Asthma Control Tests

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Prim Care Respir J 2012; 21(2): 121-134
EDITORIALS
An Impact factor and beyond

Aziz Sheikh, Paul Stephenson
Editors-in-Chief, PCRJ
Correspondence: c/o PCRJ Editorial Office, Smithy House, Waterbeck, Lockerbie, DG11 3EY, UK Tel: +44 (0)1464 600639 E-mails: aziz.sheikh@ed.ac.uk paul.stephenson@gp-d83012.nhs.uk
A = the number of times articles published in the PCRJ in 2010 and 2011 were cited by Thomson Reuters ISI-indexed journals during 2012. B = the total number of "citable items" published by the PCRJ in 2010 and 2011. ("Citable items" are usually research articles and reviews, not editorials, correspondence or educational articles.) The PCRJ 2012 Impact factor = A/B. For example, an Impact factor of 2.0 (which is considered fairly respectable) means that papers published in 2010 and 2011 received on average two citations each in Thomson Reuters ISI-listed journals in 2012. For the PCRJ, this strategic milestone helps to mark our continuing ascent4 and now firmly establishes us within the top-tier of medical journals internationally. We received a 33% increase in paper submissions between 2010 and 2011, and we suspect that the PCRJ will now increasingly be seen as a first-choice journal when authors are considering where to submit their work. PCRJ submissions are not just from primary care researchers but also from secondary care specialists and others who are undertaking applied research of direct relevance to primary care populations, so we can probably expect this increase in submissions to continue year-onyear. In preparation for this, we will shortly be advertising for additional Associate Editors to ensure we continue to maintain our reputation for offering world-class, rapid peer-review of paper submissions. We understand well the pressures that academics are under to publish in high impact journals, and whilst acknowledging the dangers of over-interpreting a simple metric we are confident that the PCRJ will increasingly be regarded by universities across the world as a top-tier journal. Although our first Impact factor will likely start at a relatively low level in this Ivy League of journals, (it is unusual for a journal to obtain an Impact factor > 1.0 in its first year) the PCRJ is now one of only a dozen or so primary care journals included in Thomson Reuters Web-of-Science and, as far as we are aware, is the only sub-specialty primary care journal to be awarded such recognition. Inevitably, this will mean that it becomes even more competitive to get published in the PCRJ. However, our rapid turnaround times particularly in relation to a first decision should (we hope) encourage authors to continue to send material for consideration, particularly if this is methodologically robust science tackling questions of real concern to front-line primary care clinicians and policymakers. For readers, we remain absolutely committed to publishing high quality research and related expert commentary, correspondence
Whats your journals Impact factor? must rank amongst the commonest questions asked of journal editors, and our experience is no different. Although we still cant quite answer this question, we are delighted to report that Thomson Reuters ISI has recently selected the PCRJ for inclusion in its Web-ofScience citation index listing and that the Journal has been awarded an Impact factor. The PCRJs first Impact factor will appear in the 2012 Journal Citation Reports (JCR) data which will be released in mid-2013 so its not too long to wait now before we can indeed provide an answer However, discussions about Impact factors do tend to baffle some and polarise others.1 It is therefore important that we clarify what this means and (more importantly) offer some thoughts as to what this important juncture means for the Journal, our contributors and, above all, our global readership. Thomson Reuters Web-of-Science covers nearly 12,000 of the worlds most important and influential journals in every area of the natural sciences, social sciences, and arts and humanities.2 Each year the Thomson Reuters editors review over 2,000 journal titles and select around 10-12% of those journals which have been evaluated for inclusion in the Thomson Reuters database. Once awarded this coveted status, journals are constantly kept under review to ensure they are maintaining the highest editorial and publication standards, an internationally diverse authorship, and are continuing to publish relevant articles which are considered scientifically important and are consequently being cited. The Impact factor was devised by Eugene Garfield, the founder of the Institute for Scientific Information (ISI now part of Thomson Reuters) as a way of quantifying the citation process.3 It is frequently used as a proxy for the relative importance of a journal within its field. Impact factors are calculated yearly for those journals included in the Thomson Reuters JCR data, and show the average number of citations received in that year for each article published during the two preceding years. Our 2012 Impact factor will therefore be calculated as follows:
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and debate, which represents the breadth of respiratory and respiratory-related allergy seen by primary care practitioners globally. Being awarded an Impact factor does help in this respect, but we are keen to take things further. In particular, we want to use social media to aid readers in interpreting study findings by bringing them into closer contact with authors and facilitating virtual, global discussions about various PCRJ papers and what they mean. We will have more to say on this at the turn of the year, but in the meantime we are delighted to note that this issue marks the launch of the new education@pcrj section of the Journal. In the very capable hands of section editors Hilary Pinnock and Jaime Correia de Sousa, this new education section is a formal manifestation of the second of the PCRJs two aims,4 which we are sure will make an enormous contribution to bridging the gap between research and clinical practice. They present their plans for the future in their editorial on pg 133.5 We are very grateful to the PCRS-UK and the IPCRG, and the many organisations, institutions and individuals across the globe that have been fundamental in helping us achieve this important strategic goal. In particular, we thank all of our Assistant and Associate Editors and the members of the International Editorial Board for their support and expertise, and we again pay tribute to Mark Levy, Editor Emeritus, for his 15-year service as Editor-in-Chief and the legacy which he left.
The decision by Thomson-Reuters ISI to award the PCRJ an Impact factor is both timely and welcome. It now positions us to take a lead in advancing the frontiers of knowledge through publishing the very best research, discussion and debate on behalf of patients with respiratory problems worldwide. For a journal of record such as the PCRJ, this is the outcome that really matters Conflicts of interest
relation to this article. 17th May 2012; online 29th May 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00047 Prim Care Respir J 2012;21(2):121-2 The authors declare no relevant conflicts of interest in
References
1. Levy ML, on behalf of the editors of the Primary Care Respiratory Journal. Impact factor and its role in academic promotion. Prim Care Respir J 2009;13(3):127. http://dx.doi.org/10.4104/pcrj.2009.00051 2. 3. 4. Testa J. The Thomson Reuters Journal Selection Process (essay). http://thomsonreuters.com/products_services/science/free/essays/journal_selection_process/ Garfield E. Citation indexing its theory and application in science, technology, and humanities. New York: John Wiley & Sons, 1979 Stephenson P, Sheikh A. A tribute to the past, and plans for the future: helping to drive top quality primary care respiratory disease management worldwide. Prim Care Respir J 2011;20(1):1-3. http://dx.doi.org/10.4104/pcrj.2011.00013 5. Pinnock H, Correia de Sousa J. education@pcrj: the launch of a new initiative for the PCRJ. Prim Care Respir J 2011;21(2):133-4. http://dx.doi.org/10.4104/pcrj.2012.00048
A question of quality? A single questionnaire for measuring asthma control, structuring asthma reviews, and monitoring health service standards
See linked article by Kiotseridis et al. on pg 139
*Hilary Pinnocka, Helen Lesterb

