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Prim Care Respir J 2012; 21(2): 121-134

121PRIMARY CARE RESPIRATORY JOURNALwww.thepcrj.org

Whats your journals Impact factor? must rank amongst thecommonest questions asked of journal editors, and our

experience is no different. A lthough we still cant quite answer

this question, we are delighted to report that Thomson Reuters

ISI has recently selected the PCRJfor inclusion in its Web-of-

Science citation index listing and that the Journalhas been

awarded an Impact factor. The PCRJsfirst Impact factor will

appear in the 2012 Journal C itation 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 towhat 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.

O nce 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 areconsidered 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. O ur 2012 Impact factor will therefore be

calculated as follows:

A = the number of times articles published in the PCRJin

2010 and 2011 were cited by Thomson Reuters ISI-indexed

journals during 2012.

B = the total number of " citable items" published by the

PCRJin 2010 and 2011. ( " Citable items" are usually research

articles and reviews, not editorials, correspondence or

educational articles.)

The PCRJ2012 Impact factor = A/B.

For example, an Impact factor of 2.0 (which is considered fairly

respectable) means that papers published in 2010 and 2011received 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 PCRJwill 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 undertak ing applied

research of direct relevance to primary care populations, so we can

probably expect this increase in submissions to continue year-on-year. In preparation for this, we will shortly be advertising for

additional A ssociate 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 PCRJwill increasingly be regarded by universities across the

world as a top-tier journal. A lthough 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 PCRJis now one of only a dozen or so primary care journalsincluded in Thomson Reuters Web-of-Science and, as far as we

are aware, is the onlysub-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

An Impact factor and beyond

Aziz Sheikh, Paul Stephenson

Editors-in-Chief, PCRJ

Correspondence: c/o PCRJEditorial Office, Smithy House,Waterbeck, Lockerbie, DG11 3EY, UK

Tel: +44 (0)1464 600639E-mails: [email protected]

[email protected]

EDITORIALS

Copyright PCRS-UK - reproduction prohibited

http://www.thepcrj.org
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Editorials

and debate, which represents the breadth of respiratory and

respiratory-related allergy seen by primary care practi tioners 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 PCRJpapers 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

M ark 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 PCRJan

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 The authors declare no relevant conflicts of interest inrelation to this article.

17th May 2012; online 29th May 2012

2012 Primary Care Respiratory Society UK . A ll rights reserved

http://dx.doi.org/10.4104/pcrj.2012.00047

Prim Care Respir J 2012;21(2):121-2

References1. 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.


2. Testa J. The Thomson Reuters Journal Selection Process (essay).

http://thomsonreuters.com/products_services/science/free/essays/journal_selection_process/

3. Garfield E. Citation indexing its theory and application in science, technology, and

humanities. New York: John Wiley & Sons, 19794. 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 J2011;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 J2011;21(2):133-4. http://dx.doi.org/10.4104/pcrj.2012.00048

The paper describing the Active Life with A sthma (A LM A )

questionnaire by K iotseridiset al.1 in this issue of the Primary Care

Respirat ory Journalraises 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 A sthma Control Questionnaire (A CQ ).2 The more

interesting questions, however, have yet to be addressed:

a) How do q uestionn aires fit into the w ell defined structure of

a prim ary care consult ation ?

Experience in UK primary care where use of the Patient Health

Q uestionnaire-9 (PHQ -9) wasintroduced asa measure of the severity

of depression in the Quality and OutcomesFramework (QO F)3 in 2006

is not entirely encouraging. Although patientswere relatively positive

and considered that completing questionnairesmade them feel as if

they were being taken more seriously,4 general practitioners (G Ps)

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 (IPC RG ) in their recent prioritisation of research

needs, identified the development of questionnaires (or just

questions) as an important means of diagnosing and assessing

respiratory conditionsin the comparatively low-technology context of

primary care.6 O bjective assessment of control is a core component of

asthma reviews which underpinsmanagement decisions.7 The ALM A

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.

