Oxygen is an essential part of the most important metabolic pathways in aerobic organisms. Oxygen delivery is merely dependent on blood, rendering blood loss a devastating event. Traumatic pre-hospital liver bleeding is a major cause of early trauma deaths in human and animals, with no established therapeutic method yet. Increasing intra-abdominal pressure (IAP) has been shown to reduce liver bleeding by half. Although reduction of blood loss could be in favor of blood oxygen delivery, however, the complex interaction between increased IAP and respiratory mechanics during severe hemorrhagic shock remained unclear. We used a novel model of liver trauma in 16 rabbits and randomly assigned them to either normotensive abdomen group or increased IAP by fluid infusion (HA) groups (n=8 each). Liver size and the amount of liver injury were evaluated. Various blood oxygenation parameters were recorded. Both groups were identical in terms of the liver size and injury. The HA group had significantly lower shock index. Arterial oxygen capacity and oxygen content were higher in the HA group. No significant statistical difference was seen between groups in terms of abdominal perfusion pressure; alveolar pressure of oxygen; dissolved oxygen in blood plasma; alveolar to arterial oxygen tension gradient; arterial to alveolar oxygen pressure ratio; the ratio between partial pressure of arterial oxygen and fraction of inspired oxygen; and respiratory index. In conclusion, the novel therapeutic method of increasing IAP by fluid infusion in a rabbit model of liver hemorrhage preserved blood oxygenation better than the classic therapeutic method. Hypoperfusion hypoxia and hypoxic hypoxia are two main categories in the classification of hypoxia.2Oxygen is a key element in aerobic cell metabolism. In a clinical point of view, oxygen content of blood and oxygen delivery are of the most important issues in critically ill and unconscious patients.3 Hemorrhagic shock is one of the most common types of shock following trauma, with a high mortality rate, especially in the pre-hospital setting.3,4 Hemorrhagic shock could be a mixture of various kinds of hypoxia, including hypoxic hypoxia , anemic hypoxia, and hypoperfusion hypoxia.2 Thus, determination and restoration of blood oxygenation and oxygen delivery is the main objectives in traumatic hemorrhaging patients.3 In a previous study of traumatic liver hemorrhage, we have shown great reduction of liver bleeding following hyperpressure intra-abdominal fluid infusion via a small catheter. In fact, hyperpressure fluid in the abdominal cavity acts like pushing a tampon on the bleeding site.5 This method is useful in pre-hospital arena where there is no direct intra-abdominal access. Although increasing the intra-abdominal pressure (IAP) is not a definitive cure, it can buy time until the patient can be brought to the medical center for definitive treatment. While this new concept promises an exciting future for the pre-hospital arena, still arguments remained about the negative effects of intra-abdominal hypertension (IAH) on the respiratory system. The rationale is that increased IAP mechanically displaces the diaphragm towards the thorax. This may lead to alveolar collapse, decreased functional residual capacity, and decreased tidal volume.6 Thereby, although IAH reduces the hemorrhage (leading to increased blood oxygenation), however at the same time it may negatively affect the respiration (leading to decreased blood oxygenation). Therefore, the respiratory effect of increased IAP for controlling traumatic intra-abdominal liver bleeding is a complex event and behaves like a two-edged sword: its benefits should be weighed against its detrimental effects. In a close analogy, shock is defined as “failure to maintain tissue perfusion and oxygenation”.The aim of this study was to elucidate effects of fluid induced intra-abdominal hypertension on blood oxygenation in a mixed model of intra-abdominal hemorrhage following severe experimental liver injury in rabbits. Results of this study may have implications on management of veterinary or medical patients with concurrent traumatic intra-abdominal bleeding and pathologic IAH (e.g. bowel edema due to heavy fluid resuscitation), or laparoscopic surgeries of traumatic patients in which a method of abdominal insufflation is routinely used.7 Sixteen male New Zealand White rabbits (2.085 ± 0.185 kg) were used in this study. The animals were randomly divided into two groups: Normotensive abdomen (NA) as controls and hypertensive abdomen (HA) as treatment groups, with 8 animals in each group. Details of surgical procedures and liver injury modeling have been reported previously,5 and are briefly described here. Intravenous access was established through marginal ear vein. This study was approved by the Urmia University Research Council and conformed to the rules of the Protection of Vertebrate Animals Used for Experimental and other Scientific Purposes.-1, Alfasan, Holland) injection. Anesthesia was deepened by halothane face mask. Orotracheal intubation was performed, and a modified Jackson-Rees non-rebreathing anesthesia circuit was used for maintenance of anesthesia.8 Right carotid artery was catheterized for arterial pressure monitoring and blood sampling. Liver was injured with a novel method under complete control on the IAP.5 Briefly, two tourniquets were preplaced around the vascular structures of the left lateral lobe of the liver: (1) proximally: a single loose tourniquet to stop the bleeding at the end of the experiment, and (2) distally: a modified Rumel tourniquet to temporarily delay the bleeding after liver transection while the abdomen was open. Heparin  was administered intravenously. The tourniquet was gently tightened. The liver lobe was resected 20% up its proximal length. Abdominal incision was closed and the tourniquet was removed to initiate the hemorrhage. The animals were promptly randomized to either NA group, or HA group.Rabbits were tranquilized by slow intravenous ketamine (15 mg kg-1 in NA group and 0 mL kg-1 in HA group).5 The procedure was continued for 20 min.The animals of NA group only received IV lactated Ringer’s fluid resuscitation  and the animals of HA group received IV lactated Ringer’s fluid resuscitation along with IP infusion of 3.86% dialysate  to produce an IAP of 11 mm Hg. The aforementioned IV lactated Ringer’s fluid resuscitation was used to keep the mean arterial blood pressure (MAP) above 30 mmHg according to the reference value 9 and modified shock index (SI)10 were recorded by a computerized data acquisition system  according to the reference methods. Alveolar pressure of oxygen , alveolar to arterial oxygen tension gradient , arterial to alveolar oxygen pressure ratio , oxygen capacity , oxygen content , the ratio between partial pressure of arterial oxygen (PaO2) and fraction of inspired oxygen , and respiratory index (RI) were obtained from an arterial blood gas analyzer . Dissolved oxygen in blood plasma  was calculated by subtracting the O2Cap from the O2Ct.3,11 Since the liver has a high oxidative metabolic rate,12 to ensure that animals were homogenous in terms of liver size and mass, we measured the maximum length of the liver lobe and generated a liver weight (LIW) profile. The LIW profile was defined as the total LIW, total lobe weight, ratio of the lobe weight to the LIW, and ratio of LIW to pre-injury body weight  and at 5-min intervals after initiation of bleeding.y weight . To ensuy weight . At the 2; PaO2/FiO2; DissO2; RI; liver lobe maximum length; ratio of the lobe weight to the LIW; ratio of LIW to pre-injury body weight; ratio of RLW to remaining LIW; ratio of RLW to total LIW; and ratio of RLW to pre-injury body weight were not normally distributed which were normalized by natural logarithm. Seven covariance structures  were examined. The Toeplitz structure was fitted for DissO2. Rests of the parameters were evaluated by first-order ante-dependence. Histograms, boxplots, scatter plots, and Shapiro–Wilk test were used to assess the data for outliers, normality of distribution and homogeneity of variances. Data for AaDOP < 0.05 was considered significant. Results are presented as mean ± SEM. Statistical analyses were conducted using PASW Statistics release 18 for Windows .Two-way repeated measures ANOVA was used to test overall differences between groups and within subjects, followed by Bonferroni test for multiple pairwise comparisons. Differences between groups for the variables related to the liver weight profile and the weight profile of transected liver parts were tested by unpaired Student’s t test. A value of P < 0.0005). No statistically significant difference in PaO2 or hemoglobin oxygen saturation levels was observed between two groups. The APP in both groups was significantly reduced between the baseline and final states (P < 0.0001). For NA group, the APP was gradually reduced in an approximately constant rate (P = 0.009).The blood loss in the HA group was significantly lower than that in the NA group (ant rate . For theP < 0.0001). The HA group had a relatively constant values of SI through the experiment, without significant differences between the baseline and final states (P = 0.88). The HA group had lower shock index values than the NA group, with statistically significant differences at the 15- and 20-min time points (P < 0.04). The APP remained in an almost steady state for the remaining part of the experiment. No significant statistical difference of APP was observed between the NA and HA groups. Shock index in the NA group  was sign2 is presented in 2 level of HA group was significantly lower than the baseline value of this group (P = 0.002). The value of PAO2Cap and O2Ct were changed in a similar fashion , however, in minutes 15 and 20, the HA group had significantly higher values of O2Cap (P < 0.03) and O2Ct (P < 0.04) than the NA group. The amount of DissO2 was statistically similar between groups and through the course of the experiment. No statistically significant change was observed for AaDO2, aA Ratio, PaO2/FiO2, and RI between two study groups or between their baseline and final states (data not shown).The amounts of O fashion . There w2Cap, and O2Ct values were in favor of the HA group, while there was no statistically significant difference among the groups in terms of AaDO2, aA Ratio, PaO2/FiO2, RI, and DissO2.Our study showed that the novel method of iatrogenic intra-abdominal hypertension with a certain level of IAP during hemorrhagic shock did not negatively affect the parameters of blood oxygenation in comparison to the group with normal intra-abdominal pressure and hemorrhagic shock. In this study, the SI, APP, O2O (14.7 mmHg) for controlling intra-abdominal hemorrhage in pigs.14-16 In our pilot study, this IAP resulted in a failure of respiratory movements and deleterious blood gas parameters, suggesting the influence of differing respiratory muscle strength between pigs and rabbits. Although the aim of this study was not to determine the ideal IAP for the control of liver bleeding, no severe respiratory effects were seen after the IAP was decreased to 11 mmHg. It should be noted that an IAP of 10 mmHg in rabbits is defined as the routine IAP for a laparoscopic study.17Previous researches used an IAP of 20 cm H18 In critically ill patients, it has been shown that APP has a higher predictive value than other routine resuscitation end-points such as IAP, arterial pH, base excess (or base deficit), and arterial lactate content.19 Since it is calculated by