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  1. Wisia Wedzicha, Editor in Chief

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The GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines include a stage 0, an “at risk” category which describes individuals in whom there is no airflow obstruction but chronic symptoms such as cough and sputum are present. In this issue of Thorax we publish a key paper by de Marco and colleagues from the European Community Respiratory Health Survey in which data from 18 000 young adults (aged 20–44 years) were analysed. Data are presented for the prevalence of COPD of different stages for the countries participating in the survey. The authors found a prevalence of 11.8% for GOLD stage 0, with an association with moderate to heavy smoking. Childhood respiratory infections, low socioeconomic status, occupational exposure, and greater healthcare resource use were associated with GOLD stage 0, showing that similar risk factors were present in this group to those in patients with established COPD. Although COPD is often diagnosed in older adults, there is now evidence that it develops much earlier in adult life. As Vestbo concludes in his accompanying editorial, to limit screening for COPD to older people would be missing a window of opportunity for COPD prevention in these younger adults.
See 89 and 120


One of the aims of asthma management is to reduce the severity of asthma exacerbations, and action plans have been used as an important tool to help the asthma patient detect and treat exacerbations. In this month’s Thorax Gibson and Powell describe a review of 26 randomised controlled trials that investigated various types of asthma action plans. The authors found that individualised action plans based on 2–4 action points using personal best peak expiratory flow and both inhaled and oral corticosteroids gave the best outcomes, while non-specific action plans improved symptoms and knowledge about the condition. However, as Partridge points out in the accompanying editorial, implementation of asthma action plans has been poor. Greater knowledge of the type of action points that are beneficial should be used to encourage widespread use of personalised action plans and thus improve asthma control.
See pages 87 and 94


Low bone mineral density (BMD) is a problem in cystic fibrosis, although little information is available on the course of bone disease in cystic fibrosis. In this issue of Thorax Buntain and colleagues describe how BMD varies with the age of individuals with cystic fibrosis. They found that BMD was within normal limits in prepubertal children with cystic fibrosis, but a BMD deficit develops in adolescence and is greater in adults with cystic fibrosis. This emphasises the importance of including various interventions to minimise loss of BMD in the management of cystic fibrosis.
See page 149


High dietary intake of fish has been associated with a reduced incidence of inflammatory conditions and thus there has been some interest in the effects of long chain fatty acids derived from fish on the risk of asthma. Woods and colleagues describe a community study of plasma long chain fatty acids, as a measure of dietary intake, in subjects with and without asthma. They found that n-3 polyunsaturated fatty acids, which occur in fish, were not related to asthma or atopy, but there was a relationship between asthma and the n-6 fatty acid DHGLA—a form of linolenic acid that comes from dietary plant sources. These results are intriguing and longitudinal studies are now required to evaluate these observations further.
See page 105


There is currently much interest in the interaction between coagulation and inflammation. Fibrin has been shown to enhance the inflammatory response, while proinflammatory cytokines increase expression of tissue factor that activates the clotting cascade. Schultz and colleagues report interesting data showing that, in patients with ventilator associated pneumonia, there is early local activation of coagulation and inhibition of fibrinolysis. In patients who developed pneumonia there was an increase in airway thrombin generation and tissue factor, with a decrease in fibrinolytic activity in bronchial lavage fluid. Severe pneumonia is associated with an early procoagulant state and this feature may be responsive to interventions.
See page 130

Scatterplot showing the prevalences (%) of chronic symptoms without airflow obstruction (stage 0).

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