A question of quality? A single questionnaire for measuring

asthma control, structuring asthma reviews, and monitoring

health service standards

*Hilary Pinnocka, Helen Lesterb

a Senior Clinical Research Fellow, Allergy and Respiratory

Research Group, Centre for Population Health Sciences, The

University of Edinburgh, Edinburgh, UKb

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 SciencesThe University of Edinburgh, Doorway 3, Medical School,Teviot Place, Edinburgh, EH8 9AG, UK

Tel: +44 (0)131 650 8102 Fax: +44 (0)131 650 9119E-mail: [email protected]

See linked article by Kiotseridis et al. on pg 139


http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2012.00047http://dx.doi.org/10.4104/pcrj.2009.00051http://dx.doi.org/10.4104/pcrj.2009.00051http://thomsonreuters.com/products_services/science/free/essays/journal_selection_process/http://dx.doi.org/10.4104/pcrj.2011.00013http://dx.doi.org/10.4104/pcrj.2011.00013http://dx.doi.org/10.4104/pcrj.2012.00048mailto:[email protected]://dx.doi.org/10.4104/pcrj.2011.00091http://dx.doi.org/10.4104/pcrj.2011.00091http://dx.doi.org/10.4104/pcrj.2011.00091http://dx.doi.org/10.4104/pcrj.2011.00091http://www.thepcrj.org/http://www.thepcrj.org/mailto:[email protected]://dx.doi.org/10.4104/pcrj.2012.00048http://dx.doi.org/10.4104/pcrj.2011.00013http://thomsonreuters.com/products_services/science/free/essays/journal_selection_process/http://dx.doi.org/10.4104/pcrj.2009.00051http://dx.doi.org/10.4104/pcrj.2012.00047


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b) Will q uestio nnaires be complet ed prop erly in clinical

practice?

The science underpinning the development of Patient Reported

Outcome M easures (PRO M s) emphasisesthe importance not only of

the precise wording of questions but also of context and mode of

delivery in ensuring that the instrument measuresconsistently what it

isintended to measure.8 Instrumentssuch asthe 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

ratesor 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 isunlikely, with clinicians

adopting a range of practical strategiesto overcome the challengesof

time, language, poor literacy and perceived disruption of consultation.

Experience with the PHQ -9 in the context of the QO F identified seven

such strategies,12 (including incorporating paraphrased questions into

the conversation and calculating a score after the consultation), thus

completely negating validation. A lthough the questions used in the

validation exercise reported by Kiotseridiset al. were obtained by self-

completion of a (5-minute) paper questionnaire, the real-life ALM A

database isa (presumably clinician-completed) web-based application

which immediately changesthe dynamicsof completion.

c) What im pact does a temp late have on an asthma review?

The ALM A database, however, is more than another PRO M 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 Templatesmay be welcomed asa meansof 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 ALM A 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 outcomesfor patients.

d) How mig ht health care systems benef it?

There isa final question for the ALM A tool: can the questionnaire raise

standardsof care acrossa healthcare community? Routine use and the

development of a database offers the opportunity to observe

standards of practice and then to benchmark good practice asa first

step to driving up quality of care. A lthough morbidity scores have

been widely used to assess asthma control as part of initiatives to

improve care acrosshealthcare communities for example in Finland17

and the USA 18 the data are generally collected by self-completed

questionnaire aspart of the evaluation of an initiative and thusdo 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 assessmorbidity.

By establishing a database of asthma assessments undertaken

within the local healthcare community, the ALM A project has an

important opportunity to monitor patient-related outcomes and the

impact of initiativeson standardsof care. An explicit focuson quality

improvement is a key aim of the UK Q OF.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 resultsof the voluntary ALM A scheme with the standards

achieved in the financially-rewarded Q O F.

A question of quality

The initiative described by Kiotseridiset al. providesan answer to one

question: asthma control recorded by the ALM A questionnaire

compareswell 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 notinvolved 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 theChief Scientists Office, Scottish Government

Commissioned article; not externally peer-reviewed; accepted 31st January 2012;

online 23rd March 2012




References1. 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 J2012;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 Med2005;99:553-8. http://dx.doi.org/10.1016/j.rmed.2004.10.008

3. NHS Confederation, British Medical Association. New GMS Contract 2003:

investing in general practice. London. March 2003

4. 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. BMJ2009;338:b663.

http://dx.doi.org/10.1136/ bmj.b663

6. Pinnock H, Ostrem A, Romn Rodrguez M et al. Prioritising the respiratory

research needs of primary care: the International Primary Care Respiratory Group

(IPCRG) e-Delphi exercise. Prim Care Respir J 2012;21(1):19-27.


7. 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://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2012.00030http://dx.doi.org/10.4104/http://dx.doi.org/10.1016/j.rmed.2004.10.008http://dx.doi.org/http://dx.doi.org/10.1136/http://dx.doi.org/10.4104/pcrj.2012.00006http://dx.doi.org/10.4104/pcrj.2010.00006http://www.thepcrj.org/http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2010.00006http://dx.doi.org/10.4104/pcrj.2012.00006http://dx.doi.org/10.1136/http://dx.doi.org/http://dx.doi.org/10.1016/j.rmed.2004.10.008http://dx.doi.org/10.4104/http://dx.doi.org/10.4104/pcrj.2012.00030


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8. 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.