subtracting the IAP from MAP9, the reduction of APP in both groups is directly related to the reduction of MAP during hemorrhagic shock. The significant reduction of APP in the HA group between the baseline and 5 min time point could be related to rapid increase of IAP at the beginning of the experiment. Afterwards, it seems that compensatory mechanisms attempted to maintain the APP in a relatively constant level, by preventing more MAP reduction. No significant difference of APP among the study groups may implicate on both groups having a similar blood perfusion in abdominal organs. The APP is an important indicator of abdominal organ perfusion and implicate on oxygen delivery, especially during intra-abdominal hypertension.10 and it is known to be a better predictor for identifying critically ill patients than either heart rate or systolic or diastolic blood pressure alone.3 The lower SI in the HA group may show better oxygenation due to less severe blood loss and shock, and an overall less critical condition in this group. Comparing both APP and SI, it may be concluded that although HA and NA groups had a similar abdominal organ perfusion, however, the HA group had an overall better oxygenation than the NA group. This phenomenon may be related to the shifting of blood from the abdominal compartment  toward the thorax and cranial body regions. Although this may result in reduction of abdominal perfusion, however, this is in cost of better oxygenation to more vital structures such as brain and heart. The amount of PAO2 could be mathematically presented by the alveolar gas equation:20The shock index is a predictive value for the severity of blood loss, shock and survivability. It was developed for prompt assessment of hemorrhagic patientsB is the barometric pressure, which for the Urmia city with 4264 feet above the sea level, PB would be about 650 mmHg; PH2O is the pressure of water vapor at 37°C and is about 47 mm Hg; FiO2 is the fraction of inspired oxygen ; PaCO2 is the partial pressure of carbon dioxide; and R is the respiratory exchange ratio, usually considered to be 0.8.11 In our study, the only unfixed parameter of this equation was the PaCO2 level, with significantly higher value in the final state of the HA group.5 Due to high diffusion rate of carbon dioxide through the alveolar membrane, it is assumed that the partial pressure of alveolar carbon dioxide is very close to PaCO2.11 Thereby, according to Dalton’s law of partial pressures2 in the HA group was resulted in decreased PAO2. At first look, it seems to be a miserable event, however, by considering the O2Cap22 and the O2Ct (discussed at length below), it can be seen that the lower PAO2 in the HA group was not clinically significant in terms of blood oxygenation and indeed the HA group was significantly more oxygenated than the NA group. The O2Ct is an integration of the primary blood parameters involved in oxygen delivery, including arterial hemoglobin oxygen saturation, hemoglobin concentration, and the PaO2,23,24 with two former parameters having more influence than the latter. Therefore, considering insignificant change of hemoglobin oxygen saturation and the PaO2 in our study groups,5 the reduction of the O2Ct through the course of the experiment seems to be mainly related to decreased hemoglobin concentration (hemodilution resulted from fluid resuscitation in the groups). Higher values in the HA than the NA group, might have resulted from lower hemorrhage in the HA group. This rationale can be confirmed confirmed by analyzing the O2Cap. This parameter is the capacity of blood to carry oxygen in the form of oxyhemoglobin. O2Cap was higher in the HA group than the NA group, showing that the HA group had a higher hemoglobin concentration. The higher values of O2Ct than the O2Cap were mainly due to the DissO23,13 which contributes to the partial pressure of arterial oxygen.11Where, P2, aA Ratio, and PaO2/FiO2 among the groups may implicate on no intrapulmonary shunt perfusion after induction of IAH in the HA group.11,25,26 The RI covers a wide variety of “factors determining the exchange of oxygen between inspired gas and blood” and is calculated as follows:11No statistically significant change of AaDOper se, or technique of liver trauma modeling.Non-significant change of this parameter probably negates malfunctions in oxygen exchange. No statistical difference between groups in terms of liver mass or size, or amount of liver injury might confirm that observations in this study could not be attributed to individual differences of rabbits in terms of liver size, liver mass, liver trauma 2Ct and the cardiac output.3 However, according to normal RI level in the HA group, and since the RI is sensitive to changes in cardiac output,11 it could be extrapolated that the cardiac output of the HA group was not significantly different from its normal values. Also, we did not measure mixed venous blood samples due to technical reasons and negative biasing effects that high volume blood samplings could have in our experiment. Since the aim of this experiment was not to evaluate oxygen consumption by tissues, we believe that this limitation did not influence our current findings.This study had some limitations. Due to technical reasons we could not measure cardiac output, although it had been shown that oxygen delivery was better described as a function of both OIn conclusion, our study on a mixed model of hemorrhage and iatrogenic IAH showed that the novel therapeutic method consisting of iatrogenic IAH, in comparison with classic method of resuscitation consisting of normal IAP, better preserves blood oxygenation parameters. This study may corroborate the safety and effectiveness of the novel concept of therapeutic intra-abdominal hyper-tension for control of severe liver bleeding. Our results may also have implications in patients with traumatic liver bleeding and concurrent pathologic IAH, or laparoscopic surgeries of traumatic liver injury patients in which abdominal insufflation is used routinely.


The study objective was to investigate the prophylactic efficacy of montelukast (MLK) 10 mg in suppressing seasonal allergic rhinitis (SAR) symptoms induced by Japanese cedar (JC) pollen and to determine how many days before exposure to JC in the artificial exposure chamber (OHIO chamber) would be optimal to start administration.n = 27), an MLK 3-day administration group (n = 27), an MLK 1-day administration group (n = 26), and a placebo group (n = 26). The mean change in total nasal symptom scores  (TNSS) and each of the nasal symptom scores during exposure of JC pollen in the OHIO chamber were investigated.This was a single-institution, double-blind, randomized placebo-controlled four-group parallel inter-group comparison study. Adult volunteers with JC pollinosis were divided into four groups: an MLK 7-day administration group (p = 0.0192). The results for the individual nasal symptoms showed that nasal obstruction was significantly suppressed in the 1-day administration group as compared with placebo (p = 0.0076), but no differences were found in sneezing score between any of the groups. For nasal discharge, we found a trend towards the effect clearing up after 3 days of administration. No serious adverse events were observed during the study.The mean change in TNSS was significantly lower in the MLK treatment group, regardless of the number of days of administration, than in the placebo group (Although this study was acute and this artificial exposure model was conducted out of the pollen season, nasal symptoms that developed in the pollen exposure chamber, especially nasal obstruction, were significantly suppressed by starting oral administration of MLK 10 mg at least 1 day before exposure. These results suggest that prophylactic administration of MLK is effective and safe in the treatment of SAR. Since the land-shape of Japan is long in the north–south direction and possesses four distinct seasons with different climates within the different regions, pollen from more than 4500 kinds of weeds and trees disperse all over the country. Although there are patients with pollinosis to each of these various pollens, Japanese cedar (JC) pollen is the cause of seasonal allergic rhinitis with the largest number of patients. A very large amount of JC pollen disperses over hundreds of kilometers from the beginning of February to late April2.The prevalence of seasonal allergic rhinitis (SAR) has been increasing over the last decade and now affects up to about 30% of the Japanese population1. In addition, the decrease in the age of onset is marked in urban areas. An increase in the amount of JC pollen in the past decade has been cited as one reason for this.According to a recent epidemiological study, the prevalence of JC pollinosis is 26.5% and an approximately 10% increase has been observed over the past 10 years3.JC pollinosis patients suffer from very severe nasal and ocular symptoms as a result of pollen dispersal over a 2.5-month period. These symptoms develop and steadily grow with daily pollen dispersion, and decreases patients' quality of life4. The actions of CysLTs released after allergen exposure in AR are mediated through the LT1 receptor, which include increased nasal vascular permeability and stimulation of mucous glands. The former produces edema formation in the nasal tissue which contributes to nasal obstruction and the latter increases mucous production and secretion which leads to rhinorrhea5.Allergic rhinitis (AR) is a type I allergic disease, and its nasal symptoms consist of sneezing, nasal discharge and nasal obstruction. Immediate and delayed allergic reactions are associated with pro-inflammatory mediators such as histamine, proteases, cysteinyl leukotrienes (CysLTs), prostaglandins, and platelet activating factor, as well as infiltration of inflammatory cells. It has been suggested that not only histamine, but also CysLTs plays an important role in the pathogenesis of allergic rhinitis6–8. It significantly improves daytime and nighttime nasal symptoms as compared with placebo. According to a systematic review of randomized trials of the effect of LTRA monotherapy, its efficacy in the treatment of SAR is better than that of placebo and equivalent to antihistamines9.Montelukast (MLK) is a cysteinyl leukotriene receptor antagonist (LTRA) that has been proved to be effective and tolerable in the treatment of SAR1. One clinical study investigating the efficacy of early intervention with LTRA in the prevention of JC pollen symptoms has shown the effectiveness of LTRA in reducing SAR symptoms throughout the JC pollen dispersal period10. However, there have been no studies on how many days before pollen dispersal it is optimal to start administration of this kind of drug.Japanese guidelines for AR, developed by Japanese AR specialists, recommend treatment plans for patients with JC pollinosis in consideration of Japanese circumstances, one of which is administration of a second-generation antihistamine or LTRA before the start of pollen dispersalThe aim of this study was to assess the optimal duration of early intervention with MLK 10 mg in the treatment of allergen-induced symptoms in patients with JC pollinosis using a pollen exposure chamber (OHIO chamber).Adult volunteers with JC pollinosis were recruited to participate in the study. The inclusion criteria were: presence of allergic symptoms, particularly nasal congestion, during the pollen season for at least 2 years, with scores of 2 or more on the specific IgE-antibody test (Uni-CAP RAST) for