Chest
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Randomized Controlled Trial Multicenter Study
Formoterol, 24 microg bid, and serious asthma exacerbations: similar rates compared with formoterol, 12 microg bid, with and without extra doses taken on demand, and placebo.
The primary objective was to determine whether high-dose formoterol, 24 mug bid, was associated with more asthma exacerbations compared with lower formoterol doses in patients with stable persistent asthma. Serious asthma exacerbations (life threatening or requiring hospitalization) were the primary end point. Secondary end points included significant exacerbations requiring systemic corticosteroids, all exacerbations, and changes in FEV1. ⋯ Treatment with formoterol, 24 microg bid, was not associated with an increase in serious asthma exacerbations compared with the lower formoterol doses or placebo.
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Randomized Controlled Trial Multicenter Study
Cilomilast for COPD: results of a 6-month, placebo-controlled study of a potent, selective inhibitor of phosphodiesterase 4.
COPD is a relentless, progressive disease. This study evaluated the efficacy of cilomilast, a selective phosphodiesterase (PDE) 4 inhibitor, in the treatment of COPD. ⋯ Cilomilast is an orally active, potent, and selective inhibitor of PDE-4. Cilomilast maintained pulmonary function and improved health status, and reduced the rate of COPD exacerbations during 24 weeks of treatment. This study supports the use of cilomilast, a novel, selective PDE-4 inhibitor, in subjects with COPD.
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While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. ⋯ The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.
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To review the literature on habit, tic, and psychogenic cough, and to make evidence-based recommendations regarding diagnosis and treatment. ⋯ The methodologies used and rigor of the diagnostic and therapeutic interventions reported in the literature are inconsistent. The putative clinical characteristics of habit cough and psychogenic cough, for the most part, have not been prospectively or systematically studied. Therefore, on the basis of expert opinion, the diagnoses of habit cough or psychogenic cough can be made only after an extensive evaluation is performed that includes ruling out tic disorders and uncommon causes of chronic cough, and when cough improves with behavior modification or psychiatric therapy. In adult patients with chronic cough that remains persistently troublesome despite an extensive and thorough evidence-based evaluation, and after behavior modification and/or psychiatric therapy have failed, unexplained cough should be diagnosed rather than habit cough or psychogenic cough. In children, the depth of investigations to rule out uncommon causes must be individualized as some investigations and/or treatment may increase morbidity. In adult and pediatric patients with chronic cough that is associated with troublesome psychological manifestations, psychological counseling or psychiatric intervention should be encouraged after other causes have been ruled out.
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To review the role of chronic interstitial pulmonary disease in the spectrum of causes of cough and its management. ⋯ In patients with cough, chronic interstitial pulmonary disease should be considered as a primary cause only after more common causes, such as upper airway cough syndrome and gastroesophageal reflux, have been excluded. Successful management depends on identification of the specific disorder.