9. 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 J2004;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;327:659-

65. 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

Med2006;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? The Example of a

Routine Diabetes Review. Qualitative Health Research 2006;16:353-76.

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 Practitioners1986;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)

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. M ore 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 patientstypically visit their cliniciansto obtain a

solution (e.g. a prescription) to a problem (e.g. a respiratory infection).

However, patientsmay perceive a risk that the clinician will not provide

the anticipated solution and therefore not address the problem to a

satisfactory standard. Thisperceived risk may be heightened asa result

of the rise in public awareness of current campaigns to discourage

cliniciansfrom 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 patientsmay 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

thesisprovidesa potential explanation for Barbaraet al.smain finding

that patients and clinicians record a different quantity of symptoms

and for the contrast between this finding and findings observed in

earlier work.

Thisnotion isfurther supported by Barbaraet al.sfinding 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. Thisbehaviour may stem from the

Perceptions of risk may explain the discrepancy between patient

and clinician-recorded symptoms

Ian Dawsona, Victoria Seniorb,*Simon de Lusignanc

aLecturer in Human Resource Management & Organisational

Behaviour, The Surrey Business School, University of Surrey, UKb

Senior Lecturer in Health Psychology, School of Psychology,

University of Surrey, UKc

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 andClinical Informatics, Department of Health Care Managementand Policy, University of Surrey, Guildford, GU2 7PX, UKTel: +44(0)1483 683089 Fax: +44(0)1483 686208E-mail: [email protected]

See linked article b y Barba ra et al. on pg 145


http://www.thepcrj.org/http://dx.doi.org/10.1016/j.pcrj.2003.11.004http://dx.doi.org/10.1016/j.jclinepi.2005.01.010http://dx.doi.org/10.1016/j.rmed.2005.08.012http://dx.doi.org/10.3399/bjgp11X572472http://dx.doi.org/10.1136/bmj.327.7416.659http://dx.doi.org/10.1370/afm.425http://dx.doi.org/10.1177/1049732305282396http://dx.doi.org/10.1136/thorax.56.10.806http://www.theipcrg.org/resneeds/harp.phphttp://www.ic.nhs.uk/mailto:[email protected]://dx.doi.org/10.4104/pcrj.2011.00098http://dx.doi.org/10.4104/pcrj.2011.00098http://dx.doi.org/10.4104/pcrj.2011.00098http://dx.doi.org/10.4104/pcrj.2011.00098http://www.thepcrj.org/http://www.thepcrj.org/mailto:[email protected]://www.ic.nhs.uk/http://www.theipcrg.org/resneeds/harp.phphttp://dx.doi.org/10.1136/thorax.56.10.806http://dx.doi.org/10.1177/1049732305282396http://dx.doi.org/10.1370/afm.425http://dx.doi.org/10.1136/bmj.327.7416.659http://dx.doi.org/10.3399/bjgp11X572472http://dx.doi.org/10.1016/j.rmed.2005.08.012http://dx.doi.org/10.1016/j.jclinepi.2005.01.010http://dx.doi.org/10.1016/j.pcrj.2003.11.004


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patientsperceived risk of not receiving help for an illnessdue to policy

agendasenacted within the health system.

The discrepancies between patient-recorded and clinician-

recorded symptoms could be attributable to the behavioural risk

management strategiesemployed, 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 actionsare defendable, the clinician then recordsa list of

symptomsthat are typical of the diagnosed condition a list that may

extend beyond the symptoms reported by the patient. Sometimes

practitionersare aware that they are using a diagnostic label to justify

their decision to treat:

when someone comes along in the f lu season, and t heyve

got a viral type infection, and it may be viral Theres a

bit of you that says this is probably viral, so I ough t t o 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 t hem antib iotics, so Ill call it bronchitis. So I actually

put dow n acute bronchit is. 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 w ith.8

Decision-making in primary care often involvessubconscious use

of heuristics or mental rules of thumb to generalise the typical

symptoms of the diagnosed illnessto 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 decisionsand diagnostic judgments.9-11 While such

heuristicsare 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 doctorswho record notesasthey 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

asa 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 issaid to reduce the risk of malpractice suits.19 Although family

practitionersare in a relatively low-liability group they appear to have

greater concernsabout malpractice suitsthan higher risk specialities.20

These tensions may have been enhanced while participating in a

clinical trial. It isplausible that physicians recorded more symptoms to

justify not prescribing antibiotics; this is an interaction which merits

exploration.

O ur interpretation highlights the complex psychological interplay

that can take place between patientsand 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 implicationsof thisstudy;1

Firstly, policy makersshould 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 promptanswers to questions raised by the authors.

