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.

Global strategy for asthma management and prevention

Prospective Cohort Study

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary.

Background
Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty.

Objectives
To assess the effects of decision aids for people facing treatment or screening decisions.

Search methods
For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008).

Selection criteria
We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions.

Data collection and analysis
Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:

A) 'choice made' attributes;

B) 'decision-making process' attributes.

Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model.

Main results
This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.

Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).

A) Criteria involving 'choice made' attributes:

Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).

B) Criteria involving 'decision-making process' attributes:

Decision aids compared to usual care interventions resulted in:

a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);

b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); and

c) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).

Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.

C) Secondary outcomes

Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.

The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

Authors' conclusions
There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.

New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.

/pdf/decision-aids-for-people-facing-health-treatment-or-1j1706q17l.pdf

Decision aids for people facing health treatment or screening decisions

/pdf/phenotyping-asthma-and-copd-2i6cq8p1cf.pdf

Phenotyping Asthma and COPD

Low 25-hydroxyvitamin D (25(OH)D) levels are common in pregnancy and associated with adverse maternal/neonatal outcomes. In pregnant women with asthma, this study examined the association of lifestyle- and asthma-related factors on 25(OH)D levels and maternal/neonatal outcomes by vitamin D status. Serum 25(OH)D was measured at 16 and 35 weeks gestation in women with asthma (n = 103). Body mass index (BMI), gestational weight gain (GWG), smoking status, inhaled corticosteroid (ICS) use, asthma control, airway inflammation, and exacerbations, and maternal/neonatal outcomes were collected. Baseline and change (Δ) in 25(OH)D were modelled separately using backward stepwise regression, adjusted for season and ethnicity. Maternal/neonatal outcomes were compared between low (25(OH)D 0.2). Preeclampsia was more common in the low (8.6%) vs. high (0%) vitamin D group (p < 0.05). Obesity and excess GWG may be associated with gestational 25(OH)D levels, highlighting the importance of antenatal weight management.

https://www.mdpi.com/2072-6643/12/10/2978/pdf

Serum 25 Hydroxyvitamin D Levels During Pregnancy in Women with Asthma: Associations with Maternal Characteristics and Adverse Maternal and Neonatal Outcomes.

Macrolides have a macrocyclic lactone ring, whose size and features have been modified from the 14 carbon structure of erythromycin in order to develop newer agents such as azithromycin (AZM). They were originally derived from products the microbial order Actinomycetales (Saccharopolyspora erythrae , formerly Streptomyces erythrae ), and are yet another respiratory harvest from the organism that have given us many antibiotics, starting with the important antituberculosis drug, streptomycin. Macrolides are widely used as antibiotics, and now form part of guideline-recommended therapy in community-acquired pneumonia. They have an expanding role in the therapy of chronic inflammatory diseases based on their additional anti-inflammatory and immunosuppressive properties. Further development has produced broad-spectrum antibacterials, such as AZM, with a longer half-life, and minimal inhibition of cytochrome CYP3A4 and, hence, fewer drug interactions. Other developments in this class include tacrolimus and its derivatives that target macrophyllin-12 (FK506 binding protein) and are potent immunosuppressive agents.

The classical airway disease that responds to long-term low-dose macrolide therapy is diffuse panbronchiolitis in Asian populations.1 The pathological lesion is centred around the bronchioles and involves intense chronic inflammation, typically neutrophilic, leading to mucus hypersecretion, progressive loss of lung function, bacterial airway infection, and often death. Building on this paradigm, macrolides have been found to be effective in other airway …

https://thorax.bmj.com/content/thoraxjnl/68/4/313.full.pdf

Macrolides for yet another chronic airway disease: severe asthma?

Objective: Asthma is common in Australian children, with a prevalence of 30%. Airway inflammation is an important determinant of asthma symptoms. Chemotherapy used for the treatment of many childhood cancers suppresses inflammation. The prevalence of asthma symptoms in children treated with chemotherapy is unknown.



Methodology: We therefore performed a survey of symptoms of asthma in children attending the oncology clinic at John Hunter Children’s Hospital during the first 6 months of 1996.



Results: Fifty children aged 1–17 years were surveyed. Thirty-two of the children were in remission and had completed treatment with chemotherapy and 18 were currently undergoing treatment with chemotherapy. There was no significant difference in the prevalence of asthma in children before, during and after chemotherapy (26%, 22% and 34%), or in the prevalence of asthma in their siblings (28%). No child was classified as having persistent asthma while on chemotherapy and there was a significant reduction in the requirement for preventive asthma drugs 12% versus 0% (P = 0.03) being reported during chemotherapy.



Conclusion: The prevalence of asthma in children who develop cancer is similar to their siblings and the same as the population as a whole. While asthma symptoms do not disappear completely during chemotherapy, the severity of asthma symptoms is less, with no need for asthma preventive treatment. The immunosuppressive side effects of the chemotherapy used in the treatment of childhood cancer appear to induce a remission in asthma symptoms. The ongoing requirement for bronchodilator therapy in patients whilst on chemotherapy suggests airway hyperreactivity persists in children while they are on chemotherapy. Prospective study of the airways of this group of patients promises to provide insights into the relationships between airway hyperreactivity, airway inflammation and asthma.

Chemotherapy reduces the prevalence of asthma symptoms in children with cancer: implications for the role of airway inflammation in asthma

The review by Brusasco et al 1 demonstrates that a simple causal hypothesis is insufficient to explain airway hyperresponsiveness in asthma. We have also refuted this hypothesis by identifying that airway eosinophilia can occur without airway hyperresponsiveness,2 and that in asthma airway hyperresponsiveness can persist despite suppresssion of airway inflammation and pancytopenia induced by chemotherapy.3 However, airway inflammation and airway hyperresponsiveness are so intrinsically linked in asthma that an alternative hypothesis must be provided.

My hypothesis is that airway inflammation can modulate the level of intrinsic airway responsiveness such that an increase in airway inflammation from, for example, allergen exposure will lead to an increase in airway responsiveness, and a decrease in airway inflammation from, for example, corticosteroid therapy will lead to a reduction in airway responsiveness. The absolute level of airway responsiveness, and hence whether it is categorised as normal or increased, will depend upon two …

https://thorax.bmj.com/content/thoraxjnl/54/7/655.4.full.pdf

Peter G. Gibson

Papers

Phenotyping Asthma and COPD

Serum 25 Hydroxyvitamin D Levels During Pregnancy in Women with Asthma: Associations with Maternal Characteristics and Adverse Maternal and Neonatal Outcomes.

Macrolides for yet another chronic airway disease: severe asthma?

Chemotherapy reduces the prevalence of asthma symptoms in children with cancer: implications for the role of airway inflammation in asthma

Airway hyperresponsiveness in asthma