2015 Guidelines on diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.

The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence. 

Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.

In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required. 

Full text:

http://erj.ersjournals.com/content/46/2/321.abstract?etoc

International guidelines on allergy immunotherapy 2015

Dear friends yesterday was published International guidelines on allergy immunotherapy 2015! Take a look!

Allergen immunotherapy (AIT) has been used to treat allergic disease since the early 1900s. Despite numerous clinical trials and meta-analyses proving AIT efficacious, it remains underused and is estimated to be used in less than 10% of patients with allergic rhinitis or asthma worldwide. In addition, there are large differences between regions, which are not only due to socioeconomic status. There is practically no controversy about the use of AIT in the treatment of allergic rhinitis and allergic asthma, but for atopic dermatitis or food allergy, the indications for AIT are not well defined. The elaboration of a wider consensus is of utmost importance because AIT is the only treatment that can change the course of allergic disease by preventing the development of asthma and new allergen sensitizations and by inducing allergen-specific immune tolerance. Safer and more effective AIT strategies are being continuously developed both through elaboration of new allergen preparations and adjuvants and alternate routes of administration. 

A number of guidelines, consensus documents, or both are available on both the international and national levels. The international community of allergy specialists recognizes the need to develop a comprehensive consensus report to harmonize, disseminate, and implement the best AIT practice. Consequently, the International Collaboration in Asthma, Allergy and Immunology, formed by the European Academy of Allergy and Clinical Immunology; the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma & Immunology; and the World Allergy Organization, has decided to issue an international consensus on AIT.

Free Full text: 

http://www.jacionline.org/article/S0091-6749%2815%2900775-7/fulltext?utm_content=buffera3d39&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

CHEST 2015 Guideline: Somatic Cough Syndrome (Psychogenic Cough) and Tic Cough (Habit Cough) in Adults and Children

American College of Chest Physicians (CHEST) published Guidelines on Somatic Cough Syndrome (Previously Referred to as Psychogenic Cough) and Tic Cough (Previously Referred to as Habit Cough) in Adults and Children.

Cough occurring in the absence of identified medical disease and that does not respond to medical treatment has sometimes been labeled as psychogenic cough, habit cough, or tic cough. Although these putative disorders should be differentially diagnosed from other forms of chronic cough, such as chronic refractory cough, unexplained cough, upper airway cough syndrome, vocal cord dysfunction syndrome, and cough hypersensitivity syndrome, there are currently no guidelines on how this differentiation should occur. This current guideline aims to assist the clinician when managing a patient with suspected psychogenic, habit, or tic cough.

In children with chronic cough diagnosed with somatic cough disorder (previously referred to as psychogenic cough), we suggest non-pharmacological trials of hypnosis or suggestion therapy or combinations of reassurance, counseling, or referral to a psychologist and/or psychiatrist 

Full text:

http://journal.publications.chestnet.org/article.aspx?articleID=2250092

New Global Initiative for Asthma 2015 strategy: a roadmap to asthma control

Today was published in ERJ: A summary of the new GINA strategy: a roadmap to asthma control!

Over the past 20 years, the Global Initiative for Asthma (GINA) has regularly published and annually updated a global strategy for asthma management and prevention that has formed the basis for many national guidelines. However, uptake of existing guidelines is poor. A major revision of the GINA report was published in 2014, and updated in 2015, reflecting an evolving understanding of heterogeneous airways disease, a broader evidence base, increasing interest in targeted treatment, and evidence about effective implementation approaches. During development of the report, the clinical utility of recommendations and strategies for their practical implementation were considered in parallel with the scientific evidence. 

This article provides a summary of key changes in the GINA report, and their rationale. The changes include a revised asthma definition; tools for assessing symptom control and risk factors for adverse outcomes; expanded indications for inhaled corticosteroid therapy; a framework for targeted treatment based on phenotype, modifiable risk factors, patient preference, and practical issues; optimisation of medication effectiveness by addressing inhaler technique and adherence; revised recommendations about written asthma action plans; diagnosis and initial treatment of the asthma−chronic obstructive pulmonary disease overlap syndrome; diagnosis in wheezing pre-school children; and updated strategies for adaptation and implementation of GINA recommendations. 

Full text of the article:

http://erj.ersjournals.com/content/early/2015/07/23/13993003.00853-2015.full

8th International Primary Care Respiratory Group World Conference in Amsterdam, 25 - 28 May 2016

We are happy to welcome you to 8th International Primary Care Respiratory Group World Conference in Amsterdam, 25 - 28 May 2016!