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


http://www.thepcrj.org/http://antibioticawareness.ca/http://www.thepcrj.org/http://www.thepcrj.org/http://antibioticawareness.ca/


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Conflicts of interest The authors declare that they have no conflicts ofinterest in relation to this article.

Commissioned article; not externally peer-reviewed; accepted 1st February 2012;

online 23rd February 2012




References1. Barbara AM, Loeb M, Dolovich L, Brazil K, Russell M. Agreement between self-

report and medical records on signs and symptoms of respiratory illness. Prim Care

Respir J2012;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. BMJ2000;320(7244):

1246-50. http://dx.doi.org/10.1136/bmj.320.7244.1246

3. 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.

4. 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 Chemotherapy2006;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 Med2003;42(4):416-22.

9. Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision making:

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-120709-

145346.

11. Kahneman D, Tversky A. Subjective probability: a judgment of representativeness.

Cognitive Psychology1972;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.x17. 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 Med1968;278(11):593-

600. http://dx.doi.org/10.1056/NEJM196803142781105

The effect of the upper airway on the lower airway was

recognised as early as the second century by Claudius G alenus,

who defined the nose as a respiratory instrument in his work De

usu partium (On the usefu lness of t he [body] part s).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 (A RIA ) initiative

focused on the co-morbidities of allergic rhinitis and included

involvement of the eyes, the paranasal sinusesand the lower airways.3

The nasal and bronchial mucosa present a number of similarities, and

one of the most important conceptsregarding 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 patientshave rhinitis and 10-40% of patientswith

rhinitishave asthma.3

The role of upper respiratory tract infections(URTIs) and how they

affect the lower respiratory tract have been lesswell studied compared

to the role of allergic diseases. Similarly, the effectsof URTIson atopic

conditions (other than asthma) have also not been documented to

any appreciable extent. A sthma in children is associated with an

increased risk ofStreptococcus pyogenesupper respiratory infections,5

even though Strep. pyogenesis 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 PA ND A S,7

supposedly of post-streptococcal etiology, is the acronym for Paediatric

Autoimmune Neuropsychiatric Disease A ssociated with Streptococcal

Streptococcus pyogenes upper respiratory infections and their

effect on atopic conditions

*Osman Mohammad Yusufa

a The Allergy and Asthma Institute, Islamabad, Pakistan

*Correspondence: Dr Osman M Yusuf, The Allergy and AsthmaInstitute, 275 Gomal Road, Sector E-7, Islamabad, Pakistan 44000

Tel: (0092) 51 2654445 Fax: (0092) 51 2654446E-mail: [email protected]

See linked article by Juhn et al. on pg 153


http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2012.00024http://dx.doi.org/10.4104/pcrj.2011.00098http://dx.doi.org/10.1136/bmj.320.7244.1246http://dx.doi.org/10.1016/S1473-3099http://dx.doi.org/10.1093/jac/dkl275http://dx.doi.org/10.1136/bmj.315.7107.520http://dx.doi.org/10.3109/http://dx.doi.org/10.1136/bmj.324.7339.729http://dx.doi.org/10.1146/annurev-psych-120709-145346http://dx.doi.org/10.1146/annurev-psych-120709-145346http://dx.doi.org/10.1016/0010-0285http://dx.doi.org/10.1037/0033-295X.103.4.650http://dx.doi.org/10.1080/01449298208914438http://dx.doi.org/10.1111/j.1742-1241.2011.02781.xhttp://dx.doi.org/10.1136/bmj.310.6971.27http://dx.doi.org/10.1001/archinternmed.2010.155http://dx.doi.org/10.1056/NEJM196803142781105mailto:[email protected]://dx.doi.org/10.4104/pcrj.2011.00110http://dx.doi.org/10.4104/pcrj.2011.00110http://dx.doi.org/10.4104/pcrj.2011.00110http://dx.doi.org/10.4104/pcrj.2011.00110http://www.thepcrj.org/http://www.thepcrj.org/mailto:[email protected]://dx.doi.org/10.1056/NEJM196803142781105http://dx.doi.org/10.1001/archinternmed.2010.155http://dx.doi.org/10.1136/bmj.310.6971.27http://dx.doi.org/10.1111/j.1742-1241.2011.02781.xhttp://dx.doi.org/10.1080/01449298208914438http://dx.doi.org/10.1037/0033-295X.103.4.650http://dx.doi.org/10.1016/0010-0285http://dx.doi.org/10.1146/annurev-psych-120709-145346http://dx.doi.org/10.1146/annurev-psych-120709-145346http://dx.doi.org/10.1136/bmj.324.7339.729http://dx.doi.org/10.3109/http://dx.doi.org/10.1136/bmj.315.7107.520http://dx.doi.org/10.1093/jac/dkl275http://dx.doi.org/10.1016/S1473-3099http://dx.doi.org/10.1136/bmj.320.7244.1246http://dx.doi.org/10.4104/pcrj.2011.00098http://dx.doi.org/10.4104/pcrj.2012.00024


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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 casesof chronic urticaria are also reported to

be associated with chronic tonsillitis,8 although the primary role of

infection in chronic urticaria iscontroversial.