a
Senior Clinical Research Fellow, Allergy and Respiratory Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK Professor of Primary Care, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
*Correspondence: Dr Hilary Pinnock, Allergy and Respiratory Research Group, Centre for Population Health Sciences The University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK Tel: +44 (0)131 650 8102 Fax: +44 (0)131 650 9119 E-mail: hilary.pinnock@ed.ac.uk The paper describing the Active Life with Asthma (ALMA) questionnaire by Kiotseridis et al.1 in this issue of the Primary Care Respiratory Journal raises as many questions as it answers. The technical issue addressed in the paper about the validity of a subset of questions as an assessment of asthma control is arguably the simplest of the questions to answer. Derived appropriately from qualitative investigation, the 14 questions
designed to measure control compared well with the gold standard Asthma Control Questionnaire (ACQ).2 The more interesting questions, however, have yet to be addressed: a) How do questionnaires fit into the well defined structure of a primary care consultation? Experience in UK primary care where use of the Patient Health Questionnaire-9 (PHQ-9) was introduced as a measure of the severity of depression in the Quality and Outcomes Framework (QOF)3 in 2006 is not entirely encouraging. Although patients were relatively positive and considered that completing questionnaires made them feel as if they were being taken more seriously,4 general practitioners (GPs) thought that asking patients to complete a questionnaire was intrusive, interrupted the flow of the consultation, and added little to their clinical judgement.5 However, the International Primary Care Respiratory Group (IPCRG) in their recent prioritisation of research needs, identified the development of questionnaires (or just questions) as an important means of diagnosing and assessing respiratory conditions in the comparatively low-technology context of primary care.6 Objective assessment of control is a core component of asthma reviews which underpins management decisions.7 The ALMA tool offers some validated morbidity questions, though how the questions can best be incorporated into an asthma consultation may be a practical concern for some clinicians.
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b) Will questionnaires be completed properly in clinical practice? The science underpinning the development of Patient Reported Outcome Measures (PROMs) emphasises the importance not only of the precise wording of questions but also of context and mode of delivery in ensuring that the instrument measures consistently what it is intended to measure.8 Instruments such as the ACQ are validated by self-selected volunteer patients completing questionnaires under the supervision of trained researchers, and new modes of administration are carefully assessed to ensure that they do not compromise response rates or validity.9,10 Developers of questionnaires have long expressed the hope that their instrument will have clinical applicability,11 but in clinical practice such careful standardisation is unlikely, with clinicians adopting a range of practical strategies to overcome the challenges of time, language, poor literacy and perceived disruption of consultation. Experience with the PHQ-9 in the context of the QOF identified seven such strategies,12 (including incorporating paraphrased questions into the conversation and calculating a score after the consultation), thus completely negating validation. Although the questions used in the validation exercise reported by Kiotseridis et al. were obtained by selfcompletion of a (5-minute) paper questionnaire, the real-life ALMA database is a (presumably clinician-completed) web-based application which immediately changes the dynamics of completion. c) What impact does a template have on an asthma review? The ALMA database, however, is more than another PROM assessing asthma control: it is a tool intended to structure asthma reviews. Structured asthma care, including assessment of control, has been shown to improve patient outcomes for example, in the Australian 3+ visit plan.13 Templates may be welcomed as a means of improving clinicians adherence to protocols,14 though they have led to concerns about imposing a routine that potentially excludes the patients agenda.15 Completing checklists may encourage the recording of negative findings that have not been explicitly elicited.16 The authors should consider recording asthma reviews or undertaking qualitative research to explore how the ALMA tool is applied, the impact it has on the process of the consultation, and crucially, whether identification of poor control triggers appropriate stepping up of treatment and improved outcomes for patients. d) How might healthcare systems benefit? There is a final question for the ALMA tool: can the questionnaire raise standards of care across a healthcare community? Routine use and the development of a database offers the opportunity to observe standards of practice and then to benchmark good practice as a first step to driving up quality of care. Although morbidity scores have been widely used to assess asthma control as part of initiatives to improve care across healthcare communities for example in Finland17 and the USA18 the data are generally collected by self-completed questionnaire as part of the evaluation of an initiative and thus do not reflect the real-life assessment of control using routinely collected data. The IPCRG Helping Asthma in Real Patients (HARP) study piloted in Ireland19 and now rolled out to the UK, Germany, France, Italy, Spain, Sweden, Norway and Australia uses some routinely collected data extracted from practice computer systems, but overcomes the lack of coded symptoms by sending questionnaires to people with
asthma to assess morbidity. By establishing a database of asthma assessments undertaken within the local healthcare community, the ALMA project has an important opportunity to monitor patient-related outcomes and the impact of initiatives on standards of care. An explicit focus on quality improvement is a key aim of the UK QOF.20 When 20% of practice income is attached to pay for performance indicators, motivation to achieve maximum points is high (UK practices achieved 98.7% of available asthma QOF points in 2010/1121). It will be interesting to compare the results of the voluntary ALMA scheme with the standards achieved in the financially-rewarded QOF. A question of quality The initiative described by Kiotseridis et al. provides an answer to one question: asthma control recorded by the ALMA questionnaire compares well to the gold standard ACQ. Time and further research will tell whether by structuring assessment of control it is possible to improve the quality of care provided to individual patients and also, by routinely monitoring structured asthma reviews, raise the quality of asthma care within a healthcare community. The question is one of quality. Conflicts of interest HP is an Associate Editor of the PCRJ, but was not involved in the editorial review of, nor the decision to publish, this article. HL works as the external contractor for NICE developing and piloting QOF indicators: her views are her own and do not represent those of NICE. Funding HP is supported by a Primary Care Research Career Award from the Chief Scientists Office, Scottish Government
Commissioned article; not externally peer-reviewed; accepted 31st January 2012; online 23rd March 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00030 Prim Care Respir J 2012;21(2):122-4
References
1. Kiotseridis H, Bjermer L, Pilman E, et al. ALMA, a new tool for the management of asthma patients in clinical practice: development, validation and initial clinical findings. Prim Care Respir J 2012;21(2):139-44. http://dx.doi.org/10.4104/ pcrj.2011.00091 2. Juniper EF, Svensson K, Mork AC, Stahl E. Measurement properties and interpretation of three shortened versions of the asthma control questionnaire. Respir Med 2005;99:553-8. http://dx.doi.org/10.1016/j.rmed.2004.10.008 3. 4. NHS Confederation, British Medical Association. New GMS Contract 2003: investing in general practice. London. March 2003 Leydon GM, Dowrick CF, McBride AS, et al. on behalf of the QOF Depression Study Team. Questionnaire severity measures for depression: a threat to the doctorpatient relationship? Br J Gen Pract 2011;61:117-23. http://dx.doi.org/ 10.3399/bjgp11X556236 5. Dowrick C, Leydon GM, McBride A, et al. Patients and doctors views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study. BMJ 2009;338:b663. http://dx.doi.org/10.1136/ bmj.b663 6. Pinnock H, Ostrem A, Romn Rodrguez M et al. (IPCRG) 7. e-Delphi exercise. Prim Care Prioritising the respiratory J 2012;21(1):19-27. research needs of primary care: the International Primary Care Respiratory Group Respir http://dx.doi.org/10.4104/pcrj.2012.00006 Pinnock H, Fletcher M, Holmes S, et al. Setting the standard for routine asthma consultations: a discussion of the aims, process and outcomes of reviewing people with asthma in primary care. Prim Care Respir J 2010;19:75-83. http://dx.doi.org/10.4104/pcrj.2010.00006
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8. 9. Fitzpatrick R, Davey C, Buxton MJ, Jones DR. Evaluating patient-based outcome measures for use in clinical trials. Health Technology Assessment 1998;2(14):1-74. Pinnock H, Sheikh A, Juniper E. Evaluation of an intervention to improve successful completion of the Mini-AQLQ: comparison of postal and supervised completion. Prim Care Respir J 2004;13:36-41. http://dx.doi.org/10.1016/j.pcrj.2003.11.004 10. Pinnock H, Sheikh A, Juniper E. Concordance between supervised and postal administration of the MiniAQLQ and ACQ is very high. J Clin Epidemiol 2005;58:809-14. http://dx.doi.org/10.1016/j.jclinepi.2005.01.010 11. Juniper EF, Bousquet J, Abetz L, Bateman ED. Identifying well-controlled and not well-controlled asthma using the Asthma Control Questionnaire. Respir Med 2006;100:616-21. http://dx.doi.org/10.1016/j.rmed.2005.08.012 12. Mitchell C, Dwyer R, Hagan T, Mathers N. Impact of the QOF and the NICE guideline in the diagnosis and management of depression: a qualitative study. Br J Gen Pract 2011;61:343-4. http://dx.doi.org/10.3399/bjgp11X572472 13. Glasgow NJ, Ponsonby A-L, Yates R, Beilby J, Dugdale P. Proactive asthma care in childhood: general practice based randomised controlled trial. BMJ 2003;327:65965. http://dx.doi.org/10.1136/bmj.327.7416.659 14. Ventres W, Kooienga S, Vuckovic N, Marlin R, Nygren P, Stewart V. Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis. Ann Fam Med 2006;4:124-1. http://dx.doi.org/10.1370/afm.425 15. Rhodes P, Langdon M, Rowley E, Wright J, Small N. What Does the Use of a Computerized Checklist Mean for Patient-Centered Care? http://dx.doi.org/10.1177/1049732305282396 16. Brownbridge G, Evans A, Fitter M, Platts M. An interactive computerized protocol for the management of hypertension: effects on the general practitioner's clinical behaviour. J Royal Coll Gen Practitioners 1986;36:198-202. 17. Haahtela T, Klaukka T, Koskela K, et al. Asthma programme in Finland: a community problem needs community solutions. Thorax 2001;56:806-14. http://dx.doi.org/10.1136/thorax.56.10.806 18. Vollmer WM, Markson LE, OConnor E, Frazier EA, Berger M, Buist AS. Association of Asthma Control with Health Care Utilization: A Prospective Evaluation. Am J Respir Crit Care Med 2002;165:195-9. 19. Sims EJ, for the HARP study group. Helping Asthma in Real Patients (The HARP study): Interim Report for the IPCRG. Available from http://www.theipcrg.org/resneeds/harp.php (accessed January 2012) 20. Department of Health. Equity and Excellence: Liberating the NHS. London: Department of Health, 2010 (Cm 7881) 21. The Information Centre. Quality and Outcomes Framework Achievement Data 2010/11. Available from http://www.ic.nhs.uk (accessed 8.1.12) The Example of a Routine Diabetes Review. Qualitative Health Research 2006;16:353-76.
Perceptions of risk may explain the discrepancy between patient and clinician-recorded symptoms
See linked article by Barbara et al. on pg 145
Ian Dawsona, Victoria Seniorb, *Simon de Lusignanc

