Anju Anand

Twitter discussions from a respirology journal club

We had the pleasure of discussing Irene Higginson and colleagues’ recent trial at our Twitter-based journal club (@respandsleepjc, #rsjc) in January, 2015, and had the honour of being joined by the lead author, Irene J Higginson, for the event. The study assessed a breathlessness-support service that combined palliative care and respiratory medicine for patients with refractory dyspnoea due to advanced disease. Our discussion generated several questions. Although the trial methods indicated that allocation was done by minimisation to reduce four potential confounders (cancer vs non-cancer, breathlessness severity, presence of informal caregiver, and ethnic origin), the data for ethnic origin and Medical Research Council dyspnoea score (MRC) was not explicitly presented in the Article. We thought these measures might be important confounders because a patient’s ethnic or cultural background might aff ect his or her response to some of the quality of life or psychosocial questionnaires. Additionally, patients with respiratory disease often, perhaps unknowingly, limit their activities to manage their shortness of breath. The MRC score allows for contextualisation of patients’ dyspnoea because it relates breathlessness to a person’s functional ability. In response, Higginson explained that there was an equal distribution of ethnic origins among participants but that this was omitted due to space limitations. Additionally, although an MRC score of at least 2 was one of the inclusion criteria, more sensitive measures of severity were used to assess dyspnoea. Despite this explanation, we believe that MRC, as a validated measure of breathlessness severity, with implications for both quality of life and mortality, should have been included in table 1. If more patients in the control group had MRC class 5 dyspnoea compared with those in the breathlessness support services group, this finding might have accounted for many of the results seen. For example, someone who is breathless while dressing might have difficulty feeling improvement in the mastery domain of the Chronic Respiratory Disease Questionnaire. Overall, our group felt that this study was important because it assessed a complex intervention and underlined the value of interdisciplinary care for patients with refractory dyspnoea. Although many in our journal club reported appreciation of the importance of such care before reading the article, perhaps the study’s main eff ect will be on policymakers, with the power to implement such programmes at other centres.

Cardiovascular and neuropsychiatric risks of varenicline

www.thelancet.com/respiratory Vol 4 March 2016 e9 with other bacteria and viruses did not lead to an improved eff ect of the azithromycin treatment. Therefore, we could not conclude whether the reported results were attributable to the antibacterial or anti-infl ammatory eff ects of the macrolide. David Hahn and Wilmore Webley suggest an alternative explanation for the observed results through treatment of the atypical pathogenic bacteria Chlamydia pneumoniae. Indeed, azithromycin is effective against this pathogen, but it is very unlikely that treatment of C pneumoniae mediates a substantial part of the treatment effects that we recorded. We deliberately chose not to include the atypical bacteria C pneumoniae and Mycoplasma pneumoniae in our study analyses because of a very low prevalence in the Danish paediatric population. In our analogous COPSAC2000 cohort study, we reported that atypical bacteria detected by PCR were identified in less than 2% of airway samples from young Danish children with asthmalike episodes, and only in 1% of children with clinical pneumonia. In other countries, both C pneumoniae and M pneumoniae might have a larger role in chronic asthma and during acute exacerbations in young children.

Gaining competence through social media

Users of social media generate and exchange information, and social media applications are being used increasingly to complement medical education. Medical trainees are adopting social media and Web-based technologies to facilitate education, communication and resource sharing. Educators include

Written Action Asthma Plans: Not Such a Simple Issue in Subspecialist Care?

and colleagues’ Figure 1A). Similarly, an average of about 3 symptomatic nights per 2-week period occurred (Sheares and colleagues’ Figure 1B). Emergency department visits for asthma averaged about two per 3 months for the year (Sheares and colleagues’ Figure 4). Hospitalizations, although infrequent, changed little during the 12 months of the study (Sheares and colleagues’ Figure 5). Thus, all one can say about the study is that the treatment plan used that did not result in control of asthma was not benefited by a written asthma action plan. In fact, these patients required more care to meet current standards for asthma control, including virtual absence of day or night symptoms and absence of need for urgent medical care (2). That would have required more frequent visits to the specialists to assess criteria for control and determine the need for additional measures to attain daily absence of symptoms. An “action plan” can then be limited to management of exacerbations, avoiding the complexity of the action plan described in the manuscript by Sheares and colleagues (1). In a critical examination of action plans, Gibson and Powell found no advantage to complex plans with traffic light cartoon or color illustrations (3). Using the language of the National Asthma Education and Prevention Program, reduction of impairment requires physician evaluation with sufficient frequency to make therapeutic decisions that can eventually result in control (2). Although exacerbations, predominantly from viral respiratory infections (4), will still occur, it is there that a simple written asthma action plan is likely to be a useful reference for the patient or family, as those occur episodically, and verbal instructions alone may be insufficiently retained when the exacerbations actually occur. Before discarding the use of a written asthma action plan, as suggested by the study of Sheares and colleagues (1), consider the specifics of both the treatment and the action plan, whether verbal or written. The devil is in the details. n