M ast cellsplay a key role in the pathogenesis of atopic diseasesas

well asin asthma. They are important effector cellsin innate immune

responsesto bacterial infections, and are critically involved in initiating

and modulating optimal host responses to bacteria by either

inflammatory or anti-inflammatory effectsdepending on the course of

the host reaction induced by the pathogen. The exact mechanism for

thisisnot known.9 However, one possible mechanism isvia 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, hasbeen shown to be effective for

treating atopic dermatitis.10

Children sensitised to house dust mite (HDM ) have early defective

antibody responsesto 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 itseffectson allergy have been studied by

Essilfie and co-workersin BA LB/c mice.12 These workersfound 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 thisissue of the PCRJ, Juhn and colleagueshave retrospectively

studied the association of Strep. pyogenesand atopic conditionsother

than asthma in children under the age of 18 years12 an area of

research which hasbeen 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. pyogenesinfections during the first 18 years

of life, and compared the incidence of Strep. pyogenesinfections

between children with and without a physician diagnosisof an atopic

condition. They used a Poisson regression to determine the association

between asthma and Strep. pyogenes infections, controlling for other

covariatesincluding asthma. They found that the incidence of Strep.

pyogenesinfections in children with atopic conditions other than

asthma, and those without atopic conditions, was 0.24 per person-

year 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. pyogenesURTIs.

The authors have looked at many potential hypothesesto 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 smok ing or allergic sensitisation status data were not

available, and the study population waspredominantly Caucasian.

Nevertheless, the overall results of this study suggest that there

may be a link between the immunogenetic predisposition to atopy

and susceptibility toStrep. pyogenesinfection, thusopening up a new

area for research. Primary care practitionersare advised to keep this in

mind when they see patients with repeated URTIs. In addition,

repeated URTIs in children with symptoms of tics such asrepeated

eye blinking or clearing of the throat may be an early sign of chronic

Strep. pyogenesinfection and PANDAS. O ne must also not forget to

examine for additional allergy-associated conditionsincluding (but not

limited to) asthma.

Acknowledgements The author gratefully acknowledges the assistance ofDr 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 wasnot 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




References1. 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.

2. Jay Grossman. One Airway, One Disease. Chest 1997;111:11S-16S.

http://dx.doi.org/10.1378 /chest. 111.2_Supplement.11S.

3. 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.2001.1188914. Togias A. Rhinitis and asthma: evidence for respiratory system integration.J Allergy

Clin Immunol2003;111(6):1171-83; quiz 84.

http://dx.doi.org/10.1067/ mai.2003.1592

5. 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 Proc2009;30(5):540-5. http://dx.doi.org/10.2500/aap.2009.30.3268

6. Weinberger M. Respiratory infections and asthma: current treatment strategies. Drug

Discov Today2004;9(19):831-7. http://dx.doi.org/10.1016/S1359-6446(04)03239-8

7. de Oliveira SK. PANDAS: a new disease? J Pediatr (Rio J) 2007;83(3):201-08.

http://dx.doi.org/10.2223/JPED.1615

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 themagnitude 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 Treat2005;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.

Thorax2011 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 J2012;21(2):153-8. http://dx.doi.org/10.4104/pcrj.2011.00110


http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2012.00034http://dx.doi.org/10.1378http://dx.doi.org/10.1067/mai.2001.118891http://dx.doi.org/10.1067/http://dx.doi.org/10.2500/aap.2009.30.3268http://dx.doi.org/10.1016/S1359-6446http://dx.doi.org/10.2223/JPED.1615http://dx.doi.org/10.1111/j.1600-0625.2008.00778.xhttp://dx.doi.org/10.1080/http://dx.doi.org/10.4104/pcrj.2011.00110http://www.thepcrj.org/http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2011.00110http://dx.doi.org/10.1080/http://dx.doi.org/10.1111/j.1600-0625.2008.00778.xhttp://dx.doi.org/10.2223/JPED.1615http://dx.doi.org/10.1016/S1359-6446http://dx.doi.org/10.2500/aap.2009.30.3268http://dx.doi.org/10.1067/http://dx.doi.org/10.1067/mai.2001.118891http://dx.doi.org/10.1378http://dx.doi.org/10.4104/pcrj.2012.00034