a
Lecturer in Human Resource Management & Organisational Behaviour, The Surrey Business School, University of Surrey, UK Senior Lecturer in Health Psychology, School of Psychology, University of Surrey, UK Professor of Primary Care and Clinical Informatics, Department of Health Care Management and Policy, University of Surrey, UK
*Correspondence: Professor Simon de Lusignan, Professor of Primary Care and Clinical Informatics, Department of Health Care Management and Policy, University of Surrey, Guildford, GU2 7PX, UK Tel: +44(0)1483 683089 Fax: +44(0)1483 686208 E-mail: s.lusignan@surrey.ac.uk
In this issue of the PCRJ, Barbara and colleagues1 report the agreement between patient-recorded and clinician-recorded symptoms of respiratory illness. Contrary to other research, the study revealed that the patients recorded fewer symptoms than were captured by the clinicians following consultation. Barbara et al.s intriguing findings raise two key questions. First, what factors might cause patients to increase the quantity of the symptoms that they report when conversing with their clinician? Second, are there any reasons why clinicians may record symptoms in addition to the symptoms presented by the patients during consultation? We believe the answer to these questions may be explained by considering the psychological factors that may underlie patient and clinician symptom-recording behaviours. More specifically, we
suggest that the different symptom-recording behaviours of patients and clinicians may be motivated by an intrinsic desire to manage perceived risks. When patients visit their physician they often arrive with an agenda and expectation of receiving a prescription, particularly when they believe they have a respiratory illness.2,3 Such expectations seem reasonable given that patients typically visit their clinicians to obtain a solution (e.g. a prescription) to a problem (e.g. a respiratory infection). However, patients may perceive a risk that the clinician will not provide the anticipated solution and therefore not address the problem to a satisfactory standard. This perceived risk may be heightened as a result of the rise in public awareness of current campaigns to discourage clinicians from prescribing certain medications (e.g. antibiotics) due to costs, misuse and a slow decline in effectiveness (see Figure 1).4,5 Consequently, patients may now perceive the risk of leaving the practice without an appropriate remedy as being much greater than in previous decades. In an attempt to manage this risk, we hypothesise that patients may report a greater quantity of symptoms during clinical consultations, with the intention of encouraging the clinician to diagnose an illness that would typically warrant a prescription. In short, the over-reporting of symptoms by patients may lead some clinicians to record a greater quantity of symptoms than those recorded by the patient prior to the consultation. This thesis provides a potential explanation for Barbara et al.s main finding that patients and clinicians record a different quantity of symptoms and for the contrast between this finding and findings observed in earlier work. This notion is further supported by Barbara et al.s finding that the symptoms which patients under-recorded (e.g. cough, fever, etc.) appear to be those that may be more difficult for a clinician to verify objectively in a short consultation. This behaviour may stem from the
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Figure 1. Canadian antibiotic awareness campaign (http://antibioticawareness.ca/)
patients perceived risk of not receiving help for an illness due to policy agendas enacted within the health system. The discrepancies between patient-recorded and clinicianrecorded symptoms could be attributable to the behavioural risk management strategies employed, either knowingly or unknowingly, by clinicians. Research shows that clinicians often recognise that patients expect to receive prescription medication as a result of a consultation and that clinicians worry that a failure to meet such expectations may damage the clinician-patient relationship.6,7 To ameliorate the perceived risk of failing to meet patients expectations the clinician may, following an examination and diagnosis, issue a prescription or alternative form of clinical intervention (e.g. referral). To ensure these actions are defendable, the clinician then records a list of symptoms that are typical of the diagnosed condition a list that may extend beyond the symptoms reported by the patient. Sometimes practitioners are aware that they are using a diagnostic label to justify their decision to treat: when someone comes along in the flu season, and theyve got a viral type infection, and it may be viral Theres a bit of you that says this is probably viral, so I ought to really code it as virus infection, dont know what virus but that doesnt matter, but because theyve got a yellow coloured sputum, you say oh well, that sounds like a bacterial thing and Im giving them antibiotics, so Ill call it bronchitis. So I actually put down acute bronchitis. So yes, in a sense, you are altering diagnoses it is playing a kind of a game in a sense for the doctor to justify what he has done, depending upon the decision he came up with. 8
Decision-making in primary care often involves subconscious use of heuristics or mental rules of thumb to generalise the typical symptoms of the diagnosed illness to the patient. Within the literature on decision-making, the psychological mechanism underlying this generalisation process is referred to as the representativeness heuristic. Similarly, there are alternative heuristics that have been identified in clinical decisions and diagnostic judgments.9-11 While such heuristics are often employed subconsciously and have received praise for enabling fast and frugal diagnoses, there is also evidence to indicate they can lead to judgmental bias in some instances.12-14 For example, clinicians who avoid making computer records during the consultation but do so afterwards, so called minimal users, are more likely to include symptoms that fit with their diagnosis and exclude those that dont than doctors who record notes as they go.15 We also know that pay for performance targets for chronic disease management temporarily distort the recording of blood pressure.16 Hence, we suggest it is also possible that the clinicians in Barbara et al.s study may have unknowingly documented additional symptoms as a result of a mental heuristic that would typically serve to facilitate efficient decision-making and maintain comprehensive medical records. Defensive practice may also stimulate doctors to write more extensive records. Defensive medicine is well established in family practice;17 one of its characteristics is more detailed note-taking18 which is said to reduce the risk of malpractice suits.19 Although family practitioners are in a relatively low-liability group they appear to have greater concerns about malpractice suits than higher risk specialities.20 These tensions may have been enhanced while participating in a clinical trial. It is plausible that physicians recorded more symptoms to justify not prescribing antibiotics; this is an interaction which merits exploration. Our interpretation highlights the complex psychological interplay that can take place between patients and clinicians; reassuringly, this interaction may be underscored by a mutual desire to elicit or maintain a positive clinician-patient relationship, avoiding potential harm from a missed infection, and keeping detailed medical records. There are two important implications of this study;1 Firstly, policy makers should be mindful of the impact that public health decisions (e.g. cutting costs) can have upon a patients perceived risk of not receiving an appropriate level of treatment. Such perceptions may cause patients to question the efficacy of the public health system and adopt counter-behaviours, workarounds to elicit their desired response. Secondly, clinicians must remain mindful of ensuring that the records they maintain are an accurate representation of the patients actual health status. To this end, we recommend that clinicians should always ensure that a clear distinction is made in medical records between patient-reported symptoms and the symptoms observed by the clinician as suggested in Weeds problem-orientated records.21 We must ensure that patients medical records are sufficiently reliable to be used to inform important decisions. Acknowledgements We would like to thank Dr Barbara for her prompt answers to questions raised by the authors.
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Editorials Conflicts of interest The authors declare that they have no conflicts of interest in relation to this article.
Commissioned article; not externally peer-reviewed; accepted 1st February 2012; online 23rd February 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00024 Prim Care Respir J 2012;21(2):124-6 selective review of the cognitive literature. BMJ 2002;324(7339):729-32. http://dx.doi.org/10.1136/bmj.324.7339.729 10. Gigerenzer G, Gaissmaier W. Heuristic Decision Making. Annual Review of Psychology 2011;62(1):451-82. http://dx.doi.org/10.1146/annurev-psych-120709145346. 11. Kahneman D, Tversky A. Subjective probability: a judgment of representativeness. Cognitive Psychology 1972;3:430-54. http://dx.doi.org/10.1016/0010-0285(72)90016-3 12. Gigerenzer G, Todd PM, and the ABC Research Group. (1999). Simple Heuristics That Make Us Smart. Oxford: Oxford University Press. 13. Gigerenzer G. Goldstein DG. Reasoning the fast and frugal way: models of bounded rationality. Psychological Review 1996;103:650-69. http://dx.doi.org/10.1037/0033-295X.103.4.650 14. Gilovich T, Griffin D. Kahneman D. (eds.). (2002). Heuristics and Biases: The Psychology of Intuitive Judgment. Cambridge, UK.: Cambridge University Press. 15. Fitter MJ and Cruickshank PJ. The computer in the consulting room: a psychological framework. Behaviour and Information Technology 1983;1:81-92. http://dx.doi.org/10.1080/01449298208914438 16. Alsanjari ON, de Lusignan S, van Vlymen J, et al. Trends and transient change in end-digit preference in blood pressure recording: studies of sequential and longitudinal collected primary care data. Int J Clin Pract 2012;66(1):37-43. http://dx.doi.org/10.1111/j.1742-1241.2011.02781.x 17. Rosser WW. Threat of litigation. How does it affect family practice? Can Fam Physician 1994;40:645-8. 18. Summerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ 1995;310(6971):27-9. http://dx.doi.org/10.1136/bmj.310.6971.27 19. Teichman PG. Documentation tips for reducing malpractice risk. Fam Pract Manag 2000;7(3):29-33. 20. Bishop TF, Federman AD, Keyhani S. Physicians' views on defensive medicine: a national survey. Arch Intern Med 2010;170(12):1081-3. http://dx.doi.org/10.1001/archinternmed.2010.155 21. Weed LL. Medical records that guide and teach. N Engl J Med 1968;278(11):593600. http://dx.doi.org/10.1056/NEJM196803142781105
References
1. Barbara AM, Loeb M, Dolovich L, Brazil K, Russell M. Agreement between selfreport and medical records on signs and symptoms of respiratory illness. Prim Care Respir J 2012;21(2):145-52. http://dx.doi.org/10.4104/pcrj.2011.00098 2. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320(7244): 1246-50. http://dx.doi.org/10.1136/bmj.320.7244.1246 3. 4. Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract 1996;43(1):56-62. Cosby JL, Francis N, Butler CC. The role of evidence in the decline of antibiotic use for common respiratory infections in primary care. The Lancet (Infectious Diseases) 2007;7(11):749-56. http://dx.doi.org/10.1016/S1473-3099(07)70263-3 5. Marra F, Patrick DM, Chong M, Bowie WR. Antibiotic use among children in British Columbia, Canada. Journal of Antimicrobial Chemotherapy 2006;58(4):830-9. http://dx.doi.org/10.1093/jac/dkl275 6. Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectationsa questionnaire study. BMJ 1997;315(7107):520-3. http://dx.doi.org/10.1136/bmj.315.7107.520 7. Himmel W, Lippert-Urbanke E, Kochen MM. Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care 1997;15(3):118-22. http://dx.doi.org/10.3109/ 02813439709018500. 8. de Lusignan S, Wells SE, Hague NJ, Thiru K. Managers see the problems associated with coding clinical data as a technical issue whilst clinicians also see cultural barriers. Methods Inf Med 2003;42(4):416-22. 9. Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision making:
Streptococcus pyogenes upper respiratory infections and their effect on atopic conditions
See linked article by Juhn et al. on pg 153
*Osman Mohammad Yusufa