The Scientific Meeting is suitable for anyone wishing to know more about research in real life, community and general practice/family medicine settings on these themes.  You do not need to be a respiratory expert.  Come and join them! 

Clinicians and researchers from all over the world choose to attend the IPCRG's scientific meetings because they:

• Get plenty of opportunity to network with colleagues from other places and meet research collaborators and lifelong friends
  
• Connect with like-minded colleagues interested in research about how to diagnose and manage people in the community with chronic diseases such as tobacco dependence, asthma, COPD, allergy and comorbidities 
  
• Learn about research methods pertinent to their own experience and needs
  
• Exchange information about challenges in, and solutions to, real life research including the use of routine primary care data
  
• Share values about family medicine and its holistic approach
  
• Debate the challenges of adapting healthcare systems to cope with communicable and non-communicable disease.

COPD 2015 Guidelines: The 2015 update of the Global Initiative for Chronic Obstructive Lung Disease

In 2011, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD. It recommended a major revision in the management strategy for COPD that was presented in the original 2001 document. Updated reports released in January 2013, January 2014, and January 2015 are based on scientific literature published since the completion of the 2011 document but maintain the same treatment paradigm. Assessment of COPD is based on the patient’s level of symptoms, future risk of exacerbations, the severity of the spirometric abnormality, and the identification of comorbidities. The 2015 update adds an Appendix on Asthma COPD Overlap Syndrome, material prepared jointly by the GOLD and GINA Science Committees.

 

The GOLD 2015 report is presented as a “strategy document” for health care professionals to use as a tool to implement effective management programs based on available health care systems. The quadrant management strategy tool is designed to be used in any clinical setting; it draws together a measure of the impact of the patient’s symptoms and an assessment of the patient’s risk of having a serious adverse health event in the future. Many studies have assessed the utility/relevance of this new tool. Evidence will continue to be evaluated by the GOLD committees and management strategy recommendations modified as required.

GOLD has been fortunate to have a network of international distinguished health professionals from multiple disciplines. Many of these experts have initiated investigations of the causes and prevalence of COPD in their countries, and have developed innovative approaches for the dissemination and implementation of the GOLD management strategy. The GOLD initiative will continue to work with National Leaders and other interested health care professionals to bring COPD to the attention of governments, public health officials, health care workers, and the general public to raise awareness of the burden of COPD and to develop programs for early detection, prevention and approaches to management.

The GOLD 2015 report: direct link

www.goldcopd.org/uploads/users/files/GOLD_Report_2015_Apr2.pdf

Millions of smokers have undiagnosed COPD

More than half of smokers with normal spirometry had some form of respiratory-related impairment associated with COPD, Dr. Elizabeth A. Regan and the Genetic Epidemiology of COPD (COPDGene) investigators reported in JAMA Internal Medicine.

The findings imply that up to 35 million current and former smokers older than age 55 years in the United States may have some form of respiratory-related impairment associated with COPD that has gone undiagnosed with standard spirometry, the researchers wrote (JAMA Internal Med. 2015 June 22 (doi:10.1001/jamainternmed.2015.2735). 

They found that 55% of current and former smokers older than age 55 years in the study who did not meet the spirometric criteria for COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] 0 score) had significant respiratory disease. Their conclusion was based on seven metrics: chronic bronchitis (seen in 12.6% of the GOLD 0 participants), history of severe respiratory exacerbations (seen in 4.3%), dyspnea score of at least 2 (seen in 23.5%), quantitative emphysema exceeding 5% (seen in 9.8%), quantitative gas trapping exceeding 20%, (seen in 12.2%), St. George’s Respiratory Questionnaire (SGRQ) total score exceeding 25 (seen in 26%), and a 6-minute walk distance of less than 350 m (seen in 15.4%).

In 108 never smokers, none had chronic bronchitis or respiratory exacerbations, 3.7% had dyspnea, 8.3% had quantitative emphysema exceeding 5%, 10.2% had quantitative gas trapping exceeding 20%, 3.7% had SGRQ scores above 25, and 3.7% had a 6-minute walk distance of less than 350 m.

Dr. Regan of National Jewish Health and the University of Colorado, Denver, and her associates gathered data from 21 sites across the United States regarding 8,872 current or former smokers who were between the ages of 45 and 80 years and were classified using GOLD spirometric criteria based on postbronchodilator spirometry: 4,388 had a GOLD 0 score, defined as a normal postbronchodilator ratio of FEV₁ to forced vital capacity exceeding 0.7 and an FEV₁ percentage of at least 80% predicted; 794 patients had a GOLD 1 score, defined as mild COPD; and 3,690 had a GOLD 2-4 score, defined as moderate to severe COPD.

