among trial results in half of the strategies. The odds of response were at least doubled using monetary incentives (odds ratio 1.87; 95% CI 1.73 to 2.04; heterogeneity P < 0.00001, I(2) = 84%), recorded delivery (1.76; 95% CI 1.43 to 2.18; P = 0.0001, I(2) = 71%), a teaser on the envelope - e.g. a comment suggesting to participants that they may benefit if they open it (3.08; 95% CI 1.27 to 7.44) and a more interesting questionnaire topic (2.00; 95% CI 1.32 to 3.04; P = 0.06, I(2) = 80%). The odds of response were substantially higher with pre-notification (1.45; 95% CI 1.29 to 1.63; P < 0.00001, I(2) = 89%), follow-up contact (1.35; 95% CI 1.18 to 1.55; P < 0.00001, I(2) = 76%), unconditional incentives (1.61; 1.36 to 1.89; P < 0.00001, I(2) = 88%), shorter questionnaires (1.64; 95% CI 1.43 to 1.87; P < 0.00001, I(2) = 91%), providing a second copy of the questionnaire at follow up (1.46; 95% CI 1.13 to 1.90; P < 0.00001, I(2) = 82%), mentioning an obligation to respond (1.61; 95% CI 1.16 to 2.22; P = 0.98, I(2) = 0%) and university sponsorship (1.32; 95% CI 1.13 to 1.54; P < 0.00001, I(2) = 83%). The odds of response were also increased with non-monetary incentives (1.15; 95% CI 1.08 to 1.22; P < 0.00001, I(2) = 79%), personalised questionnaires (1.14; 95% CI 1.07 to 1.22; P < 0.00001, I(2) = 63%), use of hand-written addresses (1.25; 95% CI 1.08 to 1.45; P = 0.32, I(2) = 14%), use of stamped return envelopes as opposed to franked return envelopes (1.24; 95% CI 1.14 to 1.35; P < 0.00001, I(2) = 69%), an assurance of confidentiality (1.33; 95% CI 1.24 to 1.42) and first class outward mailing (1.11; 95% CI 1.02 to 1.21; P = 0.78, I(2) = 0%). The odds of response were reduced when the questionnaire included questions of a sensitive nature (0.94; 95% CI 0.88 to 1.00; P = 0.51, I(2) = 0%).ElectronicWe found 32 eligible trials. The trials evaluated 27 different ways of increasing response to electronic questionnaires. We found substantial heterogeneity among trial results in half of the strategies. The odds of response were increased by more than a half using non-monetary incentives (1.72; 95% CI 1.09 to 2.72; heterogeneity P < 0.00001, I(2) = 95%), shorter e-questionnaires (1.73; 1.40 to 2.13; P = 0.08, I(2) = 68%), including a statement that others had responded (1.52; 95% CI 1.36 to 1.70), and a more interesting topic (1.85; 95% CI 1.52 to 2.26). The odds of response increased by a third using a lottery with immediate notification of results (1.37; 95% CI 1.13 to 1.65), an offer of survey results (1.36; 95% CI 1.15 to 1.61), and using a white background (1.31; 95% CI 1.10 to 1.56). The odds of response were also increased with personalised e-questionnaires (1.24; 95% CI 1.17 to 1.32; P = 0.07, I(2) = 41%), using a simple header (1.23; 95% CI 1.03 to 1.48), using textual representation of response categories (1.19; 95% CI 1.05 to 1.36), and giving a deadline (1.18; 95% CI 1.03 to 1.34). The odds of response tripled when a picture was included in an e-mail (3.05; 95% CI 1.84 to 5.06; P = 0.27, I(2) = 19%). The odds of response were reduced when "Survey" was mentioned in the e-mail subject line (0.81; 95% CI 0.67 to 0.97; P = 0.33, I(2) = 0%), and when the e-mail included a male signature (0.55; 95% CI 0.38 to 0.80; P = 0.96, I(2) = 0%). AUTHORS' CONCLUSIONS: Health researchers using postal and electronic questionnaires can increase response using the strategies shown to be effective in this systematic review.

/pdf/methods-to-increase-response-to-postal-and-electronic-4sjz3r84m4.pdf

Methods to increase response to postal and electronic questionnaires

Chronic obstructive pulmonary disease (COPD) is a complex condition with pulmonary and extra-pulmonary manifestations. This study describes the heterogeneity of COPD in a large and well characterised and controlled COPD cohort (ECLIPSE). We studied 2164 clinically stable COPD patients, 337 smokers with normal lung function and 245 never smokers. In these individuals, we measured clinical parameters, nutritional status, spirometry, exercise tolerance, and amount of emphysema by computed tomography. COPD patients were slightly older than controls and had more pack years of smoking than smokers with normal lung function. Co-morbidities were more prevalent in COPD patients than in controls, and occurred to the same extent irrespective of the GOLD stage. The severity of airflow limitation in COPD patients was poorly related to the degree of breathlessness, health status, presence of co-morbidity, exercise capacity and number of exacerbations reported in the year before the study. The distribution of these variables within each GOLD stage was wide. Even in subjects with severe airflow obstruction, a substantial proportion did not report symptoms, exacerbations or exercise limitation. The amount of emphysema increased with GOLD severity. The prevalence of bronchiectasis was low (4%) but also increased with GOLD stage. Some gender differences were also identified. The clinical manifestations of COPD are highly variable and the degree of airflow limitation does not capture the heterogeneity of the disease.