JC pollen; absence of any abnormal findings on physical examination.The exclusion criteria were: subjects who have nasal diseases  or an infectious disease  that would interfere with evaluating the efficacy of the drug; subjects who have a systemic disease including asthma, hypertension, diabetes mellitus; subjects who had undergone surgery, including laser surgery for the purpose of treating AR within 6-months prior to the start of the study; a history of hypersensitivity to the study drug; pregnant women or breast-feeding women, and women who were hoping to become pregnant. The following medications were prohibited throughout the study periods: steroid injections, oral or intranasal steroids, antihistamines, all other LTRA, or tranquilizers, or topical decongestants.Subjects who were considered ineligible by the physician in charge were excluded as well.This study was conducted in conformity with good clinical practice guidelines and the Declaration of Helsinki of 1995 (as revised in Edinburgh in 2000). The study protocol was reviewed and approved by an independent institutional review board of the Shinanozaka Clinic . Informed consent was obtained from all subjects before participation in the study.This was a single-center, double-blind, randomized, placebo-controlled four-group parallel inter-group study conducted in the non-pollen season, from May to June 2010, during which time the subjects did not have SAR symptoms.11. The OHIO chamber, located in the Samoncho Clinic in Tokyo, is a specialized room capable of accommodating a maximum of 14 persons that was set up for the purpose of dispersing a fixed concentration of JC pollen. Subjects are exposed to JC pollen at a concentration of 8000 grains/m3 for 3 hours, and were instructed to grade and record the severity of their nasal symptoms  every 15 minutes according to the following 5-point scale: 0 = none (no symptoms); 1 = mild (symptoms present but easily tolerated); 2 = moderate ; 3 = severe ; 4 = very severe (difficult to tolerate and interferes with the activities of daily living).The study protocol is shown in the The total nasal symptom score (TNSS) was the sum of the subjects’ self-rated scores of three nasal symptoms .During the screening period, which was 2–4 weeks before the start of administration of the study drug, informed consent was obtained from the subjects, and they were examined to confirm that they met the inclusion criteria and did not fulfill any of the exclusion criteria. The screening exposure in the OHIO chamber was performed in order to ensure they would respond adequately to the pollen stimulation. The TNSS of the subjects during the last 1 hour was assessed. Subjects were enrolled in the study if their TNSS score was at least 3 and their score for nasal obstruction was at least 2 on one occasion.Administration of the study drug was commenced 14 days (±1 day) after the completion of the screening period. The actual drug consisted of capsules filled with MLK 10 mg and crystalline lactose. The placebo consisted of capsules containing crystalline lactose alone, whose external appearance was indistinguishable from that of the actual drug. The subjects were randomly divided into the following four groups who took one capsule daily at bedtime (from day 1 to day 7): a group that took MLK 10 mg for 7 days (7-day group); a group that took the placebo for 4 days and then took MLK 10 mg for 3 days (3-day group); a group that took the placebo for 6 days and then took MLK 10 mg for 1 day (1-day group); and a group that took placebo for 7 days (placebo group). Subjects were exposed to pollen in the OHIO chamber on the morning of the last medication (day 8). The exposure started at 9 a.m. The use of rescue drugs such as antihistamines, LTRA, systemic or intranasal steroids, and vasoconstrictor was not allowed during the treatment period.The primary efficacy endpoints were evaluated by comparing the changes from baseline in the TNSS of the subjects during the last hour of allergen exposure. The values before entering the chamber were used as the baseline values.The secondary efficacy endpoints were the changes from baseline in each of the nasal symptom scores  during the last hour of allergen exposure and changes in the volume of nasal discharge and number of sneezes. The amount of nasal discharge was measured by collecting previously weighed facial tissues every 30 minutes. The weight difference between the tissue before and after use was considered the amount of nasal discharge (g). The number of sneezes was counted and self-reported by each subject every 15 minutes.Safety was evaluated throughout the study period. All subjects were asked about their health status and adverse reactions during this period.p < 0.05 were considered to be statistically significant.For analyzing the backgrounds of the four treatment groups, we used an analysis of variance (ANOVA) for age, an IgE titer, the disease duration and the TNSS at screening period, and a chi-square analysis of the sex ratio. Values of 12 in order to analyze the dose–response patterns of medication days in the mean change in TNSS scores during the last hour of allergen exposure. To explore the dose–response pattern, the contrast coefficient vectors of administration  were set as follows: (1) a linear [3 1 −1 −3], (2) plateau by 3-day administration [5 1 −3 −3], and (3) plateau by 1-day administration [3 −1 −1 −1]. The error covariance was estimated with a repeated-measure analysis of covariance model with the baseline score as the covariate. The analysis model was included in the interaction between administrations and time point. P-value was calculated with adjustment of multiplicity by concurrent analysis of three patterns. The significance level was set at the one-sided 2.5%. The differences between the placebo group and the active treatment groups had been confirmed beforehand after calculation of the average of the mean TNSS scores during the last hour of allergen exposure and the two-sided 95% confidence interval (CI). The same method was applied to analyze the mean changes in the individual nasal scores .Analysis of the primary efficacy endpoint, the prophylactic efficacy of MLK, was performed using the maximum contrast methodt-test, values of p < 0.05 were considered to be statistically significant). If the 7-day administration was superior to placebo, the second analysis set was performed. In the second set, the 3-day administration group was compared with placebo, in the same manner as in the first step. If the 3-day administration was superior to placebo, the third analysis set was be performed. In the third analysis set, the 1-day administration group was compared with placebo, in the same manner.In the comparison of treatment groups, the statistical superiority of each of the three treatment groups  compared with placebo was analyzed by following a hierarchy of conditions (step-down procedures). First, the 7-day administration group was compared with placebo .n = 27, 27, and 26, respectively) and the placebo group (n = 26). There were no drop-outs in this study. The background of the subjects and their baseline characteristics are shown in Out of a total 230 subjects who were screened for eligibility, 106 subjects , who satisfied the inclusion criteria and did not have exclusion criteria, completed the study. They were randomly assigned to the three MLK treatment groups  was 3.17 (2.78–3.56), 2.27 (1.95–2.59), 2.01 (1.70–2.33), and 2.31 (1.98–2.64) for the placebo, 1-day, 3-day, and 7-day administration groups, respectively, suggesting that there were differences in the efficacy of suppression of nasal symptoms between placebo and active treatment groups. According to this analysis, the dose–response patterns evaluated by the maximum contrast method indicated that the selected contrast pattern was [3 −1 −1 −1] with a p-value of 0.0076, demonstrating that the drug effect reached plateau after 1 day of administration. For nasal discharge, the selected contrast pattern was [5 1 −3 −3]. Although significant differences were not found among the treatment groups (p = 0.0565), it was suggested that the trend toward effects reached plateau by 3 days’ administration. For sneezing, no clear tendency was found in the mean change in scores of the treatment groups (p = 0.1853)  . Since aNo significant differences were found among the groups in the amounts of nasal discharge and the number of sneezes .No serious adverse events were observed in this study. Ten adverse events were documented, of which mild drowsiness in two subjects were regarded as being possibly related to MLK. All of the adverse events were mild and were resolved without any medication.13. However, a recent study demonstrated that symptoms elicited in the chamber are similar to those observed during the pollen season14. Thus this study model was considered to be suitable one. The maximum contrast method is a statistical procedure first introduced to analyze dose–response patterns for biomedical or toxicological studies to determine the minimum effective dose in clinical trials, the minimum toxic dose in toxicity studies, or a plausible dose–response pattern in dose–response studies11. We applied this method to investigate the optimal duration of administration of the study drug in the prevention of SAR symptoms. The study demonstrated that significant suppression in TNSS during exposure of pollen were observed in the MLK-treated groups, regardless of the number of days of administration, as compared with the placebo group. As for individual symptoms, nasal obstruction and nasal discharge but not sneezing were suppressed in MLK-treated groups and showed a similar pattern to the TNSS profile. Interestingly, the effect for nasal obstruction was shown to be significantly lower in the MLK groups, irrespective of the number of days of administration, compared to the placebo group. These findings indicate that administration of MLK 10 mg at least 1 day prior to pollen exposure reduces the development of nasal symptoms in the subjects with JC pollinosis.This study was conducted to investigate how many days from JC pollen dispersal to the start of administration of LTRA is sufficient in order to suppress symptoms induced in an artificial pollen exposure chamber. Nasal and ocular symptoms induced by constant but high concentrations of pollen for a short duration in the strictly controlled chamber are the result of an acute allergic reaction, whereas symptoms elicited during the natural pollen season are the result of the repeated exposure of pollen over a long duration16. According to a systematic review and meta-analysis of randomized studies, treatment with MLK for 2–4 weeks reduced daytime and nighttime nasal symptoms, rhinoconjunctivitis quality of life, and eye symptoms compared with placebo17. On the other hand, an environmental exposure unit (EEU) study in which the efficacy of MLK was evaluated and compared with levocetirizine in the subjects with SAR18, treatment with MLK showed significant improvement in the nose and eye symptoms, especially in nasal obstruction, as compared with placebo. Also, it showed an early onset of action of MLK after 1.5 hours of administration and remained effective for 24 hours.Several studies have been published evaluating the clinical efficacy and safety of MLK monotherapy or combined with antihistamine in the treatment of SAR under natural pollen exposure5. Direct challenge of LTD4 on the nasal mucosa in patients with AR significantly increased nasal secretions within 5 minutes with increased nasal