Compared with 108 never smokers, the GOLD 0 group had a worse quality of life score (mean SGRQ total score 17.6 for GOLD 0 and 7 for never smokers) and a lower 6-minute walk distance (447 m vs. 493 m). In a subset of 300 patients in the GOLD 0 group whose CT scans were visually scored, 42% (127) had evidence of emphysema or airway thickening. In a subset of 100 never smokers, 10% had evidence of emphysema or airway thickening.

Current guidelines do not include treating smokers with normal spirometry, but physicians recognize the role of medication in treating symptoms and effective treatments need to be determined for GOLD 0 patients, the researchers said. Respiratory medications were being prescribed to 20% of the GOLD 0 participants in COPDGene who had at least one impairment, yet these patients reported more symptoms.

7th Edition of British-Romanian Meetings: Respiratory Medicine Protocols #Vama2015

We are inviting you to the 7th Edition of British-Romanian Meetings: Respiratory Medicine Protocols, organized by our friend doctor Tudor Toma. His message to you: 

Va invitam sa va inscrieti pentru intalnirea de la Vama din acest an, intalnire care va avea loc in perioada 22- 24 octombrie, 2015. Locurile sunt limitate la maxim 60 de participanti. Pentru inscriere folositi pagina de aici sau trimiteti un email de intentie la d-na Lavinia Bodislav (lavinia@rotravelplus.com)

Programul din acest an va fi axat pe ateliere practice si va beneficia de participarea unor lideri de opinie din Romania si Marea Britanie.

Lectori confirmati pentru 22-24 octombrie 2015:
Dr. Neel Sharma, Consultant Respiratory Physician, East Sussex Healthcare.
Dr. Saroj David, Consultant Radiologist, Lewisham & Greenwich NHS Trust, Londra.
Dr. Anastasia Rachmanidou, Consultant ENT Surgeon, Lewisham & Greenwich NHS Trust, Londra.
Dr. Irina Strambu, Bucuresti.
Dr. Andrew Hearn, Respiratory Registrar, Lewisham & Greenwich NHS Trust, Londra.
Dr. Helen Garthwaite, Respiratory Registrar, Royal Free London NHS Foundation, Londra.
Dr. Cynthia Borg, Consultant General and Bariatric Surgery, Lewisham & Greenwich NHS Trust, Londra.

Majoritatea continutului intalnirii si informatii suplimentare vor fi pe retelele de socializare, asadar urmariti pe Twitter @Vama_Workshop informatiile in timp real despre pregatirea acestui simpozion.

Va multumim pentru participare si va asteptam cu drag la #Vama2015. 

Doctor Tudor Toma 

2015 guidelines for the treatment of idiopathic pulmonary fibrosis released by leading respiratory societies

Updated guidelines on the treatment of idiopathic pulmonary fibrosis (IPF) have been released by an international group of leading respiratory societies, The new guidelines, issued by the American Thoracic Society, the European Respiratory Society, the Japanese Respiratory Society, and the Latin American Thoracic Association, were published in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.

"In these updated guidelines, we analyzed new evidence reported since our 2011 guideline was issued and updated our treatment recommendations accordingly," said Ganesh Raghu, MD, Professor of Medicine, University of Washington, director of the Center for Interstitial Lung Disease, UW Medicine at the University of Washington Medical Center, and chair of the committee that produced the guidelines. "The updated guidelines do not recommend one treatment regimen over another. All of these recommendations must be weighed individually, considering all the factors used to grade each one, including the confidence in effect estimates, evidence from outcomes studies, desirable and undesirable consequences of treatment, treatment costs, the implications of treatment on health equity, and the feasibility of treatment," Raghu added.

Evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, with recommendations rated as either "strong" or "conditional." Conditional recommendations are synonymous with weak recommendations.