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The G lobal A lliance against Chronic Respiratory Diseases estimates

that there are 210 million cases of chronic obstructive pulmonary

disease (C O PD) globally.1 The G lobal Initiative for Chronic

O bstructive Lung Disease (G O LD) guidelines2 and the International

Primary Care Respiratory G roup (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 ex-

smokers aged over 35 years of age and using spirometry or

questionnaires or both to identify likely CO PD patients who then

require high quality diagnostic standard spirometry.4,5 In this issue of

the PCRJthere 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

CO PD case-finding.6 In the second, Abramson et al. report a mixed

methods study on the accuracy of asthma and CO PD diagnosis in

Australian primary care.7

There are considered perspectives available from both

proponents and opponents to the concept of CO PD case-finding in

primary care as previously debated and then summarised recently

in this journal.8 Furthermore, there is no consensus as to which case-

finding method is best microspirometry versus standard spirometry

and whether these should be performed either pre- or post-

bronchodilator8-10 and with or without questionnaire screening.4,11

Thorn and colleagues6 report that a pre-bronchodilator FEV1/FEV6

ratio


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score cut-off used. C ombining spirometric and questionnaire

approaches might improve the positive predictive value of the case-

finding approach. A lthough Sichletidis et al.10 reported that

combining the IPAG questionnaire and PiK o-6 flow meter was

associated with a small improvement in the positive predictive value

compared to the PiK o-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.

M icrospirometry (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 case-

finding 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 C O PD13 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 post-

bronchodilator microspirometry to confirm the validity of pre-

bronchodilator measurements are required.

However, we need to ensure that this debate on the tools

required for primary care CO PD case-finding has real relevance to

grass-roots general practice. A bramson and colleagues report that

CO PD is substantially under-diagnosed in primary care in Australia.7

Guidelines recommend that a diagnosis of C O PD 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

CO PD made during a 12-month period, over 28% of the diagnoses

were made without spirometry. O f the 199 patients with baseline

diagnostic spirometry, evidence of post-bronchodilator airflow

limitation consistent with C O PD was found in 91 patients, of whom

51 (56% ) had a doctor diagnosis of asthma alone. In qualitative

interviews with the participating general practitioners (G Ps), 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 C O PD in

primary care.

Initiation of therapy in CO PD 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 G P for differentiating C O PD from

asthma. As treatments for C O PD 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, AstraZeneca, 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 . A ll rights reserved



References1. Global surveillance, prevention and control of chronic respiratory diseases: a

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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 J2006;15(1):20-34.

http://dx.doi.org/ 10.1016/j.pcrj.2005.10.0044. Soriano JB, Zielinski J, Price D. Screening for and early detection of chronic obstructive

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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.


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 real-

life study and cost-effectiveness analysis. Prim Care Respir J 2012;21(2):159-66.


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 J2012;21(2):167-73.

http://dx.doi.org/10.4104/ pcrj.2011.001038. 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.


9. Frith P, Crockett A, Beilby J, et al. Simplified COPD screening: validation of the PiKo-

6(R) in primary care. Prim Care Respir J 2011;20(2):190-8.


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.


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.


http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2012.00046http://dx.doi.org/http://dx.doi.org/10.1016/http://dx.doi.org/10.4104/pcrj.2009.00055http://dx.doi.org/10.4104/pcrj.2011.00104http://dx.doi.org/10.4104/http://dx.doi.org/10.4104/pcrj.2011.00050http://dx.doi.org/10.4104/pcrj.2011.00040http://dx.doi.org/10.4104/pcrj.2011.00038http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2011.00038http://dx.doi.org/10.4104/pcrj.2011.00040http://dx.doi.org/10.4104/pcrj.2011.00050http://dx.doi.org/10.4104/http://dx.doi.org/10.4104/pcrj.2011.00104http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2009.00055http://dx.doi.org/10.1016/http://dx.doi.org/http://dx.doi.org/10.4104/pcrj.2012.00046


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12. Price DB, Tinkelman DG, Nordyke RJ, Isonaka S, Halbert RJ. Scoring system and

clinical application of COPD diagnostic questionnaires. Chest2006;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.

Q uality of life (Q oL) 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, Q oL

indices can highlight the important impact of a condition.1 O ne 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 Q oL 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 Respirato ry Journal, Stjrne and colleagues6 report on the high

costs and health-related Q oL in acute rhinosinusitis in a Swedish

primary care setting. Using a prospective, observational study design

at 11 sites, Q oL and cost analyses in adults with acute rhinosinusitis

were assessed. Subjects were evaluated by the rhinosinusitis-specific

M ajor 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. A t 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 Q oL, 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 to6,111 ) with a mean cost of 10,260 SEK (1,102). O f 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-specif ic symptom scores and Q oL. Further,

direct and indirect costs of this disease have not been well-studied

before, and have never been evaluated in Scandinavia.