mucosal blood flow and nasal resistance20. CysLts also increased vascular permeability which results in nasal obstruction19, a symptom which causes a deterioration in QOL the most in the patients with SAR. Since LTRA does not stimulate the sensory nerves5, sneezing seems not to be a correlated symptom. Although treatment with MLK showed significant improvement in sneezing in clinical studies of patients with AR7, its mechanisms have not been clearly demonstrated. Our findings, that a significant suppression of nasal obstruction and discharge in MLK groups was observed compared with that in placebo, appears to be consistent with the pharmacological features of this drug21.In the present study, the effects of MLK on individual nasal symptoms showed that there was no significant difference in sneezing, but it suppressed nasal discharge and nasal congestion during pollen exposure and a significant difference in nasal obstruction was found in the last hour of exposure. CysLts have multi-functional properties in the pathogenesis of AR22. After treatment with MLK in patients with mild asthma, a significant decrease in the number of eosinophils was observed in a randomized, double-blind crossover study23. Thus, MLK taken several days in advance suppresses the infiltrations of inflammatory cells, especially eosinophils, into the nasal mucosa, which may be attributable to a reduction in the nasal obstruction.Reduction in the number of eosinophils is known to be another pharmacological action of LTRA1. Several studies published in Japanese journals have confirmed the prophylactic effects of antihistamines24. In contrast, there have been only two studies of LTRAs in the prophylactic treatment of SAR compared with placebo or antihistamine25. Both randomized controlled studies were conducted with grass/cereals pollinosis or JC pollinosis patients under natural pollen exposure. One study, in which the number of participants was not large enough, showed that cetirizine or MLK monotherapy administered 6 weeks prior to the beginning of pollen season did not show significant improvement in rhinitis symptoms, whereas the treatment with combined these two drugs was effective in preventing in-season symptom25. The other study conducted in Japan, however, showed that LTRA started before the pollen season was significantly effective in reducing SAR symptoms and deterioration of QOL as compared with placebo10. In the present study, using a JC pollen exposure chamber, MLK administered prior to pollen exposure significantly suppressed allergen induced symptoms. Since limited data are available regarding the prophylactic efficacy in the treatment of SAR with LTRA, a study in large number of participants would be needed in a clinical setting.Treatment with a second-generation antihistamine just before pollen dispersal has been popular in Japan in the management of SAR and its ability to suppress the symptoms or delay the onset of symptoms has been superior to treatment which was started after the appearance of SAR symptoms during the pollen dispersion period26. Although our study is an acute environmental exposure model, the results showing suppression of symptoms in response to administration of MLK for at least 1 day appear to be valid. The short duration of taking drugs before pollen dispersal would be beneficial to patients with SAR because of the large quantity of JC pollen which disperses for a long time period.Onset of action of MLK in SAR under natural pollen exposure has been investigated in double-blind placebo controlled trials. The results of these showed that significant relief in daytime and nighttime symptoms can been achieved starting on day 2In conclusion, MLK 10 mg treatment started 1 or more days in advance before pollen exposure significantly suppressed the nasal obstruction and discharge induced in the OHIO chamber. This study is the first one to investigate assessing the preventive effects of MLK using a pollen exposure chamber. Our results indicate that SAR due to JC pollen would be more effectively controlled by pre-seasonal treatment with MLK in a clinical settings.


In this experimental medicine study, we use an adaptive trial design to determine the optimal dosing regimen for IL-2 to improve Treg function while limiting activation of Teffs in participants with T1D.Type 1 diabetes (T1D) is caused by autoimmune destruction of the insulin-producing β cells in the pancreatic islets, leading to insulinopenia and hyperglycaemia. Genetic analyses indicate that alterations of the interleukin-2 (IL-2) pathway mediating immune activation and tolerance predispose to T1D, specifically the polymorphic expression of the IL-2 receptor-α chain (CD25) on T lymphocytes. Replacement of physiological doses of IL-2 could restore self-tolerance and prevent further autoimmunity by enhancing the function of CD4Adaptive study of IL-2 dose frequency on Tregs in type 1 diabetes(DILfrequency) is a mechanistic, non-randomised, repeat dose open-label, response-adaptive study of 36 participants with T1D. The objective is to establish the optimal dose and frequency of ultra-low dose IL-2: to increase Treg frequency within the physiological range, to increase CD25 expression on Tregs, without increasing CD4+ Teffs. DILfrequency has an initial learning phase where 12 participants are allocated to six different doses and frequencies followed by an interim statistical analysis. After analysis of the learning phase, the Dose and Frequency Committee will select the optimal targets for Treg frequency, Treg CD25 expression and Teff frequency. Three groups of eight participants will be treated consecutively in the confirming phase. Each dose and frequency selected will be based on statistical analysis of all data collected from the previous groups.The Ethical approval for DILfrequency was granted on 12 August 2014.The results of this study will be reported, through peer-reviewed journals, conference presentations and an internal organisational report.NCT02265809, ISRCTN40319192, CRN17571. This is an experimental medicine response-adaptive study that is statistically designed to analyse three coprimary immunological end points to efficiently determine the optimal dose-frequency ultra-low dose interleukin-2 (IL-2) in type 1 diabetes (T1D).The study will investigate the effects of repeated doses of ultra-low dose IL-2 on the immune system of participants with T1D.The mechanism of action of ultra-low dose IL-2 will be characterised in T1D prior to considering larger phase II/III clinical trials.The study is not designed to test the efficacy of ultra-low dose IL-2 treatment in T1D.+ FOXP3+ T regulatory cells (Tregs).4–6aType 1 diabetes (T1D) is caused by a loss of tolerance of the immune system (autoimmunity) to the body's own insulin-producing β cells of the pancreas, leading to their dysfunction and/or destruction resulting in insulin deficiency and hyperglycaemia.IL2RA encoding CD25, PTPN2, IL2-IL21 and BACH2) that are associated with an increased risk of developing T1D.FOXP3 (a transcription factor that drives CD25 expression and the suppressive function of Tregs) or mutations in the CD25 gene (IL2RA) itself, cause severe autoimmune syndromes including T1D.IL2RA showed that reduced CD25 expression on T cells is associated with susceptibility to T1D.https://www.medicines.org.uk/emc/medicine/19322) which has extensive human safety data available. Proleukin has been used for the treatment of cancer and more recently, in trials for the treatment of the inflammatory disorders graft-versus-host-disease18The interleukin-2 (IL-2) pathway is one of the most important genetically validated pathways with therapeutic relevance to T1D.daptive study of IL-2 dose on regulatory T cells in type 1 diabetes’ (DILT1D)We are implementing an innovative, experimental medicine strategy to deliver immunotherapy that systematically targets the key aetiological pathways in T1D.6 IU of Proleukin three times a week for a month was terminated prematurely because β-cell function was impaired. Rapamycin is used routinely for immunosuppression in pancreatic islet transplantation and therefore, the observed decline in β-cell function could be due to the high dose of Proleukin activating Teffs. Alternatively, Proleukin may have altered the effects of Rapamycin on β cells.The goal of DILfrequency is to find the optimal dose and frequency of subcutaneous Proleukin that specifically increases Treg frequency, and the amount of CD25 on Tregs, without expanding the Teff population in participants with T1D. There is an urgent need for this information because previous trials of Proleukin in inflammatory diseasesIn DILT1D and DILfrequency we are taking a different approach: by using all of the data generated in the studies together with statistical modelling we aim to find the optimal dose and dosing-schedule for the future administration of Proleukin to attempt to preserve β-cell function in newly diagnosed participants with T1D.21. This is a single centre study located at the National Institute for Health Research/Wellcome Trust Cambridge Clinical Research Facility, Addenbrooke's Hospital and the University of Cambridge Clinical School. The co-ordination of the study will be carried out by the National Institute for Health Research Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust.DILfrequency is a mechanistic, non-randomised, repeat dose, open-label, response-adaptive study of Proleukin, recombinant IL-2 Thirty-six participants with T1D will be included in the study. Participants will be enrolled into DILfrequency for approximately 10–18 weeks depending on the duration of their treatment. Every participant has 12 visits beginning with a screening visit followed by a treatment period of 10 visits and a follow-up visit approximately 4 weeks after the final dose of drug . The triBox 1Type 1 diabetes18–70 years of ageDuration of diabetes less than 60 months from diagnosisWritten and informed consent to participateEligible participants will have a history of T1D and be less than 60 months from diagnosis . Potentihttp://www.clinical-trials-type1-diabetes.com/ with updates for participant engagement posted on https://www.facebook.com/ClinicalTrialsType1Diabetes and tweeted on https://twitter.com/t1diabetestrial. Interested potential participants may then directly contact the study team to discuss the study. Treating physicians, diabetes nurses and research nurses may identify potential participants and with permission, forward the patient's contact details to the study team. The study team will also contact potential participants who have already registered an interest in taking part in a clinical trial by enrolling in the ADDRESS-2 register,30To maximise participation in DILfrequency we will deploy the active internet recruitment strategy that was successfully established for DILT1D.Box 2Hypersensitivity to Proleukin or any excipientsHistory of severe cardiac diseaseHistory of malignancy within the past 5 years History or current use of immunosuppressive agents or steroidsHistory of unstable diabetes with recurrent hypoglycaemiaHistory of live vaccination 2 weeks prior to first treatmentActive autoimmune hyperthyroidism or hypothyroidismActive clinical infectionMajor pre-existing organ dysfunction or previous organ allograftFemales who are pregnant, lactating or intend to get pregnant during the studyMales who intend to father a pregnancy during the studyDonation of more than 500 mL of blood within 2 months prior to Proleukin administrationParticipation in a previous therapeutic clinical trial within 