The following recommendations are new or revised from the 2011 guidelines:

• The recommendation against the use of the following agents for the treatment of IPF is strong:
  • Anticoagulation (warfarin)
  • Imatinib, a selective tyrosine kinase inhibitor against platelet-derived growth factor (PDGF) receptors
  • Combination prednisone, azathioprine, and N-acetylcysteine
  • Selective endothelin receptor antagonist (ambrisentan)
• The recommendation for the use of the following agents for the treatment of IPF is conditional:
  • Nintedanib, a tyrosine kinase inhibitor that targets multiple tyrosine kinases, including vascular endothelial growth factor, fibroblast growth factor, and PDGF receptors
  • Pirfenidone
• The recommendation against the use of the following agents for the treatment of IPF is conditional:
  • Phosphodiesterase-5 inhibitor (sildenafil)
  • Dual endothelin receptor antagonists (macitentan, bosentan)

Recommendations remaining unchanged from the 2011 guidelines include a conditional recommendation against the use of N-acetylcysteine monotherapy for IPF and a conditional recommendation for the use of antiacid therapy.

"Our systematic review of the available evidence on IPF treatments points to the need for additional research and long-term studies of their safety and efficacy," said Dr. Raghu. "This is especially true for treatments that received conditional recommendations in the guidelines. The guidelines empower the clinician to make the most appropriate treatment choices for the patient confronted with IPF and encourage shared decision-making with the well informed patient to choose the most appropriate treatment options tailored to the individual patient's needs," emphasized Raghu.

WHO Report on the global tobacco epidemic 2015

Too few governments levy appropriate levels of tax on cigarettes and other tobacco products. They therefore miss out on a proven, low-cost measure to curb demand for tobacco, save lives and generate funds for stronger health services, according to the "WHO Report on the global tobacco epidemic 2015".

 

The report focuses on raising taxes on tobacco. Although 33 countries impose taxes that represent more than 75% of the retail price of a packet of cigarettes, many countries have extremely low tax rates. Some have no special tax on tobacco products at all.

“Raising taxes on tobacco products is one of the most effective – and cost-effective – ways to reduce consumption of products that kill, while also generating substantial revenue,” says Dr Margaret Chan, WHO Director-General. “I encourage all governments to look at the evidence, not the industry’s arguments, and adopt one of the best win-win policy options available for health.”

Strategies to support the implementation of demand reduction measures contained within the WHO Framework Convention on Tobacco Control (WHO FCTC), such as the “MPOWER” package, have helped save millions of lives in the past decade. MPOWER was established in 2008 to promote government action on 6 tobacco control strategies – 1 for each letter of the MPOWER acronym – to stamp out the tobacco epidemic, namely to:

• Monitor tobacco use and prevention policies;
• Protect people from tobacco smoke;
• Offer help to quit tobacco use;
• Warn people about the dangers of tobacco;
• Enforce bans on tobacco advertising, promotion and sponsorship; and
• Raise taxes on tobacco.

The main findings of the report, funded by Bloomberg Philanthropies, include the fact that raising taxes is the least implemented MPOWER measure in terms of population coverage, and the one that has seen the least improvement in terms of government action since 2008. However, by 2014, 11 countries had raised taxes so that they represent more than 75% of the retail price of a packet of cigarettes, joining the 22 countries that had similarly high taxes in place in 2008.

Dr Douglas Bettcher, Director of WHO’s Department for the Prevention of Noncommunicable Diseases (NCDs), says higher tobacco taxes and prices are proven methods to reduce consumption and promote quitting the use of tobacco products.

“Evidence from countries such as China and France shows that higher tobacco product prices linked to increased taxes lead to declines in smoking prevalence and tobacco-related harm, such as lung cancer deaths,” says Dr Bettcher.

Dr Vera da Costa e Silva, Head of the WHO FCTC Secretariat, notes that the Convention offers governments policies to curb illicit trade in tobacco products to reduce demand and boost tax revenues from tobacco sales. “Countries should consider implementing the provisions of the Protocol to Eliminate Illicit Trade in Tobacco Products to confront the illegal market,” she adds.

Tobacco taxation could also be a key source of funding for implementing the post-2015 Sustainable Development Goals.

Tobacco-related illness is one of the biggest public health threats the world has ever faced. Approximately 1 person dies from a tobacco-related disease every 6 seconds, equivalent to around 6 million people a year. That is forecast to rise to more than 8 million people a year by 2030, unless strong measures are taken to control the epidemic.

Tobacco use is also one of the 4 main risk factors behind the global epidemic of noncommunicable diseases, primarily cancers, cardiovascular and lung diseases, and diabetes. In 2012, these diseases killed 16 million people prematurely (before the age of 70 years), with more than 80% occurring in low- and middle-income countries.

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Venture capital-backed healthcare startups are addressing diseases and conditions affecting virtually every part of the human body.