a
The Allergy and Asthma Institute, Islamabad, Pakistan
*Correspondence: Dr Osman M Yusuf, The Allergy and Asthma Institute, 275 Gomal Road, Sector E-7, Islamabad, Pakistan 44000 Tel: (0092) 51 2654445 Fax: (0092) 51 2654446 E-mail: osman_allergy@yahoo.com The effect of the upper airway on the lower airway was recognised as early as the second century by Claudius Galenus, who defined the nose as a respiratory instrument in his work De usu partium (On the usefulness of the [body] parts).1 However, the modern concept of the upper and lower respiratory passages being a continuum and forming a single unified airway has been highlighted only over the last 10-15 years.2 The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative focused on the co-morbidities of allergic rhinitis and included
involvement of the eyes, the paranasal sinuses and the lower airways.3 The nasal and bronchial mucosa present a number of similarities, and one of the most important concepts regarding nose/lung interactions is their functional complementarity.4 Interactions between the upper and lower airways are well known; it has been observed that over 80% of asthma patients have rhinitis and 10-40% of patients with rhinitis have asthma.3 The role of upper respiratory tract infections (URTIs) and how they affect the lower respiratory tract have been less well studied compared to the role of allergic diseases. Similarly, the effects of URTIs on atopic conditions (other than asthma) have also not been documented to any appreciable extent. Asthma in children is associated with an increased risk of Streptococcus pyogenes upper respiratory infections,5 even though Strep. pyogenes is not known to be a cause of asthma exacerbations.6 Strep. pyogenes is a well-known causative agent of a number of autoimmune conditions. The relatively new disease PANDAS,7 supposedly of post-streptococcal etiology, is the acronym for Paediatric Autoimmune Neuropsychiatric Disease Associated with Streptococcal
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infection. Tics and obsessive-compulsive symptoms are the major clinical signs of the disease, which develops after Streptococcus infection and which is almost certainly caused by autoimmune mechanisms (though the exact nature of the autoimmune mechanism remains unclear). Some cases of chronic urticaria are also reported to be associated with chronic tonsillitis,8 although the primary role of infection in chronic urticaria is controversial. Mast cells play a key role in the pathogenesis of atopic diseases as well as in asthma. They are important effector cells in innate immune responses to bacterial infections, and are critically involved in initiating and modulating optimal host responses to bacteria by either inflammatory or anti-inflammatory effects depending on the course of the host reaction induced by the pathogen. The exact mechanism for this is not known.9 However, one possible mechanism is via the Th-1 pathway through the induction of interleukin-12 (IL-12); a topical preparation OK-432, prepared from the penicillin-treated Su strain of type III Group A Strep. pyogenes, has been shown to be effective for treating atopic dermatitis.10 Children sensitised to house dust mite (HDM) have early defective antibody responses to bacteria that are associated with asthma, and the presence of antibacterial IgE has been associated with a reduced risk for asthma.11 This suggests that a functioning humoral immune system prevents the development of asthma, and possibly the development of other atopic diseases as well. The immune systems response to infections and its effects on allergy have been studied by Essilfie and co-workers in BALB/c mice.12 These workers found that the combination of infection and allergic airways disease promotes bacterial persistence, leading to the development of a phenotype similar to steroid-resistant neutrophilic asthma and hence the suggestion that steroid-resistant asthma may result from dysfunction in innate immune cells. Targeting bacterial infection in steroid-resistant asthma may therefore have therapeutic benefit. In this issue of the PCRJ, Juhn and colleagues have retrospectively studied the association of Strep. pyogenes and atopic conditions other than asthma in children under the age of 18 years12 an area of research which has been poorly studied in the past. They selected 143 (44%) of their total sample size who met the criteria of having atopic conditions other than asthma. They collected the laboratory test results of cultures, rapid antigen detection, and polymerase chain reaction tests for Strep. pyogenes infections during the first 18 years of life, and compared the incidence of Strep. pyogenes infections between children with and without a physician diagnosis of an atopic condition. They used a Poisson regression to determine the association between asthma and Strep. pyogenes infections, controlling for other covariates including asthma. They found that the incidence of Strep. pyogenes infections in children with atopic conditions other than asthma, and those without atopic conditions, was 0.24 per personyear and 0.18 per person-year, respectively. They conclude that, in addition to asthma, allergic rhinitis but not atopic dermatitis is associated with an increased risk of Strep. pyogenes URTIs. The authors have looked at many potential hypotheses to explain this linkage, but none with any amount of convincing evidence.12 In addition, and as stated by the authors themselves, there are several limitations to this study, not least the fact that it is retrospective and
observational, so only an associational relationship could be documented. Furthermore, relevant risk factors like exposure to indoor cigarette smoking or allergic sensitisation status data were not available, and the study population was predominantly Caucasian. Nevertheless, the overall results of this study suggest that there may be a link between the immunogenetic predisposition to atopy and susceptibility to Strep. pyogenes infection, thus opening up a new area for research. Primary care practitioners are advised to keep this in mind when they see patients with repeated URTIs. In addition, repeated URTIs in children with symptoms of tics such as repeated eye blinking or clearing of the throat may be an early sign of chronic Strep. pyogenes infection and PANDAS. One must also not forget to examine for additional allergy-associated conditions including (but not limited to) asthma. Acknowledgements The author gratefully acknowledges the assistance of Dr Arzu Mammadova, Allergist, Central Hospital of Oil Workers, Department of Chest Diseases, Baku, Azerbaijan, who kindly provided information on PANDAS. Conflicts of interest The author is an Associate Editor of the PCRJ, but was not involved in the editorial review of, nor the decision to publish, this article.
Commissioned article; not externally peer-reviewed; accepted 3rd April 2012; online 17th May 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00034 Prim Care Respir J 2012;21(2):126-7
References
1. Lenfant C. Introduction. In: Corren J, Togias A, Bousquet J, eds. Upper and Lower Respiratory Disease Lung Biology in Health and Disease C Lenfant editor Vol 181. NY: Marcel Dekker 2004:iii-iv. Jay Grossman. One Airway, One Disease. Chest 1997;111:11S-16S. http://dx.doi.org/10.1378 /chest. 111.2_Supplement.11S. Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108(5)(Suppl):S147-334. http://dx.doi.org/10.1067/mai.2001.118891 Togias A. Rhinitis and asthma: evidence for respiratory system integration. J Allergy Clin Immunol 2003;111(6):1171-83; quiz 84. http://dx.doi.org/10.1067/ mai.2003.1592 Frey D, Jacobson R, Poland G, Li X, Juhn Y. Assessment of the association between pediatric asthma and Streptococcus pyogenes upper respiratory infection. Allergy Asthma Proc 2009;30(5):540-5. http://dx.doi.org/10.2500/aap.2009.30.3268 Weinberger M. Respiratory infections and asthma: current treatment strategies. Drug Discov Today 2004;9(19):831-7. http://dx.doi.org/10.1016/S1359-6446(04)03239-8 de Oliveira SK. PANDAS: a new disease? J Pediatr (Rio J) 2007;83(3):201-08. http://dx.doi.org/10.2223/JPED.1615
2. 3.
4.
5.
6. 7. 8.
Calado G, Loureiro G, Machado D, et al. Streptococcal tonsillitis as a cause of urticaria Tonsillitis and urticaria. Allergol Immunopathol (Madr) 2011 Oct 5. [Epub ahead of print]. 9. Metz M, Magerl M, Khl NF, Valeva A, Bhakdi S, Maurer M. Mast cells determine the magnitude of bacterial toxin-induced skin inflammation. Exp Dermatol 2009;18(2):160-6. Epub 2008 Jul 17. http://dx.doi.org/10.1111/j.1600-0625.2008.00778.x 10. Horiuchi Y. Topical streptococcal preparation, OK-432, for atopic dermatitis. J Dermatolog Treat 2005;16(2):117-20. http://dx.doi.org/10.1080/ 09546630510032709 11. Hales BJ, Chai LY, Elliot CE, et al. Antibacterial antibody responses associated with the development of asthma in house dust mite-sensitised and non-sensitised children. Thorax 2011 Nov 21. [Epub ahead of print] 12. Juhn YJ, Frey D, Lic X, Jacobson R. Streptococcus pyogenes upper respiratory infection and atopic conditions other than asthma: a retrospective cohort study. Prim Care Respir J 2012;21(2):153-8. http://dx.doi.org/10.4104/pcrj.2011.00110
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Spirometry: an essential tool for screening, case-finding, and diagnosis of COPD