2 months prior to Proleukin administrationAbnormal ECGAbnormal full-blood count,Chronic renal failure  and/or evidence of severely impaired liver functionAlanine transaminase or aspartate transaminase >3× upper limit of normal (ULN) at screening;Alkaline phosphatase and bilirubin 2× ULN at screening (isolated bilirubin >2× ULN is acceptable if bilirubin is fractionated and direct bilirubin <35% is measured).The coprimary end points will be calculated from the change from baseline measurements and the average of the last three trough values where: the three coprimary end points are the frequency of Tregs, CD25 expression on Tregs and the frequency of Teffs. Baseline measurements are taken at visit two prior to drug administration and trough values are those obtained immediately before drug is administered representing the constant, lowest level observed assuming that a steady state has been achieved. +CD4+ fluorescence-activated cell sorting (FACS) gate (highCD127low within the CD3+CD4+ gateTregs % CD25+CD4+CD25highCD127low) gate.CD25 expression on Tregs is defined as the mean fluorescence intensity (MFI) of CD25 allophycocyanin (APC) within the Treg  CD45RACentral memory %+ Effector memory % = Total Memory effectors %Change in the ratio Naïve effectors %:Total Memory effectors % defines the Teff primary end point.Teff populations (non-Tregs) account for all the other CD3The number of Tregs and Teffs and CD25 expression on Tregs are defined within the CD3CS) gate .Tregs %The FACS assay used to measure the three primary end points will be carried out according to good laboratory practice at the Clinical Immunology Laboratory, Department of Immunology, Addenbrooke's Hospital, Cambridge, which is an MHRA accredited laboratory for Good Clinical Practice.Change in Treg frequency, phenotype and proliferation will be measured by FACS at baseline, during and following treatment with Proleukin.Change in Teff frequency, phenotype and proliferation will be measured by FACS at baseline, during and following treatment with Proleukin.Change in natural killer (NK) cell frequency, phenotype and proliferation will be measured by FACS at baseline, during and following treatment with Proleukin.Change in B lymphocyte cell frequency, phenotype and proliferation will be measured by FACS at baseline, during and following treatment with Proleukin.Change in T and NK cell intracellular signalling will be measured by FACS at baseline, during and following treatment with Proleukin.Change in full-blood count will be measured by automatic analyser at baseline, during and following treatment with Proleukin.Change in plasma/serum levels of IL-2, IL-6, IL-10 and tumour necrosis factor α will be measured by ELISA.Change in metabolic control will be measured by self-monitoring of blood glucose and insulin use; glycated haemoglobin (HbA1c), C-peptide and autoantibody status will be clinically measured and recorded.The values for the end points will be measured during the treatment period and followed for 4 weeks after the last dose for each participant.Genotype of T1D-associated loci in DNA extracted from blood of participants.Gene expression and epigenetic analysis of purified lymphocyte subsets.IL-2 sensitivity of Tregs, Teffs and NK subsets in cryopreserved peripheral blood mononuclear cells (PBMCs).Treg suppression and T effector proliferation assays on cryopreserved PBMCs.Antigen specific T cell assays on cryopreserved PBMCs.® analysis of whole blood.SysmexSerum/plasma levels of cytokines, soluble receptors and inflammatory markers.Serum/plasma and cellular metabolites.Recruitment analysis.Safety and tolerability will be accessed by clinical history, physical examination, temperature, blood pressure, heart rate, 12-lead ECGs, clinical laboratory tests and adverse event recording.6 IU/m2/day because doses above this level may activate Teffs. The doses and frequencies selected for participants in the confirming phase are allowed to be different to those used in the learning phase.At the start of the study in the learning phase the first 12 participants will be allocated the doses and frequencies  that areThe first dose of Proleukin will be administered subcutaneously by participants at the study site following instruction by an appropriately trained delegated member of the trial team. Further doses may then be self-administered by participants or an appropriately qualified member of the study team depending on participant preference. The date and time of each dose administered will be recorded in the source documents. In the community, the date and time of each dose administered will be recorded in the participant's study diary that will become part of the source documents. The study diary, injection sites and count of unused medication will be carried out at each study visit while on treatment to confirm compliance.The role of the DFC is to provide decisions regarding the choice of dose and frequency of Proleukin to administer to participants in the confirming phases . After each group has completed its dosing schedule the data with be extracted from the DILfrequency OpenClinica database. The data will be delivered to the DFC within two working days of that date. The data will include assessments of safety, dose and dose-frequencies assigned for all participants to that time point and Teff and Treg frequencies and CD25 expression on Tregs, collated from all visits.A safety assessment will be made by a clinician;Determine if steady state has been achieved for each participant;Define the numerical targets for Treg increase, increased CD25 expression on Tregs and a minimal increase in Teffs at the first DFC;Define the dose and dose-frequencies for the next group of participants.The DFC will make the following decisions:Plots of all the participant profiles ;Plots of the sequence of doses and dose intervals;Scatter plots of the coprimary end points  versus dose and dose interval.Log-likelihood;Raw output from statistical packages;Residual plots of each model fitted.Scatter plots of the coprimary end point adjusted for covariates versus dose and dose interval with superimposed fitted linear regression models with 95% confidence bands reporting:The DILfrequency statisticians are responsible for preparing the DFC report that will include:The details of the report may evolve as the study progresses. The quorate DFC will be comprised of a statistician, physician (chair and CI) and scientist, each member has a single vote and decisions can be reached by a majority. The Trial Steering Committee (TSC), comprising: an independent chairperson; the CI; the Cambridge Clinical Trials Unit, trial coordinator; a scientist and statistician with relevant experience, may be asked to review split decisions. Prior to the DFC meetings, any protocol violations will be reported to the statisticians and analyses will include the whole population.This study is an exploratory study that is not designed to formally test a hypothesis in a confirmatory fashion and so a formal power calculation is inappropriate. The sample size of 36 is achievable within the proposed time scale, given the recruitment rates we obtained at our study site for DILT1D study.Setting a minimum estimated probability of reaching the target to allow a dose/frequency to be considered eligible for further allocation;The ranking of the probabilities if multiple dose/frequencies are eligible.A tri-variate normal distribution will be assumed for the three coprimary end points . A model linking dose and dose-frequency to the mean and covariance parameters will be developed. At the first interim analysis the DFC will fix the numerical values that define the target range of the primary end point. The probability of each dose/frequency laying within the target range set at the first interim analysis will be tabulated along with the parameter estimates for all models considered, using SE and 95% CIs. The plausibility of the modelling assumptions generated by the study statistician will be reviewed by the DFC. In subsequent cohorts the choice of dose/frequencies to allocate will be determined by:If no dose/frequencies from those observed are eligible for allocation then other dose/frequencies may be considered. The decision guidelines are to be finalised prior to the first interim analysis based on simulations of the operating characteristics for a variety of scenarios. The simulations will be updated if any of the prior assumptions are not close to the interim values, this includes whether a more complex model is required.Summary statistics will be provided for all coprimary and secondary end points, broken down by dose/frequency. Any such summary must use a minimum of five participants to ensure statistical plausibility, and any smaller subgroups will be merged to achieve the minimum size. Continuous variables will be summarised using mean, SD, median, maximum and minimum; categorical and binary variables will be summarised using frequency tables reporting in an ‘x/n (p %)’ format. A formal statistical analysis plan will be finalised in advance of the final data analysis.DILfrequency will be an open-label, sequential study designed to estimate the optimal frequency and dose of administration of ultra-low doses of Proleukin that is required to maintain an increase in Tregs and an increased Treg response, that is CD25 expression, without expanding Teffs in patients with T1D. The secondary objective is to characterise the effects of repeated doses of Proleukin on the immune system. For example, a subset of NK cells express CD25 and are highly responsive to IL-2The selection of primary end points for the DILfrequency study has been informed by our experience in DILT1D in which a dose-dependent increase in Tregs was observed and an increase in CD25 expression on Tregs was found to be a sensitive and reproducible marker of Proleukin administration (unpublished results). It will be important to establish that repeat dosing in DILfrequency does not lead to an increase in Teffs. Therefore, Teffs are the third of the coprimary end points that will be measured in DILfrequency. In addition to the three coprimary end points, this study will define the cellular outcome of frequent administration of Proleukin by detailed immunophenotyping, genetic, epigenetic and transcriptional analyses of peripheral blood subsets from participants before, during and after Proleukin treatment. These exploratory assays will be performed in order to define the mechanism of drug action and to understand the effect of repeated dosing of Proleukin on biomarkers.DILfrequency challenges any pretrial assumptions about what the ‘optimal’ dose-frequency should be, by continuously adapting the dose-frequency after each interim analysis. The adaptive protocol outlined here allows for the most efficient derivation of the optimum dose-frequency and potentially, fewer participants are required compared to an equivalent fixed trial design. Furthermore, the DILfrequency design has the flexibility to adapt to a wider range of dose frequencies of Proleukin than could be pragmatically investigated in a single fixed-dose study. The higher number of participants at or near the optimal dose and dose-frequency in DILfrequency improves the statistical power for analysing mechanistic and biomarker data in addition to the information gained by obtaining multiple measures from each participant over time.We propose that our approach to drug development can be adopted widely across a range of disorders and that it is an important foundation to a future of precision medicine.