/pdf/characterisation-of-copd-heterogeneity-in-the-eclipse-cohort-518tf1zgph.pdf

Characterisation of COPD heterogeneity in the ECLIPSE cohort

Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update)

Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care

Objective To evaluate the effect of opt-in compared with opt-out recruitment strategies on response rate and selection bias. Design Double blind randomised controlled trial. Setting Two general practices in England. Participants 510 patients with angina. Intervention Patients were randomly allocated to an opt-in (asked to actively signal willingness to participate in research) or opt-out (contacted repeatedly unless they signalled unwillingness to participate) approach for recruitment to an observational prognostic study of patients with angina. Main outcome measures Recruitment rate and clinical characteristics of patients. Results The recruitment rate, defined by clinic attendance, was 38% (96/252) in the opt-in arm and 50% (128/258) in the opt-out arm (P = 0.014). Once an appointment had been made, non-attendance at the clinic was similar (20% opt-in arm v 17% opt-out arm; P = 0.86). Patients in the opt-in arm had fewer risk factors (44% v 60%; P = 0.053), less treatment for angina (69% v 82%; P = 0.010), and less functional impairment (9% v 20%; P = 0.023) than patients in the opt-out arm. Conclusions The opt-in approach to participant recruitment, increasingly required by ethics committees, resulted in lower response rates and a biased sample. We propose that the opt-out approach should be the default recruitment strategy for studies with low risk to participants.

https://www.bmj.com/content/bmj/331/7522/940.full.pdf

Recruiting patients to medical research: double blind randomised trial of “opt-in” versus “opt-out” strategies

### What you need to know

Covid-19 is likely to remain an important differential diagnosis for the foreseeable future in anyone presenting to hospital with a flu-like illness, lymphopenia on full blood count, and/or a change in normal sense of smell (anosmia) or taste.12

Most people with covid-19 infection do not develop pneumonia3; however, chest radiography of people who are seriously ill with respiratory symptoms when they present to hospital can help to identify those with covid-19 pneumonia.

In this article we offer advice to non-radiologists on how to look for changes on chest radiograph that may be suggestive of covid-19 pneumonia, as prompt review and report from an onsite or remote radiologist is not always available.

The recommendations in this article are based on a combination of emerging evidence, current guidelines, and our clinical experience. 

For the radiograph examples used in this article, we cannot confirm whether each patient tested positive for covid-19 because we did not have access or ethical approval to access these patients’ clinical records; however, they were all diagnosed with covid-19 pneumonia as they had supportive radiographical features during the covid-19 pandemic.

No fixed definition of covid-19 pneumonia exists; in this article the term is used when describing patients with clinical features of covid-19 infection who have either clinical or radiological evidence of pneumonia,45 or acute respiratory distress.1

Like other pneumonias, covid-19 pneumonia causes the density …

https://www.bmj.com/content/bmj/370/bmj.m2426.full.pdf

The role of chest radiography in confirming covid-19 pneumonia.

BACKGROUND: Doctors have high levels of self-treatment, investigation and referral, but little is known about how medical students seek health care. METHODS: We carried out a questionnaire survey of Year 2 and 4 students, exploring their health-seeking behaviour and attitudes to self-care. SETTING: A London medical school. RESULTS: The response rate was 80%. Nearly all students (99%) were registered with a general practitioner (GP). A total of 43% had informally consulted doctors who were friends or relatives in the previous 12 months (61% of those with a doctor as a family member had informally consulted, and 33% of those without a doctor as a family member had informally consulted; P = 0.001). In all, 13% of Year 4 students and 2.2% of Year 2 students had received a prescription from a friend (P = 0.007). Almost a quarter (22%) of Year 4 and 1.3% of Year 2 students reported having directly contacted a specialist (P = 0.01). A third (32%) (43% Year 4, 1.3% Year 2; P = 0.006) of those referred in the previous 12 months had contacted the consultant directly. In all, 9.2% (0% Year 2, 20% Year 4; P = 0.001) had initiated their own investigations, and 25% (47% Year 4, 7% Year 2; P = 0.001) had been examined by a colleague. Students agreed that it was appropriate for doctors to self-investigate (52%), self-refer (59.1%) and self-prescribe (39.2%). CONCLUSION: Medical students appear to bypass their GPs and initiate investigations, referrals or treatment. This is associated with increased clinical access or access through family members. Self-management of illness is learnt early on in students' careers and is increased with availability and increasing clinical access.

Where students go when they are ill: how medical students access health care.

Over three million people in the United Kingdom are estimated to have chronic obstructive pulmonary disease (COPD), of whom more than two million remain undiagnosed, representing the so called “missing millions” alluded to in the draft national strategy for COPD.1 2 3 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of stable chronic obstructive pulmonary disease in primary and secondary care,4 which update the COPD guidelines first published by NICE in 2004.5 The summary contains the most important recommendations relating to new diagnostic criteria for COPD, changes to the classification of severity of airflow obstruction, the need for multidimensional severity assessment, a new algorithm for inhaled drug treatments (figure⇓), and the value of early pulmonary rehabilitation.



Algorithm for use of inhaled therapies 



NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the updated recommendations are given in italic in square brackets.

### Diagnosing COPD

Melvyn Jones

Papers

Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care

Recruiting patients to medical research: double blind randomised trial of “opt-in” versus “opt-out” strategies

The role of chest radiography in confirming covid-19 pneumonia.

Where students go when they are ill: how medical students access health care.

Management of stable chronic obstructive pulmonary disease in primary and secondary care: summary of updated NICE guidance