A llergy 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 ini tially

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

Acute rhinosinusitis does quality of life explain continued

rates of antibiotic overusage?

*Sam Friedlandera

aAssistant 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, UniversityHospitals of Cleveland, Cleveland, Ohio, USATel: 440-248-1630 Fax: 440-349-8160

E-mail: [email protected]

See linked a rticle b y Stj rne et al. on pg 174


http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2010.00060http://dx.doi.org/10.1378/chest.129.6.1531http://dx.doi.org/10.1016/S0140-6736mailto:[email protected]://dx.doi.org/10.4104/pcrj.2012.00011http://dx.doi.org/10.4104/pcrj.2012.00011http://dx.doi.org/10.4104/pcrj.2012.00011http://dx.doi.org/10.4104/pcrj.2012.00011http://www.thepcrj.org/http://www.thepcrj.org/mailto:[email protected]://dx.doi.org/10.1016/S0140-6736http://dx.doi.org/10.1378/chest.129.6.1531http://dx.doi.org/10.4104/pcrj.2010.00060


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Editorials

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 A llergy,

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. A dditional teaching slides are

available on a wide variety of respiratory conditions, providing

Continuing M edical Education (C M E) credits for trainees, primary

care physicians and specialists.

Conflicts of interest The author declares speakers honoraria for Teva andSunovion.

Commissioned article; not externally peer-reviewed; accepted 10th May 2012;





References1. Friedlander SL, Larkin EK, Rosen CL, Palermo TM, Redline S. Decreased quality of life

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. Fokkens WJ, Lund V, Mullol J, et al. The european position paper on rhinosinusitis and

nasal polyps 2012. Rhinology- Supplement 2012;23:1-299.

3. Cherry DK, Woodwell DA, Rechtsteiner EA. National ambulatory medical care survey:

2005 summary.Adv Data 2007;387:1-39.

4. Wang DY, Wardani RS, Singh K, et al. A survey on the management of acute

rhinosinusitis among asian physicians. Rhinology2011;49(3):264-71.

5. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: Establishing definitions for

clinical research and patient care.J Allergy Clin Immunol2004;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 Immunol2008;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

J2009;88(4):E17-9.

9. Ciprandi G, Buscaglia S, Pesce G, Villaggio B, Bagnasco M, Canonica GW. Allergicsubjects express intercellular adhesion molecule--1 (ICAM-1 or CD54) on epithelial

cells of conjunctiva after allergen challenge.J Allergy Clin Immunol1993;91(3):783-

92. 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 Pract2012 (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

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

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. O ne of the factors which

probably contributes to the presence of respiratory symptoms is

obesity, defined as a body mass index (BM I) of > 30 kg/m2.

The increasing prevalence of obesity is one of the major global

Obesity, airflow limitation, and respiratory symptoms: does it

take three to tango?

*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 ABHaelen, The NetherlandsTel: +31-475-587600 Fax: +31-475-587592

E-mail: [email protected]

See linked a rticle b y Zutler et al. on pg 194


http://www.thepcrj.org/http://education.aaaai.org/courseshttp://dx.doi.org/10.4104/pcrj.2012.00045http://dx.doi.org/10.1001/archpedi.157.12.1206http://dx.doi.org/10.1016/j.jaci.2004.09.029http://dx.doi.org/10.4104/http://dx.doi.org/10.4104/http://dx.doi.org/10.1016/S1081-1206http://dx.doi.org/10.1016/0091-6749http://dx.doi.org/10.1128/CVI.00172-06http://dx.doi.org/10.1093/fampra/cms022http://dx.doi.org/10.1086/380641http://dx.doi.org/10.1093/cid/cis370http://dx.doi.org/10.1016/j.otohns.2007.07.021http://dx.doi.org/10.1016/S1473-3099mailto:[email protected]://dx.doi.org/10.4104/pcrj.2012.00028http://dx.doi.org/10.4104/pcrj.2012.00028http://dx.doi.org/10.4104/pcrj.2012.00028http://dx.doi.org/10.4104/pcrj.2012.00028http://www.thepcrj.org/http://www.thepcrj.org/mailto:[email protected]://dx.doi.org/10.1016/S1473-3099http://dx.doi.org/10.1016/j.otohns.2007.07.021http://dx.doi.org/10.1093/cid/cis370http://dx.doi.org/10.1086/380641http://dx.doi.org/10.1093/fampra/cms022http://dx.doi.org/10.1128/CVI.00172-06http://dx.doi.org/10.1016/0091-6749http://dx.doi.org/10.1016/S1081-1206http://dx.doi.org/10.4104/http://dx.doi.org/10.1016/j.jaci.2004.09.029http://dx.doi.org/10.1001/archpedi.157.12.1206http://dx.doi.org/10.4104/pcrj.2012.00045http://education.aaaai.org/courses


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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 wasthe fifth

leading risk factor for death, accounting for nearly 3 million deathsper

year.