The aim of this study was to evaluate adrenaline prescription in the Emergency Department (ED) and the patients' capacity to correctly simulate adrenaline administration.Adrenaline is the first-line emergency treatment for anaphylaxis. The only adrenaline auto-injector (AAI) currently available in Portugal is Anapen® trainer and a medical record review was performed.Patients with food allergy (FA) and hymenoptera venom allergy (HVA) followed in our department were invited to simulate adrenaline administration with an Anapen® with them and 19 (53%) admitted carrying it on a daily basis. Fourteen (39%) performed the simulation correctly, although 7 of them did not massage the injection site, as instructed by the manufacturer. On average, 2 training sessions were performed per patient but, despite this, 22 (61%) failed at various steps, including 4 who injected with the wrong end. Six reported using their Anapen® in a real life situation, but curiously 4 of them did not simulate the administration effectively.A total of 36 individuals  were included; 28 with HVA (26 on venom immunotherapy) and 8 with FA. Twenty-seven went to an ED. Adrenaline was administered in only 3 and just5 of them were discharged with an AAI prescription. The remaining 22 had their AAI prescribed and taught how to use it, only after consultation with an Allergist. Twenty-three (64%) had their AnapenAccording to the WAO guidelines, patients with anaphylaxis history should carry an AAI. Adrenaline underuse and a deficient prescription of adrenaline (14%) on discharge from the ED as well in non-specialized centres was evident. Approximately two thirds of our patients failed to demonstrate proper administration, regardless of previous patient education. This is an unacceptably high proportion of at risk patients. This device requires repeated and regular training sessions since this is the only AAI available in Portugal. Adrenaline is potentially lifesaving if the patient is willing to use it and is capable of injecting it correctly. Practice makes perfect.


To identify COPD associated gene susceptibility and lung function in a longitudinal cohort including COPD and subjects who were at risk for developing COPD, and to replicate this in two cross-sectional and longitudinal populations in Chinese Han population.Three cohorts were recruited in this study, including an 18-year follow-up population (306 COPD and 743 control subjects) in one village in 1992 and it changed to 409 COPD and 611 controls in 2010, a 2 year follow-up study in another village (374 COPD and 377 controls) and another 2 year follow-up one in a city (541 COPD and 560 controls) in 2010. Sixteen candidate single nucleotide polymorphisms (SNPs) were selected for genotyping. Among them, 5SNPs in or near HHIP, 1SNP in IREB2 and 1SNP in FAM13A were previously reported to be associated with COPD susceptibility or lung function decline. And another 9SNPs were selected from HapMap website as HHIP tags. In 2010, totaling 1,324 COPD patients and 1,548 healthy controls were finally included in our genetic susceptibility analyses.We identified two new regions showing an association with COPD susceptibility in the Human Hedgehog interacting protein (HHIP) rs11100865 and rs7654947, and we confirmed that the family with sequence similarity 13 member A gene (FAM13A) rs7671167 was associated with the development of COPD in Chinese Han population. And the HHIP rs7654947 and FAM13A rs7671167 were associated with lung function decline, and this result was replicated in other two populations.These results suggest an important role of the HHIP and FAM13A regions as genetic risk factors for COPD development and lung function decline in Chinese Han population. Future research on these genes should focus on the molecular mechanisms of these genes on developing COPD and creating therapies to alleviate reduced lung function.The online version of this article (doi:10.1186/s12931-015-0209-3) contains supplementary material, which is available to authorized users. Chronic obstructive pulmonary disease (COPD) is a leading global cause of morbidity and mortality, and will become the fourth leading cause of death by the year 2030 . AlthougRecently, some large-scale genome-wide association studies (GWAS) on COPD have identified susceptible genes and loci associated with COPD -9, and t1) decline.Moreover, GWAS on cross-sectional or longitudinal lung function have identified some genes which are associated with lung function, several previously unrecognized loci related to two clinically important pulmonary functions in a cross-sectional analysis ,11-13. SOur research presented here highlights an approach that takes advantage of genome-wide association analyses using longitudinal and extensive follow-up data to identify susceptibility genes in COPD that influence lung function decline. This study identified two new loci and confirmed one locus with the development of COPD, and revealed one previously unreported locus and a third locus associated with lung function in three independent follow-up study cohorts.In the first stage, study subjects were recruited from 15 villages in Haokou, Qianjiang, Hubei, China. We screened subjects, from the population of 15 villages totaling 25,000 people to determine the risk groups and subjects with COPD, as described in Figure 1 decline with genetic variants was also replicated in these individuals.The replication cohorts were recruited from two different environmental living conditions and locations that were different from the first cohort. The subjects with COPD in the rural replication cohort were enlisted from scattered rural areas in Hubei province except Haokou. In the two replication cohorts, a total of 374 cases and 377 controls from the rural cohort, and 541 cases and 560 controls from the urban cohort in 2010 were enrolled and 205 COPD patients underwent lung function follow-up observations for approximately 2 years. The association of FEVAll the research procedures performed in this study were screened and approved by the Research Ethics Committee, Huazhong University of Science and Technology, Wuhan, China.http://www.hapmap.org/) for the Chinese Han population (Chinese Han from Beijing–CHB). Tag SNPs were selected for the gene by using Tagger in Haploview (http://www.broadinstitute.org/haploview/haploview). Under the pair-wise mode used, a minimal set of markers were selected. All the captured alleles were correlated at an r2 ≥ 0.8 with a marker. Nine tagged SNPs  were selected in the HHIP region in CHB. Taken together, a total of 14SNPs in or near the HHIP, 1SNP in IREB2 and 1SNP in FAM13A were selected for genotyping in our study.There were 5 single nucleotide polymorphisms (SNPs) in or near HHIP , 1SNP in IREB2 (rs13180) and 1SNP in FAM13A (rs7671167) genotyped in our study. These have been reported to be associated with COPD susceptibility or lung function in Caucasians and in the meta-analysis studies were shown as probable risk genetic variants related to COPD or lung function decline. In meta-analysis, the SNPs in HHIP, FAM13A and IREB2, which were reported in different study cohorts that focused on lung function or COPD susceptibility ,19-22 weThe linkage disequilibrium (LD) between the SNPs in the HHIP locus were examined with the Haploview 4.2 program  for all control subjects .Genomic DNA was extracted from peripheral venous blood, which was drawn from each subject, after their informed consent was obtained, by using the Blood Genomic DNA Purification Kit  according to the manufacturer’s protocol. 16 single nucleotide polymorphisms (SNPs) in genes which have been reported to be associated with COPD susceptibility or decreased lung function in Caucasians ,20,21,26t test. The Hardy–Weinberg equilibrium was assessed by the goodness-of-fitness chi-square test to compare the observed genotype frequencies to the expected genotype frequencies in the controls.The differences in the distribution of categorical variables in characteristics of subjects were tested using the Pearson’s chi-square test and continuous variables by Student’s 1 decline in individuals with different genotypes of SNPs were inspected by student’s t test when the data met the normal distribution and were expressed as means ± SEMs. All statistical analyses were conducted by using Statistical Package for the Social Sciences (SPSS) version 19.0 software  or GraphPad Prism 5 software .Logistic regression was used to evaluate the associations between SNPs of HHIP, IREB2 and FAM13A genotypes and COPD susceptibility. The odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated after adjustments for age, sex and smoking history. The comparisons of FEVTable The replication cohorts, totaling 374 cases  and 377 controls , were from the rural cohort in 2010, and 541 cases  and 560 controls  were from the urban cohort in 2010.There were no significant differences in the distribution of age and gender between cases and controls in either group of subjects.In the first cohort, the regular smokers, who were considered to be in the risk groups of COPD, had lung function tests performed according to the same operational standards every five years in Haokou. There were 306 COPD patients and 743 healthy controls at the beginning of our study in 1992, but at the end of the study in 2010, there were 409 cases and 611 controls. Among the cases in 2010, there were 112 individuals who had normal lung function and were part of the healthy control group in 1992. Regardless of their status in 1992 or 2010, all subjects who had completed our study were genotyped. We compared the genotypes of cases with their gender- and age- matched healthy controls both in 1992 and 2010, especially for the cases from controls and their control subjects who still had normal lung function in 2010  and 1SNP in FAM13A (rs7671167) were associated with an increased risk of COPD in 2010. Among the 5SNPs identified in subjects of 1992, rs12504628 and rs13118928 were not significantly associated with an increased COPD risk in 2010. The SNPs in HHIP (rs11100865 and rs7654947) and in FAM13A (rs7671167) were significantly associated with risk of COPD. A relationship with increased COPD risk in the group subjects of cases from controls and their healthy controls was observed with the genotypes of these 5SNPs. The genotypes of rs7671167 revealed similar results as in subjects of 2010 displaying an association with increased COPD risk. No significant differences were found in the other 3SNPs in HHIP.In the 18 years of observations, some of the subjects had changed their status from healthy controls to COPD with their genetic differences playing critical roles. We analyzed the relationship of genotypes and COPD by comparing the different SNPs genotypes and COPD status, especially for subjects who, over the study period, had developed obstructive