See linked articles by Thorn et al. on pg 159 and Abramson et al. on pg 167 Using the FEV1/FEV6 <0.73 criterion, compared to standard spirometry, the sensitivity and specificity of the copd-6 test was 79.2% and 80.3%, respectively. In terms of negative and positive predictive values the copd-6 had an accuracy of negatively predicting COPD (i.e. excluding the disease) 91.9% of the time, but only positively identifying COPD 57% of the time. These results are similar to those reported recently by Frith9 and Sichletidis10 using the Piko-6 device. However, there is no agreement between all these articles as to the appropriate cut-off for FEV1/FEV6 or whether FEV1/FEV6 should be combined with a questionnaire (see Table 1). Kotz and van Schayck,8 in an accompanying editorial to the Frith9 and Sichletidis10 articles, eloquently describe the necessity for higher sensitivity at the risk of losing specificity in order to minimise falsenegatives. In other words, maximising the chances of positively identifying COPD means that more patients would have to be referred for confirmatory diagnostic spirometry, arguably unnecessarily. All three microspirometry studies6,9,10 demonstrate a high negative predictive value i.e. they predict with at least 90% accuracy that the patient does not have COPD. As the severity and symptom profiles of the patients missed by the screening strategies are not reported, whether these patients had mild disease or were asymptomatic is unknown. Case-finding questionnaires could be utilised instead of microspirometry. As reviewed by Soriano and colleagues,4 a casefinding questionnaire offers greater convenience than microspirometry, although questionnaires based on symptoms alone may miss some asymptomatic patients. Price et al.12 reported that a case-finding questionnaire (IPAG) based on variables associated with an increased or decreased risk of having COPD including age, body mass index, allergies, hospitalisations and symptoms had an 89 93% accuracy of negatively predicting COPD depending upon the
Erika J Simsa,b, *David Priceb,c

a
b c
Norwich Medical School, Faculty of Health, University of East Anglia, UK Research in Real Life Ltd, Oakington, Cambridge, UK Centre of Academic Primary Care, University of Aberdeen, UK
*Correspondence: Professor David Price, Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Rd, Aberdeen, Scotland, AB25 2AY, UK Tel: +44 (0)1224 554588 Fax: +44 (0)1224 840683 E-mail: david@respiratoryresearch.org
The Global Alliance against Chronic Respiratory Diseases estimates that there are 210 million cases of chronic obstructive pulmonary disease (COPD) globally.1 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines2 and the International Primary Care Respiratory Group (IPCRG)3 have identified that many patients are diagnosed late, and consequently that case-finding strategies should be employed. Rather than just using case-finding as a means of diagnosing patients, the strategy proposed by the IPCRG involves reviewing at risk populations i.e. current and exsmokers aged over 35 years of age and using spirometry or questionnaires or both to identify likely COPD patients who then require high quality diagnostic standard spirometry.4,5 In this issue of the PCRJ there are two papers which shed further light on aspects of this diagnostic process. In the first paper, Thorn and colleagues report on the copd-6 a simple hand-held microspirometer device (Vitalograph, Ireland) that measures FEV1/FEV6 and its usefulness and cost-effectiveness in providing pre-standard spirometry for COPD case-finding.6 In the second, Abramson et al. report a mixed methods study on the accuracy of asthma and COPD diagnosis in Australian primary care.7 There are considered perspectives available from both proponents and opponents to the concept of COPD case-finding in primary care as previously debated and then summarised recently in this journal.8 Furthermore, there is no consensus as to which casefinding method is best microspirometry versus standard spirometry and whether these should be performed either pre- or postbronchodilator8-10 and with or without questionnaire screening.4,11 Thorn and colleagues6 report that a pre-bronchodilator FEV1/FEV6 ratio <0.73, measured using the hand-held copd-6, could be used as a case-finding test prior to referral for diagnostic spirometry in order to confirm or refute a diagnosis of COPD. Using diagnostic postbronchodilator spirometry, they then demonstrated a COPD prevalence of 25.2% in a patient population of 305 current and exsmokers (at least 15 pack years) aged 45 to 85 years who had been identified from 21 urban and rural primary health centres in Sweden.
Table 1. Sensitivity and specificity of FEV1/FEV6 at cut-offs recommended by authors