On survival comparisons between adult cystic fibrosis patients in Canada versus the United States: Twitter discussions from @respandsleepjc (#rsjc)

With the advancements in medical management of cystic fibrosis (CF) in the last two decades, life expectancy for individuals with CF is now much longer. Much of this is attributed to a comprehensive, multidisciplinary and patientcentered approach to medical care, lung transplantation, as well as aggressive treatment of malnutrition. Comparison of survival in CF between countries has long been a point of interest for researchers in order to understand trends in disease progression and severity and how this may impact morbidity and survival. In 2011, the median age of survival for adults with CF was 48.5 years and 36.8 years in the United States. This article applies a standardized approach to survival analysis in CF patients in both Canada and the United States in order to confirm this observed difference in survival. Additionally, the complexities involved in comparing national survival rates are explored.

Correspondence: Twitter discussions from a respirology journal club: a randomized trial of itraconazole versus prednisolone in acute-stage ABPA complicating asthma

Oral corticosteroids are currently the treatment of choice in acute ABPA. However, there are several major side effects of oral corticosteroids that can limit its use. Therefore, this study was conducted to compare itraconazole versus prednisolone in the treatment of acute-stage ABPA complicating asthma. It was found that the proportion of subjects demonstrating a composite response to treatment at 6 weeks was significantly higher in the prednisolone group versus the itraconazole group. Moreover, it was found that the percentage decline in immunoglobulin E (IgE) was similar for both the group of subjects with complete remission after 3 and 6 months of stopping treatment and the group of subjects with exacerbations after 1 and 2 years.

Vitamin D supplementation in patients with COPD: Twitter discussions on behalf of the University of Toronto Respirology and Sleep Journal Club.

e24 www.thelancet.com/respiratory Vol 3 August 2015 Authors’ Reply We thank Anju Anand and colleagues for their comments and Twitter discussion about our Article on vitamin D3 supplementation in patients with chronic obstructive pulmonary disease (COPD; ViDiCO). The trend towards increased exacerbation risk among patients with higher baseline concentrations of 25-hydroxyvitamin D (25[OH]D) who were randomly assigned to receive vitamin D has been reported in findings from another trial. This effect is not necessarily inconsistent with the antiinflammatory effects of vitamin D; suppression of responses to type 1 interferon might compromise the response to respiratory viruses, and could lead to an increased risk of upper respiratory infection that might precipitate exacerbations. Irrespective of potential adverse eff ects in patients with higher serum concentrations of 25(OH)D, the findings from two trials suggest that the benefits of vitamin D supplementation for prevention of exacerbations are restricted to participants who are deficient in vitamin D at baseline. Clinicians who wish to off er vitamin D supplementation to patients with COPD should therefore check the patients’ serum 25(OH)D concentrations and offer targeted supplementation to deficient individuals, rather 4 Anand, Anju (respandsleepjc). Thoughts why is daily vit D perhaps better than bolus for vit D? May 28, 2015, 1654h GMT. Tweet. 5 Martineau, Adrian (rsjcguest). Daily may work better because it elevates parent metabolite, or because bolus causes unwanted upregulation of CYP2A4. May 28, 2015, 1659h GMT. Tweet. 6 Anand, Anju (respandsleepjc). Dr. Martineau we r discussing diff erential dropout+lost to FU. Did you consider regression models to look @ this (multiple imputation)? May 28, 2015, 1701h GMT. Tweet. 7 Stanbrook, Matthew (drstanbrook). Why did ViDiCO not stratify randomization for low vs normal Vitamin D levels, since a prespecifi ed subgroup analysis? May 28, 2015, 1635h GMT. Tweet. 8 Martineau, Adrian (rsjcguest). Knowledge of vitD status at baseline could have raised issues re randomising patients with known defi ciency to placebo. May 28, 2015, 1642h GMT. Tweet. analysis if they had used multiple imputations. Finally, participants were stratifi ed into groups on the basis of their FEV1 and participation in the sputum induction substudy. However, because one of the prespecified subgroup analyses was to examine whether the eff ect of the intervention on the coprimary outcomes of time to fi rst moderate or severe exacerbation and fi rst upper respiratory infection was modifi ed by baseline vitamin D status, we believe that the stratifi ed randomisation should ideally have been done on the basis of the patients’ baseline vitamin D status. Martineau responded that knowledge of patients’ baseline vitamin D status could have raised concerns regarding randomly assigning those with a known defi ciency to placebo. Overall, our group felt that although the study showed a reduced risk of exacerbation with vitamin D3 in patients who were defi cient in vitamin D, many of us would not initiate vitamin D3 supplementation in such patients for the purpose of reducing exacerbations. However, we agree with Martineau and colleagues that a randomised controlled trial of vitamin D supplementation in patients with COPD who are defi cient in vitamin D would be important to confi rm this study’s fi ndings.