ventilatory dysfunction from normal subjects in the study. Figure In the replication cohorts, 12SNPs were successfully genotyped. Among the five SNPs which were identified as being associated with increased COPD risk in either group of subjects in the first stage, it was shown that the genotypes in rs11100865, rs7654947 and rs7671167 were associated with risk of this disease in both the rural replication cohort and the urban cohort. This result was consistent with the cohort study in the first stage. Additionally, in urban replication cohort, the genotypes of rs13118928 were also observed as associating with an increased COPD risk.In 2010, a total of 1,333 COPD cases and 1,552 controls in both stages of our study were added together to replicate the identified SNPs in the entire population of our study. Table Based on the 18-year follow-up and the two replication cohorts, we identified two new loci (rs11100865 and rs7654947) that were associated with increased COPD susceptibility, and confirmed that one loci (rs7671167) in FAM13A was associated with the development of COPD in Chinese Han population.2.The linkage disequilibrium among these SNPs in the HHIP region, which were identified as probably being associated with increased COPD susceptibility, is shown in Figure 1 decline in every subject over the 18 years is variable for different SNPs genotypes. The FEV1 decline in each genotype from the 18-year follow-up observations is shown in Figure 1 decreases were higher in those CC or CT subjects than TT. There were significant differences in the groups of cases and controls in 1992 and cases in 2010 (p<0.05). In rs7671167, the FEV1 decreases occurred more frequently in CC subjects compared with CT or TT in cases from the controls. The difference was statistically significant (p = 0.0059). The decrease of FEV1 in other SNPs in different genotypes showed no significant differences in either group of subjects. The remaining 14 loci were not associated with a decline of pulmonary function (data not shown).In our research, the FEV1 decline in follow-up individuals, in replication cohorts is demonstrated. The individuals with CT and CC alleles in the rural replication cohort cases and CC in the urban replication cases of rs7654947 showed a greater FEV1 decline compared with the TT subjects. In rs7671167, the cases in rural replication cohort with the CC allele had a greater FEV1 decline compared to cases with the TT allele. In either replication cohorts , there was no significant differences in genotypes on the decline of FEV1 in other SNPs. This result was consistent with the association of FEV1 decline with the COPD risk variants in the first 18-year follow-up stage.In Figure Based on our 18-year follow-up and 2-year follow-up in the two replication cohorts, we have identified one new loci (rs7654947 in HHIP) that was associated with lung function decline, and one loci (rs7671167 in FAM13A) that was associated with lung function decline and was consistent with previous research performed on Caucasians .1 decline after the 18-year follow-up observation and 2-year longitudinal observation in two replication cohorts. These differences were statistically significant.In our genome-wide association study on gene susceptibility of COPD comprising 306 COPD and 743 control subjects in an 18-year follow-up population, and 915 COPD patients with 937 controls in two replication cohorts of a 2-year follow-up, a total longitudinal of 1,333 COPD cases and 1,552 controls were recruited in this study. Two new loci (rs11100865 and rs7654947) in HHIP and one SNP (rs7671167) in FAM13A were identified as being associated with increased COPD risk. The SNP of rs7654947 (a new locus) in HHIP was associated with FEV1 decline of individuals in different genotypes of them, in the 18 years follow-up. Distinguishable from other GWAS performed on cross-sectional cohorts, our study is based on a prospective follow-up cohort that lasted for 18 years and has identified important genetic variants associated with increased COPD risk.This is the first time that a longitudinal 18 years study was applied to the gene susceptibility of COPD and lung function decline, and to demonstrate two new SNPs in HHIP that associated with COPD susceptibility. Nevertheless, the two other SNPs (rs12504628 and rs13118928) at the HHIP locus associated with risk of COPD in subjects of 1992 in the follow-up population, were previously shown to be associated with lung function and risk of developing COPD in Caucasians ,27 and r1 with twin studies focused on lung function [There are many common genetic variants in the loci of chromosomes 4 (HHIP and FAM13A)  and 15  in HHIP that were associated with COPD susceptibility. Moreover, we found rs7654947 in HHIP and rs7671167 in FAM13A were related to decline in lung function. For the first time, we used a longitudinal prospective study with 18-year follow-up observations, to identify new loci both associated with COPD susceptibility and lung function decline in a Chinese Han population. Further GWAS will be required to investigate more candidate SNPs for COPD risk prediction.


To systematically review whether the provision of information on cardiovascular disease (CVD) risk to healthcare professionals and patients impacts their decision-making, behaviour and ultimately patient health.A systematic review.An electronic literature search of MEDLINE and PubMed from 01/01/2004 to 01/06/2013 with no language restriction and manual screening of reference lists of systematic reviews on similar topics and all included papers.(1) Primary research published in a peer-reviewed journal; (2) inclusion of participants with no history of CVD; (3) intervention strategy consisted of provision of a CVD risk model estimate to either professionals or patients; and (4) the only difference between the intervention group and control group (or the only intervention in the case of before-after studies) was the provision of a CVD risk model estimate.After duplicates were removed, the initial electronic search identified 9671 papers. We screened 196 papers at title and abstract level and included 17 studies. The heterogeneity of the studies limited the analysis, but together they showed that provision of risk information to patients improved the accuracy of risk perception without decreasing quality of life or increasing anxiety, but had little effect on lifestyle. Providing risk information to physicians increased prescribing of lipid-lowering and blood pressure medication, with greatest effects in those with CVD risk >20% (relative risk for change in prescribing 2.13 (1.02 to 4.63) and 2.38 (1.11 to 5.10) respectively). Overall, there was a trend towards reductions in cholesterol and blood pressure and a statistically significant reduction in modelled CVD risk (−0.39% (−0.71 to −0.07)) after, on average, 12 months.There seems evidence that providing CVD risk model estimates to professionals and patients improves perceived CVD risk and medical prescribing, with little evidence of harm on psychological well-being. This systematic review is the first to address the impact of provision of cardiovascular disease risk model estimates on patients’ or physicians’ behaviour or health outcomes.The use of broad inclusion criteria and the systematic search of multiple databases allowed us to include studies in which assessment of the impact of provision of a risk score alone was not the primary outcome.Despite this, the small number and heterogeneity of included studies limit the strength of conclusions that can be made. Most report only short-term changes and those that address behaviour change use mostly self-reported measures and are underpowered to detect small changes that may be clinically important at the population level.Even though there have been advances in diagnosis, treatment and prevention of cardiovascular disease (CVD) in recent decades, CVD still remains the single largest cause of death worldwide.Such risk models have been incorporated into many major clinical guidelines for routine practiceThe purpose of this review was, therefore, to assess whether provision of a CVD risk model estimate to either patients or practitioners, as opposed to other simultaneous or subsequent interventions, such as lifestyle advice or exercise programmes, impacts patient or practitioner behaviour or health outcomes.We performed a systematic literature review following an a priori established study protocol (available on request). Reporting was according to the PRISMA statement.19As part of a larger systematic review on CVD risk scores, we performed an electronic literature search of MEDLINE and PubMed from 01/01/2004 to 01/06/2013 with no language restriction. The search strategy is described in full in online supplementary appendix 1. Briefly, it included terms for CVD, coronary heart disease, hypertension, hyperlipidaemia, stroke or cerebrovascular disease in combination with terms for risk assessment, prediction, score or decision support, and named risk scores. We also reviewed the reference lists of systematic reviews on this topicWe included studies that met the following criteria: (1) primary (randomised and non-randomised) studies published in a peer-reviewed journal; (2) inclusion of participants with no history of CVD; (3) intervention strategy consisted of provision of a CVD risk model estimate to either physicians or patients ; and (4) the only difference between the intervention group and control group (or the only intervention in the case of before-after studies) was the provision of a CVD risk model estimate. Observational and qualitative studies, studies calculating CVD scores for the secondary prevention of CVD or including both primary and secondary prevention where it was not possible to separate out the primary prevention group, and conference abstracts, editorials, commentaries, letters and reviews were excluded.We selected studies in a three-stage process. In the first stage, titles of all studies identified from the electronic search were screened in duplicate by six reviewers involved in a large systematic review on CVD risk prediction led by ES and KGMM to identify all studies that described the application of a risk model into clinical practice or focused on risk-based management. In the second stage, this process was repeated with seven reviewers based on abstract. In the third stage, we combined those studies identified from stage 2 with studies from systematic reviews on similar topics,JU-S and BS independently extracted data from all studies included in the review using a standardised data extraction form to reduce bias. The data extracted included: (1) study characteristics ; (2) selection of participants ; (3) participant characteristics ; and (4) measured outcome(s). Reviewers were not blinded to publication details. We requested additional