Thorn6 Device copd-6 Frith9 Piko-6 Sichletidis10 Piko-6 Piko-6 & IPAG <0.7 80% 94% 20% 6% 64% 98% <0.7 74% 97% 26% 3% 71% 97%
FEV1/FEV6 cut-off* Sensitivity Specificity 1-SN (false-negative) 1-SP false-positive) Positive Predictive Value Negative Predictive Value
<0.73 79% 80% 21% 20% 57% 92%
<0.75 81% 71% 19% 29% 52% 91%
*Cut-off recommended by authors.
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score cut-off used. Combining spirometric and questionnaire approaches might improve the positive predictive value of the casefinding approach. Although Sichletidis et al.10 reported that combining the IPAG questionnaire and PiKo-6 flow meter was associated with a small improvement in the positive predictive value compared to the PiKo-6 flow meter alone, perhaps the choice of tool(s) used microspirometry and/or questionnaire should be dependent on what is most appropriate for the patient. Microspirometry (with or without questionnaire) could be used during opportunistic face-to-face consultations (analogous to the measurement of blood pressure in the consulting room), while questionnaires sent by post or email could be used as a means of identifying patients who wouldnt normally visit the primary care health centre. If case-finding using FEV1/FEV6 were to be implemented, should it be performed pre- or post-bronchodilator? Indeed, while Frith9 and Thorn6 utilised pre-bronchodilator measurements, Sichletidis10 advocated post-bronchodilator measurements. So which provides most utility pre-bronchodilation or post-bronchodilation when using microspirometry? Thorn reported that pre-bronchodilator FEV1 measured using the copd-6 was on average 0.18L lower than the post-bronchodilator FEV1 recorded during standard spirometry, suggesting that as a case-finding measurement pre-bronchodilator values may be acceptable. Conducting post-bronchodilator casefinding would also increase the training required, the need for clinical supervision, and the cost.6 This would potentially reduce the utility of the test. Indeed, since the UK National Institute of Health and Clinical Excellence (NICE) guideline for COPD13 advocates opportunistic case-finding conducted in at risk populations, the case-finding test would need to be available for use at general practice facilities, smoking cessations clinics or local pharmacies. Comparative studies evaluating pre-bronchodilator and postbronchodilator microspirometry to confirm the validity of prebronchodilator measurements are required. However, we need to ensure that this debate on the tools required for primary care COPD case-finding has real relevance to grass-roots general practice. Abramson and colleagues report that COPD is substantially under-diagnosed in primary care in Australia.7 Guidelines recommend that a diagnosis of COPD should be made on the basis of spirometry, symptoms and smoking history.2,11 Yet, in a retrospective review of 278 new doctor diagnoses of asthma and COPD made during a 12-month period, over 28% of the diagnoses were made without spirometry. Of the 199 patients with baseline diagnostic spirometry, evidence of post-bronchodilator airflow limitation consistent with COPD was found in 91 patients, of whom 51 (56%) had a doctor diagnosis of asthma alone. In qualitative interviews with the participating general practitioners (GPs), the authors report that cost, both in terms of finance and staff time, was the principal driver for not conducting spirometry.7 This is an important insight, and one which needs to be considered whilst debating the utility of various case-finding strategies for COPD in primary care. Initiation of therapy in COPD has been shown to be more effective at earlier rather than later stages in the disease
progression.14,15 Case-finding strategies are essential if patients are to be identified in the early stages of the disease. Spirometry is an essential tool in the armoury of the GP for differentiating COPD from asthma. As treatments for COPD and asthma are diverging due to substantial improvements in our understanding of the pathogenesis of both diseases, the correct diagnosis is imperative in order to maximise the long-term outcome for the patient. Conflicts of interest
DP has consultant arrangements with Almirral, Astra Zeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Merck, Mundipharma, Medapharma, Novartis, Napp, Nycomed, Pfizer, Sandoz and Teva. He or his research team have received grants and support for research in respiratory disease from the following organisations in the last 5 years: UK National Health Service, Aerocrine, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Merck, Mundipharma, Novartis, Nycomed, Orion, Pfizer, and Teva. He has spoken for: Almirral, AstraZeneca, Activaero, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Merck, Mundipharma, Pfizer and Teva. He has shares in AKL Ltd which produces phytopharmaceuticals. He is the sole owner of Research in Real Life Ltd. EJS declares that she has no conflicts of interest in relation to this article. Commissioned article; not externally peer-reviewed; accepted 12th May 2012; online 18th May 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00046 Prim Care Respir J 2012;21(2):128-30
References
1. 2. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach Geneva: World, Health Organisation2007 25 August 2007. Global Initiative for Chronic Obstructive Lung Disease Global Strategy for The Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (Updated 2009): Medical Communications Resources, Inc; 2009. 3. Levy ML, Fletcher M, Price DB, Hausen T, Halbert RJ, Yawn BP. International Primary Care Respiratory Group (IPCRG) Guidelines: diagnosis of respiratory diseases in primary care. Prim Care Respir J 2006;15(1):20-34. http://dx.doi.org/ 10.1016/j.pcrj.2005.10.004 4. Soriano JB, Zielinski J, Price D. Screening for and early detection of chronic obstructive pulmonary disease. Lancet 2009;374(9691):721-32. http://dx.doi.org/10.1016/ S0140-6736(09)61290-3 5. Price D, Crockett A, Arne M, et al. Spirometry in primary care case-identification, diagnosis and management of COPD. Prim Care Respir J 2009;18(3):216-23. http://dx.doi.org/10.4104/pcrj.2009.00055 6. Thorn J, Tilling B, Lisspers K, Jorgensen L, Stenling A, Stratelis G. Improved prediction of COPD in at-risk patients using lung function pre-screening in primary care: a reallife study and cost-effectiveness analysis. Prim Care Respir J 2012;21(2):159-66. http://dx.doi.org/10.4104/pcrj.2011.00104 7. Abramson MJ, Schattner RL, Sulaiman ND, Del Colle EA, Aroni R, Thien F. Accuracy of asthma and COPD diagnosis in Australian general practice: a mixed methods study. Prim Care Respir J 2012;21(2):167-73. http://dx.doi.org/10.4104/ pcrj.2011.00103 8. Kotz D, van Schayck OC. Interpreting the diagnostic accuracy of tools for early detection of COPD. [Editorial] Prim Care Respir J 2011;20(2):113-15. http://dx.doi.org/10.4104/pcrj.2011.00050 9. Frith P, Crockett A, Beilby J, et al. Simplified COPD screening: validation of the PiKo6(R) in primary care. Prim Care Respir J 2011;20(2):190-8. http://dx.doi.org/10.4104/pcrj.2011.00040 10. Sichletidis L, Spyratos D, Papaioannou M, et al. A combination of the IPAG questionnaire and PiKo-6(R) flow meter is a valuable screening tool for COPD in the primary care setting. Prim Care Respir J 2011;20(2):184-9. http://dx.doi.org/10.4104/pcrj.2011.00038 11. Price D, Freeman D, Cleland J, Kaplan A, Cerasoli F. Earlier diagnosis and earlier treatment of COPD in primary care. Prim Care Respir J 2011;20(1):15-22.
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http://dx.doi.org/10.4104/pcrj.2010.00060 12. Price DB, Tinkelman DG, Nordyke RJ, Isonaka S, Halbert RJ. Scoring system and clinical application of COPD diagnostic questionnaires. Chest 2006;129(6):1531-9. http://dx.doi.org/10.1378/chest.129.6.1531 13. Excellence NNIfHaC. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. National Clinical Guideline Centre - Acute and Chronic Conditions; 2010. 14. Decramer M, Celli B, Kesten S, Lystig T, Mehra S, Tashkin DP. Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT): a prespecified subgroup analysis of a randomised controlled trial. Lancet 2009;374(9696):1171-8. http://dx.doi.org/10.1016/S0140-6736(09)61298-8 15. Jenkins CR, Jones PW, Calverley PM, et al. Efficacy of salmeterol/fluticasone propionate by GOLD stage of chronic obstructive pulmonary disease: analysis from the randomised, placebo-controlled TORCH study. Respir Res 2009;10:59.
Acute rhinosinusitis does quality of life explain continued rates of antibiotic overusage?
See linked article by Stjrne et al. on pg 174
*Sam Friedlandera
a
Assistant Clinical Professor, CASE, Department of Allergy/Immunology and Sleep Medicine, University Hospitals of Cleveland, Cleveland, Ohio, USA
*Correspondence: Professor Sam Friedlander, Department of Allergy/Immunology and Sleep Medicine, CASE, University Hospitals of Cleveland, Cleveland, Ohio, USA Tel: 440-248-1630 Fax: 440-349-8160 E-mail: Samuel.Friedlander@uhhospitals.org Quality of life (QoL) measurement is central to quantifying the burden of illness over a range of disease states. Particularly for diseases that infrequently result in mortality or hospitalisation, QoL indices can highlight the important impact of a condition.1 One such illness is acute rhinosinusitis, one of the most common reasons for which patients seek out medical attention. Approximately 6-15% of the population is affected by acute rhinosinusitis and it is estimated that 2-5 episodes of common viral colds occur per year in adults.2 In school-aged children the numbers are even higher, with 7-10 occurrences per year. The resultant healthcare utilisation worldwide is great, comprising 3-10% of all physician visits.3,4 As a result, there is a pressing research need to study acute rhinosinusitis and its impact on QoL and economic cost, its co-morbid risk factors, and the prevention of harm from the overuse of antibiotics.5 Primary care providers have the major responsibility for managing this condition, and thus it is appropriate to study acute rhinosinusitis in a primary care setting. In this issue of the Primary Care Respiratory Journal, Stjrne and colleagues6 report on the high costs and health-related QoL in acute rhinosinusitis in a Swedish primary care setting. Using a prospective, observational study design at 11 sites, QoL and cost analyses in adults with acute rhinosinusitis were assessed. Subjects were evaluated by the rhinosinusitis-specific Major Symptoms Score and overall QoL measure EQ-5DTM at days 0 and 15. Those with clinically suspected fulminant bacterial rhinosinusitis (e.g. fever, worsening of symptoms after initial improvement or double sickening, persistent unilateral facial or tooth pain) were excluded. A high rate of subjects reported symptoms detrimental to QoL. At the initial visit, 88% of participants reported pain/discomfort and 43% had problems with usual
activities, although only 11% reported extreme pain. The vast majority of subjects 91% improved their symptom scores by at least 30% between days 0 to 15. In addition to patients decreased QoL, the paper by Stjrne and colleagues informs us of the high economic cost to society of acute rhinosinusitis, mainly related to indirect costs. Interestingly, they found a wide variation in cost, from 1,728 to 54,357 SEK (194 to 6,111 ) with a mean cost of 10,260 SEK (1,102 ). Of this, 7,781 SEK was due to indirect costs from a fall in productivity related to employment status and work absence. The authors are to be commended for conducting a high-quality, multicentre study of acute rhinosinusitis in a primary care setting. They have added to the limited evidence base on acute rhinosinusitis and its effects on disease-specific symptom scores and QoL. Further, direct and indirect costs of this disease have not been well-studied before, and have never been evaluated in Scandinavia. Allergy is a risk factor for acute rhinosinusitis7 and a quarter of the subjects in this paper6 report having seasonal allergies. This highlights the importance of assessing for the role of allergies. There are multiple pathophysiological explanations for the connection between allergy and rhinosinusitis.2 This includes impaired ciliary function in allergic rhinitis8 and elevated expression of ICAM-1, the receptor for rhinovirus.9 Also, numbers of plasmacytoid dendritic cells, important for combating viral infection, are decreased in asymptomatic patients with chronic nasal allergic inflammation.10 Another major concern is the global overuse of antibiotics for the treatment of acute rhinosinusitis, a mainly viral disease.11 This was largely borne out in this study by Stjrne and colleagues,6 since 60% were treated by their provider with antibiotics. Usually, the number of patients taking a medicine is less than those that were prescribed it. Ironically, although 60% were initially recommended by their doctor to take antibiotics, 69% actually reported using antibiotics. Not enough information is available to explain why antibiotics were recommended or used, although the high numbers suggest that overuse occurred. Potentially, subjects not initially prescribed antibiotics might have returned to the same or different medical provider to obtain them. It is estimated that only 0.5-2% of viral colds result in bacterial rhinosinusitis, so it is disappointing that such high rates of antibiotics continue to be prescribed.12 Clinical practice guidelines recommend antibacterial treatment for persistent symptoms lasting more than 10 days or for patients with severe symptoms, in order to speed