A link between obesity and the respiratory system is well

established. O besity affects pulmonary function at rest, with a

reduction in functional residual capacity (FRC )7 asits most prominent

effect. However, the effectsof 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 asa 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 O bese subjects free of

respiratory disease report decreased ability to perform daily physical

activitiesdue 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 effectsof excessbody fat masson

the lungs, obesity is increasingly linked to chronic respiratory

conditions. O besity predisposes to obstructive sleep apnoea, 11

pulmonary embolism,12 and asthma.12 Furthermore, obesity probably

contributes to heterogeneity in pulmonary and systemic

manifestationsin patientswith chronic obstructive pulmonary disease

(COPD).13 Like obesity, COPD isa major cause of worldwide morbidity

and mortality, and the burden of C O PD will increase over the next few

decades. The degree of airflow limitation in CO PD isa poor predictor

of patient-related outcomes including dyspnoea, cough, exercise

tolerance and health status.14 Therefore, it isimportant to understand

the impact of concomitant conditions, including obesity, on relevant

outcomes in CO PD. While it was recently reported that obese CO PD

patients have increased dyspnoea at rest and poorer health status

compared to normal weight patients,14 some favourable effects of

obesity in C O PD have been described. O besity resultsin a reduction of

static lung hyperinflation in CO PD, irrespective of the severity of

disease.15 Also, peak cycling capacity is preserved in obese CO PD

patientscompared to non-obese patientswith a comparable degree

of airflow limitation,15 although the distance covered during a 6-

minute walk test (6M WT) isreduced.16 M oreover, dyspnoea ratingsare

consistently lower during cycling in obese patients, probably due to

the beneficial effectsof the excessive fat masson dynamic ventilatory

mechanics.15 Finally, in patients with severe CO PD, obesity is

associated with improved survival,17 while its contribution to the

increased cardiovascular morbidity and mortality in less advanced

disease remainsto be established.18

Since the worldwide prevalence of both chronic airflow

obstruction aswell asobesity 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 priori ty. The study by Zutleret al.19 in thisissue of the

PCRJgreatly enhancesour 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 C O PD, respiratory symptoms including

productive cough and exercise-induced dyspnoea were evaluated.

Clinical assessment included pre-bronchodilator spirometry, and

measurement of BM I, 6M WT, and lower extremity function. The

frequenciesof airflow obstruction (FEV1/FVC < 0.70) and obesity were

nearly 19% and 40% , respectively. O bese 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 symptomsand enhancing performance in obese

patients per sein 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, i t is not clear whether more severe

impairment in lung function than waspresent in thisstudy19 (median

FEV1 was83% 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 CO PD would clinically benefit from weight reduction,

since obesity is not necessarily associated with adverse outcomes in

patients with CO PD.15,17 Until the gaps in our understanding of the

relationship between obesity, chronic airflow limitation and respiratory

symptomshave been filled, the question asto whether it takestwo or

three to tango remains unanswered

Conflicts of interest The author declares that he has no conflicts of interestin relation to this article.

Funding None.

Commissioned article; not externally peer-reviewed; accepted 29th April 2012;





References1. 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 J1996;9(4):687-95.

http://dx.doi.org/10.1183/ 09031936.96.09040687

2. 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


http://www.thepcrj.org/http://dx.doi.org/10.4104/pcrj.2012.00040http://dx.doi.org/10.1183/http://www.thepcrj.org/http://www.thepcrj.org/http://dx.doi.org/10.1183/http://dx.doi.org/10.4104/pcrj.2012.00040


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Editorials

community respiratory health survey. Health Qual Life Outcomes 2010;8:107.

http://dx.doi.org/10.1186/1477-7525-8-107

3. WHO. Obesity: preventing and managing the global epidemic. Report of a WHO

Consultation. WHO Technical Report Series 894. 2000.

4. WHO. Global database on Body Mass Index. [Website]; 2012 [updated 2012; cited];

Available from: http://apps.who.int/bmi/index.jsp.

5. 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.

asthma control tests

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