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associated with obesity in school-aged children. Arch Pediatr Adolesc Med 2003;157(12):1206-11. http://dx.doi.org/10.1001/archpedi.157.12.1206 2. 3. 4. 5. Fokkens WJ, Lund V, Mullol J, et al. The european position paper on rhinosinusitis and nasal polyps 2012. Rhinology - Supplement 2012;23:1-299. Cherry DK, Woodwell DA, Rechtsteiner EA. National ambulatory medical care survey: 2005 summary. Adv Data 2007;387:1-39. Wang DY, Wardani RS, Singh K, et al. A survey on the management of acute rhinosinusitis among asian physicians. Rhinology 2011;49(3):264-71. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: Establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004;114(6 Suppl):155-212. http://dx.doi.org/10.1016/j.jaci.2004.09.029 6. Stjarne P, Odeback P, Stallberg B, Lundberg J, Olsson P. High costs and burden of illness in acute rhinosinusitis: Real-life treatment patterns and outcomes in swedish primary care. Prim Care Respir J 2012;21(2):174-9. http://dx.doi.org/10.4104/ pcrj.2012.00011 7. Schatz M, Zeiger RS, Chen W, Yang SJ, Corrao MA, Quinn VP. The burden of rhinitis in a managed care organization. Ann Allergy Asthma Immunol 2008;101(3):240-7. http://dx.doi.org/10.1016/S1081-1206(10)60488-7 8. Vlastos I, Athanasopoulos I, Mastronikolis NS, et al. Impaired mucociliary clearance in allergic rhinitis patients is related to a predisposition to rhinosinusitis. Ear Nose Throat J 2009;88(4):E17-9. 9. Ciprandi G, Buscaglia S, Pesce G, Villaggio B, Bagnasco M, Canonica GW. Allergic subjects express intercellular adhesion molecule--1 (ICAM-1 or CD54) on epithelial cells of conjunctiva after allergen challenge. J Allergy Clin Immunol 1993;91(3):78392. http://dx.doi.org/10.1016/0091-6749(93)90198-O 10. Hartmann E, Graefe H, Hopert A, et al. Analysis of plasmacytoid and myeloid dendritic cells in nasal epithelium. Clin Vaccine Immunol 2006;13(11):1278-86. http://dx.doi.org/10.1128/CVI.00172-06 11. Venekamp RP, Rovers MM, Verheij TJ, Bonten MJ, Sachs AP. Treatment of acute rhinosinusitis: Discrepancy between guideline recommendations and clinical practice. Fam Pract 2012 (Epub ahead of print). http://dx.doi.org/10.1093/fampra/cms022 12. Gwaltney JM,Jr, Wiesinger BA, Patrie JT. Acute community-acquired bacterial sinusitis: The value of antimicrobial treatment and the natural history. Clin Infect Dis 2004;38(2):227-33. http://dx.doi.org/10.1086/380641 13. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute Commissioned article; not externally peer-reviewed; accepted 10th May 2012; online 17th May 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00045 Prim Care Respir J 2012;21(2):130-1 bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54(8):e72-e112. http://dx.doi.org/10.1093/cid/cis370 14. Rosenfeld RM. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3):365-77. http://dx.doi.org/10.1016/j.otohns.2007.07.021 15. Molstad S, Erntell M, Hanberger H, et al. Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the swedish strama programme. Lancet Infect Dis 2008;8(2):125-32. http://dx.doi.org/10.1016/S1473-3099(08)70017-3
resolution and prevent serious sequelae.13,14 The EPOS 2012 guidelines have stricter recommendations and stratify treatment based on case categorisation; 1) common cold/acute viral rhinosinusitis 2) acute post-viral rhinosinusitis (moderate symptoms recommend intranasal steroids but no antibiotics), and 3) acute bacterial rhinosinusitis (severe symptoms antibiotics and intranasal steroids recommended).2 For antibiotic rates to decrease, we need to continue to educate medical providers. In addition, there must be changes in societal expectations, since patient demand is a strong barrier to limiting prescription rates. Subjects in this study by Stjrne and colleagues reported poor QoL.6 They noted high rates of pain/discomfort and limitation to usual activities, so understandably they desired symptom relief. But antibiotics are not always beneficial and can cause harm. Physicians should be aided by national programmes to educate both healthcare providers and the general population.15 This is a timely message. The American Academy of Allergy, Asthma, and Immunology has recently updated its teaching slides on both acute and chronic rhinosinusitis. This was an international effort involving experts from around the world from the fields of allergy and immunology, otolaryngology, and radiology. These new teaching slides provide a review of the epidemiology, diagnosis and management of rhinosinusitis, and can be accessed without charge at: http://education.aaaai.org/courses. Additional teaching slides are available on a wide variety of respiratory conditions, providing Continuing Medical Education (CME) credits for trainees, primary care physicians and specialists. Conflicts of interest
Sunovion. The author declares speakers honoraria for Teva and
References
1. Friedlander SL, Larkin EK, Rosen CL, Palermo TM, Redline S. Decreased quality of life
Obesity, airflow limitation, and respiratory symptoms: does it take three to tango?
See linked article by Zutler et al. on pg 194
*Frits ME Franssena
a
Program Development Center, CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands
*Correspondence: Dr Frits ME Franssen, CIRO+, Center of Expertise for Chronic Organ Failure, PO Box 4080, 6080 AB Haelen, The Netherlands Tel: +31-475-587600 Fax: +31-475-587592 E-mail: fritsfranssen@ciro-horn.nl
Respiratory symptoms such as dyspnoea and chronic cough are common in the general population1 and are associated with reduced health status even in people without any disease of the airways.2 The presence of objective lung function impairment or bronchial hyperresponsiveness does not alter this association,2 indicating that other factors contribute to dyspnoea and chronic cough in the general population. Unravelling these factors remains a relevant challenge and a prerequisite to prevention and treatment of respiratory symptoms. One of the factors which probably contributes to the presence of respiratory symptoms is obesity, defined as a body mass index (BMI) of > 30 kg/m2. The increasing prevalence of obesity is one of the major global
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public health problems of the current decade. It is projected that this obesity epidemic will escalate even further, especially as a result of a dramatic rise in obesity in low- and middle-income countries.3 In 2008, an estimated 500 million adults around the world were obese.4 Obesity substantially raises the risk of morbidity and mortality. It is related to the development of cardiovascular risk factors such as reduced HDL, non-insulin dependent diabetes mellitus and hypertension,5 and to the incidence of cardiovascular events.6 In addition, obesity is a major risk factor for gallbladder disease, osteoarthritis, accidents, and certain types of cancer. In 2009, the World Health Organization (WHO) estimated that obesity was the fifth leading risk factor for death, accounting for nearly 3 million deaths per year. A link between obesity and the respiratory system is well established. Obesity affects pulmonary function at rest, with a reduction in functional residual capacity (FRC)7 as its most prominent effect. However, the effects of obesity on airway function are limited. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) are usually preserved,8 and so the FEV1/FVC ratio often remains normal. However, obese subjects are at increased risk of expiratory flow limitation as a result of their breathing at lower lung volume,7 and small airways airflow obstruction may be present. Diffusing lung capacity of carbon monoxide (DLCO) is also in the normal range or increased in obesity.9 Obese subjects free of respiratory disease report decreased ability to perform daily physical activities due to increased breathlessness in comparison with healthy age- and gender-matched normal weight subjects.10 In addition, breathing discomfort is significantly higher at any given submaximal cycle work rate in obese subjects.10 In addition to the physiologic effects of excess body fat mass on the lungs, obesity is increasingly linked to chronic respiratory conditions. Obesity predisposes to obstructive sleep apnoea,11 pulmonary embolism,12 and asthma.12 Furthermore, obesity probably contributes to heterogeneity in pulmonary and systemic manifestations in patients with chronic obstructive pulmonary disease (COPD).13 Like obesity, COPD is a major cause of worldwide morbidity and mortality, and the burden of COPD will increase over the next few decades. The degree of airflow limitation in COPD is a poor predictor of patient-related outcomes including dyspnoea, cough, exercise tolerance and health status.14 Therefore, it is important to understand the impact of concomitant conditions, including obesity, on relevant outcomes in COPD. While it was recently reported that obese COPD patients have increased dyspnoea at rest and poorer health status compared to normal weight patients,14 some favourable effects of obesity in COPD have been described. Obesity results in a reduction of static lung hyperinflation in COPD, irrespective of the severity of disease.15 Also, peak cycling capacity is preserved in obese COPD patients compared to non-obese patients with a comparable degree of airflow limitation,15 although the distance covered during a 6minute walk test (6MWT) is reduced.16 Moreover, dyspnoea ratings are consistently lower during cycling in obese patients, probably due to the beneficial effects of the excessive fat mass on dynamic ventilatory mechanics.15 Finally, in patients with severe COPD, obesity is associated with improved survival,17 while its contribution to the
increased cardiovascular morbidity and mortality in less advanced disease remains to be established.18 Since the worldwide prevalence of both chronic airflow obstruction as well as obesity is increasing, and a large proportion of people with respiratory symptoms are currently undiagnosed and untreated,2 unravelling the combined effects of these conditions is a major healthcare priority. The study by Zutler et al.19 in this issue of the PCRJ greatly enhances our understanding of the complex interactions between obesity, airflow obstruction and respiratory symptoms, and performance. In a cohort of 371 middle-aged subjects without an ICD9-CM diagnosis of COPD, respiratory symptoms including productive cough and exercise-induced dyspnoea were evaluated. Clinical assessment included pre-bronchodilator spirometry, and measurement of BMI, 6MWT, and lower extremity function. The frequencies of airflow obstruction (FEV1/FVC < 0.70) and obesity were nearly 19% and 40%, respectively. Obese subjects were much less likely to have airflow limitation. Remarkably, not airflow limitation but obesity, was associated with increased respiratory symptoms, poor self-reported health and decreased functional performance. The findings of this study are clinically relevant to healthcare professionals confronted with globally expanding populations of patients with dyspnoea, obesity, chronic airflow limitation or any combination of these. The study suggests that strategies aimed at improving respiratory symptoms and enhancing performance in obese patients per se in the general population might need to focus on weight reduction rather than on diagnosing and treating airflow limitation. Whether strategies aimed at reducing obesity are indeed effective, and what amount of weight loss would result in clinically important improvements in these outcomes, needs further investigation. Furthermore, it is not clear whether more severe impairment in lung function than was present in this study19 (median FEV1 was 83% of predicted) would outweigh the impact of obesity on respiratory symptoms and functional capacity in a general population. Finally, it is currently unknown whether subjects with concomitant obesity and COPD would clinically benefit from weight reduction, since obesity is not necessarily associated with adverse outcomes in patients with COPD.15,17 Until the gaps in our understanding of the relationship between obesity, chronic airflow limitation and respiratory symptoms have been filled, the question as to whether it takes two or three to tango remains unanswered Conflicts of interest
in relation to this article. Funding None. Commissioned article; not externally peer-reviewed; accepted 29th April 2012; online 17th May 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00040 Prim Care Respir J 2012;21(2):131-3 The author declares that he has no conflicts of interest
References
1. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996;9(4):687-95. http://dx.doi.org/10.1183/ 09031936.96.09040687 Voll-Aanerud M, Eagan TM, Plana E, et al. Respiratory symptoms in adults are related to impaired quality of life, regardless of asthma and COPD: results from the European
2.
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community respiratory health survey. Health Qual Life Outcomes 2010;8:107. http://dx.doi.org/10.1186/1477-7525-8-107 3. 4. 5. WHO. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO Technical Report Series 894. 2000. WHO. Global database on Body Mass Index. [Website]; 2012 [updated 2012; cited]; Available from: http://apps.who.int/bmi/index.jsp. Brown CD, Higgins M, Donato KA, et al. Body mass index and the prevalence of hypertension and dyslipidemia. Obesity research. [Research Support, U.S. Gov't, P.H.S.]. 2000;8(9):605-19. 6. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation 1983;67(5):968-77. http://dx.doi.org/ 10.1161/01.CIR.67.5.968 7. Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol 2010;108(1):206-11. http://dx.doi.org/10.1152/ japplphysiol.00694.2009 8. Sin DD, Jones RL, Man SF. Obesity is a risk factor for dyspnea but not for airflow obstruction. Arch Intern Med 2002;162(13):1477-81. http://dx.doi.org/10.1001/ archinte.162.13.1477 9. Collard P, Wilputte JY, Aubert G, Rodenstein DO, Frans A. The single-breath diffusing capacity for carbon monoxide in obstructive sleep apnea and obesity. Chest 1996;110(5):1189-93. http://dx.doi.org/10.1378/chest.110.5.1189 10. Ofir D, Laveneziana P, Webb KA, O'Donnell DE. Ventilatory and perceptual responses to cycle exercise in obese women. J Appl Physiol 2007;102(6):2217-26. http://dx.doi.org/10.1152/japplphysiol.00898.2006 11. Crummy F, Piper AJ, Naughton MT. Obesity and the lung: 2. Obesity and sleepdisordered breathing. Thorax 2008;63(8):738-46. http://dx.doi.org/ 10.1136/thx.2007.086843 12. Beuther DA, Sutherland ER. Overweight, obesity, and incident asthma: a metaanalysis of prospective epidemiologic studies. Am J Respir Crit Care Med 2007;175(7):661-6. http://dx.doi.org/10.1164/rccm.200611-1717OC 13. Agusti A, Calverley PM, Celli B, et al. Characterisation of COPD heterogeneity in the ECLIPSE cohort. Respiratory research 2010;11:122. 14. Cecere LM, Littman AJ, Slatore CG, et al. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD 2011;8(4):275-84. http://dx.doi.org/10.3109/15412555.2011.586660 15. Ora J, Laveneziana P, Ofir D, Deesomchok A, Webb KA, O'Donnell DE. Combined Effects of Obesity and COPD on Dyspnea and Exercise Tolerance. Am J Respir Crit Care Med 2009;180:964-71. 16. Ramachandran K, McCusker C, Connors M, Zuwallack R, Lahiri B. The influence of obesity on pulmonary rehabilitation outcomes in patients with COPD. Chron Respir Dis 2008;5(4):205-9. http://dx.doi.org/10.1177/1479972308096711 17. Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999;160(6):1856-61. 18. Franssen FM, O'Donnell DE, Goossens GH, Blaak EE, Schols AM. Obesity and the lung: 5. Obesity and COPD. Thorax 2008;63(12):1110-17. http://dx.doi.org/10.1136/thx.2007.086827 19. Zutler M, Singer JP, Omachi TA, et al. Relationship of obesity with respiratory symptoms and decreased functional capacity in adults without established COPD. Prim Care Respir J 2012;21(2):194-201. http://dx.doi.org/10.4104/ pcrj.2012.00028
education@pcrj: the launch of a new initiative for the PCRJ

*Hilary Pinnocka, Jaime Correia de Sousab
a
Senior Clinical Research Fellow, Allergy and Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, UK Senior Lecturer, Community Health Department, Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Portugal
*Correspondence: Dr Hilary Pinnock, Allergy and Respiratory Research Group, Centre for Population Health Sciences, The University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK Tel: +44 (0)131 650 8102 Fax: +44 (0)131 650 9119 E-mails: hilary.pinnock@ed.ac.uk jaimecsousa@gmail.com The PCRJ has two declared aims in the context of primary care respiratory medicine: firstly, to be an authoritative setting for the publication of high quality internationally-relevant research; and secondly, to inform and educate healthcare professionals worldwide of the research and service developments in this field.1 This issue sees the launch of a new section in the Journal, education@pcrj, which will significantly promote the second of these two aims. As newly appointed Section Editors, we are delighted to accept the challenge laid down by the Editors-in-Chief, and look forward to delivering this core component of the PCRJs editorial strategy. Our aim is to satisfy the needs of grass roots primary care clinicians in
implementing and applying research findings in practice.1 Pre-empting this launch, journalwatch@pcrj first appeared in the March 2012 issue.2 Produced by the Editors-in-Chief, this will be a regular feature of education@pcrj from now on, enabling busy primary care clinicians to keep up-to-date with the latest research evidence from the top respiratory and general medical journals worldwide. Guideline summaries have always been a popular feature of the Journal3,4 and these will appear in education@pcrj on a regular basis. Similarly, Evidence into practice articles, short review articles of no more than 2000 words in length, will demonstrate how evidence from research can lead to changes in clinical practice. The PCRJ has previously published Case-based learning5 articles similar to the traditional type of Case report, but in the future these will be incorporated into education@pcrj and re-formatted. The section in this issue on the importance of co-morbid rhinitis in patients with asthma demonstrates our new approach. It starts with a short clinical scenario reflecting where we start as clinicians and Scadding and Walker then provide a clinical overview of the management of the patient with co-morbid rhinitis and asthma together with an authoritative review of the evidence base.7 Exemplifying the fine balance between clinical practicalities and academic theory is the juxtaposition of a table summarising the academic evidence for a link between rhinitis and asthma with a practical illustration of how to use a nasal spray (which should be required reading for every primary care clinician and pharmacist). This review is then followed by two Perspectives a new article category for the PCRJ: Osman Yusuf highlights the issues when
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working in primary care in a low- and middle-income country;7 and Ruth McArthur provides some practical tips from her experience as a specialist nurse in a UK general practice.8 Plans are well advanced for the next few issues. The September issue will feature a clinical scenario of a 54 year-old man consulting about a long-standing cough, with Perspectives from primary and secondary care which explain how they would manage the problem within their national and health service contexts. In December we will focus on COPD, building on a clinical review of the approach to assessment and management advocated by the latest update of the GOLD guideline.9 However, this is only the beginning. Future ideas involve not just the hard copy version of the PCRJ, but also developing the facilities available on the Journal website (www.thepcrj.org). By asking authors to provide PowerPoint slides to accompany their articles, we hope to build an online library of topic-based resources which will draw on the rich source of relevant publications from the PCRJ as well as signpost the materials already available from the Primary Care Respiratory Society UK, the International Primary Care Respiratory Group, and other member organisations around the world. Education needs to be a two-way process. At its simplest, we need your feedback, please. Is the concept working? Which of these ideas do you think will be most helpful? How can we further develop education@pcrj? What are the topics you would like to see covered? We will continue to welcome submissions of Guideline summaries, Evidence into practice articles, Case-based learning articles and Perspectives, all of which should stimulate the development of issue-based educational themes. One of the PCRJs aims is to encourage debate, and we are discussing ways in which we can enable more innovative interaction. Perhaps we should enable readers to respond to the published perspectives on clinical scenarios by submitting prompt perspectives from their clinical practice which could be posted on an interactive section of the PCRJ website? Should we consider devising multiple choice questions to accompany articles? perhaps arranging CME (Continuing Medical Education) accreditation. Should we commission Evidence into practice articles on a FAQ format? An example of this would be papers in which authors provide evidence-based answers to a series of questions regarding the translation of guidelines into practice. Should we also invite them, when appropriate, to provide an education leaflet for patients about the review subject?
As the newly appointed editors of education@pcrj, we are excited by the potential of this initiative. Please let us know what you think of our ideas either by e-mailing us direct or via the PCRJ Editorial Office and offer to be part of the initiative by suggesting ideas and submitting articles for the education section. Together we can inform and educate primary care health professionals and in so doing promote excellence in their care of patients with respiratory and respiratory-related allergic diseases.1 Conflicts of interest The authors declare that they have no conflicts of interest in relation to this article. Funding HP is supported by a Primary Care Research Career Award from the Chief Scientists Office, Scottish Government
Commissioned article; not externally peer-reviewed; accepted 12th May 2012; online 29th May 2012 2012 Primary Care Respiratory Society UK. All rights reserved http://dx.doi.org/10.4104/pcrj.2012.00048 Prim Care Respir J 2012;21(2):133-4
References
1. Stephenson P, Sheikh A. A tribute to the past, and plans for the future: helping to drive top quality primary care respiratory disease management worldwide. Prim Care Respir J 2011;20(1):1-3. http://dx.doi.org/10.4104/pcrj.2011.00013 2. 3. Journalwatch@pcrj. Prim Care Respir J 2012;21(1):115-17. http://dx.doi.org/10.4104/pcrj.2012.00014 Levy ML, Le Jeune I, Woodhead MA, Macfarlaned JT, Lim WS, on behalf of the British Thoracic Society Community Acquired Pneumonia in Adults Guideline Group. Primary care summary of the British Thoracic Society Guidelines for the management of community acquired pneumonia in adults: 2009 update. Prim Care Respir J 2010;19(1):21-7. http://dx.doi.org/10.4104/pcrj.2010.00014 4. Angier E, Willington J, Scadding G, Holmes S, Walker S. Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline. Prim Care Respir J 2010;19(3):217-22. http://dx.doi.org/10.4104/pcrj.2010.00044 5. Mir E, Shah A. Allergic bronchopulmonary aspergillosis in a patient with chronic obstructive pulmonary disease. Prim Care Respir J 2012;21(1):111-14. http://dx.doi.org/10.4104/pcrj.2012.00001 6. Scadding G, Walker S. Poor asthma control? then look up the nose. The importance of co-morbid rhinitis in patients with asthma. Prim Care Respir J 2012; 21(2):222-8. http://dx.doi.org/10.4104/pcrj.2012.00035 7. Yusuf OM. Management of co-morbid allergic rhinitis and asthma in a low and middle income healthcare setting. 8. 9. Prim Care Respir J 2012;21(2):228-30. Prim Care http://dx.doi.org/10.4104/pcrj.2012.00036 McArthur R. A practical approach to managing asthma and rhinitis. Respir J 2012;21(2):230-32. http://dx.doi.org/10.4104/pcrj.2012.00037 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: updated 2011. Available from http://www.goldcopd.com (accessed May 2012)
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Prim Care Respir J 2012; 21(2): 121-134

An Impact factor and beyond

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*Hilary Pinnocka, Helen Lesterb

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Ian Dawsona, Victoria Seniorb, *Simon de Lusignanc

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Figure 1. Canadian antibiotic awareness campaign (http://antibioticawareness.ca/)

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*Osman Mohammad Yusufa

The Allergy and Asthma Institute, Islamabad, Pakistan

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Spirometry: an essential tool for screening, case-finding, and diagnosis of COPD

Erika J Simsa,b, *David Priceb,c

Table 1. Sensitivity and specificity of FEV1/FEV6 at cut-offs recommended by authors

<0.73 79% 80% 21% 20% 57% 92%

<0.75 81% 71% 19% 29% 52% 91%

*Cut-off recommended by authors.

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PRIMARY CARE RESPIRATORY JOURNAL www.thepcrj.org

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education@pcrj: the launch of a new initiative for the PCRJ

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Available online at http://www.thepcrj.org

PRIMARY CARE RESPIRATORY JOURNAL www.thepcrj.org

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