unpublished data from the authors of papers in which it was mentioned that additional data were available or additional data were required to meet the inclusion criteria or for clarification of results.http://www.casp-uk.net/#!casp-tools-checklists/c18f8) as an initial framework and then classified each study as high, medium or low quality. No studies were excluded based on quality assessment alone.JU-S and BS conducted quality assessment at the same time as data extraction. Since our review included studies with different designs, we used a checklist based on the Critical Appraisal Skills Programme guidelines for cohort studies and randomised controlled trials , modelled cardiovascular risk, medication prescribing, anxiety and psychological well-being, and contact with healthcare professionals after provision of risk information. For data on continuous outcomes, where possible, we expressed results as the difference in the mean change between groups. Where standardised mean changes were presented in the studies, we used the SD of the control group to convert data to non-standardised changes. Where this was not possible, we presented the results as mean±SD. For data on binary variables, such as a change in prescribing or meeting targets, we presented data as ORs or relative risk and 95% CIs. Where possible we combined data from different studies using random effects meta-analysis, but due to variations in study design and reporting, we were only able to do this for a small number of outcomes. We analysed all data according to the different outcomes and the recipient of the CVD risk score (physician or patient). For outcomes with data from three or more studies, we assessed the heterogeneity between studies using the IAfter duplicates were removed, the initial electronic search identified 9671 papers . One hun20–36A summary of the characteristics of those 17 studies is shown in et al showed in their RCT that the risk perception after 4 weeks did not differ between those who received the risk estimate only  and those who did not . Similar pattern of results were present when the comparison was made between those who received risk estimate + lifestyle advice  and those who received lifestyle advice only .Two before-and-after studies reported the immediate effects of receiving risk information. In one, patients tended to initially overestimate their risk and giving risk information resulted in a significant reduction in perceived risk .et alThree studies also reported changes in risk perception at different time intervals after receipt of risk information. In two, patients tended to initially overestimate their risk and giving risk information resulted in a sustained significant reduction in perceived risk after 2–4 weeks One before-and-after study in general practice29Four studies reported on smoking cessation.25Two studies reported on intention to increase physical activity. Both showed no effect with one before-and-after study including 11.4% of participants with CVD risk >20% showing no change in the number of participants in the action or maintenance stages of change for exercise (n=145/298 prerisk information and n=151/298 postrisk information)29Two RCTs showed no difference in self-reported alcohol consumption. One including only participants with CVD risk >20% reported no difference in mean alcohol intake at 1 month (standardised difference in means=−0.033 (−0.36 to 0.29), p=0.84)25Four RCTs reported the between-group difference in mean change in total cholesterol or low-density lipoprotein cholesterol (LDL). Two were cluster randomised studies in which physicians in the intervention group received risk information about their patients.et al with Price et al gave a non-significant decrease, and pooling both with the other two studies showed a trend towards lower cholesterol but this was not significant ) or 12 months ).No significant differences were found with high-density lipoprotein cholesterol (HDL) or total cholesterol to HDL ratio after adjusting for baseline risk,34et alet alet alFive RCTs reported the difference in mean change in blood pressure between patients with and without risk information.et alIn the two other trials, risk information was provided to patients.Two studies reported changes in weight and found no significant difference in mean weight (standardised difference in means 0.065 (−0.22 to 0.35), p=0.66) or body fat percentage (standardised difference in means 0.063 (−0.23 to 0.35), p=0.67) among participants with CVD risk >20% at 1 month36et alPrice et alet alet alFive RCTs reported changes in modelled CVD risk. In three, risk information was provided to physicians.et al at 12 months with the three studies providing risk information to physicians gave a significant reduction in risk score . In the same study, patients with a CVD risk >20% were twice as likely to have their medication changed when physicians were presented with the risk score (relative risk (RR) 2.32 (1.01 to 5.29), p=0.03).. In the et al28Three RCTs reported changes in blood pressure-lowering medication. As with lipid-lowering medication, Hall One study including only participants whose blood pressure was above currently recommended targets reported the mean blood pressure threshold for intensifying treatment.Three RCTs found no effect of risk information on either change in medication in all participants (RR 1.17 (0.89 to 1.53), p=0.273) or those with CVD risk >20% (RR 1.26 (0.87 to 1.84), p=0.219),29Psychological well-being following receipt of risk information was assessed in four studies. Three showed no difference. In the first, a before-after study, there was no significant difference in the 12-item General Health Questionnaire (GHQ) score after 6 months in either those at low/moderate risk or those at high risk and no significant difference between the groups .24Three studies also explored changes in anxiety. Two were before-and-after studies and used the Spielberger state anxiety inventory. As with psychological well-being in the same study, a significant reduction in mean anxiety from 32.3, SD 8.72 to 28.1, SD 8.60 was seen in high-risk participants after 10 days ,29Two studies reported the effect on healthcare usage of giving risk information. In one,A further study in the USA including only participants with CVD risk >20% or with raised LDL showed no significant difference in healthcare usage at 9 months between those receiving risk information (n=218) and controls (n=217) with no difference in the percentage with any follow-up visit p=0.28), number of follow-up visits (p=0.14), number of telephone (p=0.75) or email (p=0.96) contacts., number To our knowledge, this is the first systematic review to address specifically whether the provision of CVD risk model estimates alone impacts patient or practitioner behaviour or health outcomes. Despite the widespread adoption of risk scores in guidelines,The main strengths of this review are the use of broad inclusion criteria and the systematic search of multiple databases in addition to the inclusion of studies identified in previous systematic reviews on related topics. This allowed us to include studies in which assessment of the impact of provision of a risk score alone was not the primary outcome. While this reduces publication bias, the literature on CVD risk is diverse and rapidly expanding, and so it remains possible that there are additional studies of relevance that we were not able to identify. Furthermore, additional studies may have been published since June 2013, the date of the literature search. We are not aware, however, of any papers that would alter the overall conclusions of this review.The other main limitation, as with most systematic reviews, is the extent and quality of the published data. Given the interest in CVD prevention and widespread use of CVD risk scores, it is both surprising and concerning that so few studies concerning their impact on care have been published. Additionally, of the 17 studies identified, most report only short-term changes (<6 months) and those that address behaviour change use mostly self-reported measures and are underpowered to detect small changes that may be clinically important at the population level. The small number and heterogeneity of the studies also made combining results difficult. Not only did they report different outcomes at different time periods with participants of varying baseline risk, but many of the studies adjusted for different baseline variables without reporting unadjusted changes or provided insufficient data to allow us to calculate effects adjusted for baseline risk. Data on the SD of outcomes were also not available for most studies, meaning it was not possible to calculate standardised changes in outcomes. A further limitation was that the small number of studies differed in whether the risk model estimates were presented to patients or physicians. This meant that in most cases there were only one or two studies presenting risk model estimates to the same group and reporting the same outcome. To provide the greatest interpretation of this limited data, where we were able to synthesise the data, in addition to presenting these separately, we also presented an overall summary estimate. Although this means these estimates need to be interpreted with caution, they probably reflect real life as in routine clinical practice this distinction is often not as clear cut: physicians will often discuss risk estimates with patients and patients will often ask physicians for advice on interpreting estimates.Despite these limitations, the results from this review are of relevance to the large number of clinicians worldwide who use CVD risk information with patients regularly in their practice, and policymakers involved in designing and implementing strategies for the prevention of CVD, including the recent debate about the NHS programme of CVD risk reduction in the UK.The finding that providing patients with risk information changes risk perception and increases the accuracy of perceived risk is consistent with previous reviews which have shown that global risk information with accompanying education or counselling increases the accuracy of perceived risk.With this inaccuracy in risk perception along with existing experience from other areas about the challenges of behaviour change, it is perhaps not surprising that there is no evidence that simply providing patients with a number leads to statistically significant changes in habitual environmentally cued behaviours such as diet, smoking, physical activity or alcohol intake. Where there were differences between the groups, most were in favour of providing risk information but the studies were generally of poor quality, underpowered and imprecise with most relying on self-reported information. While we are, therefore, unable to rule out the possibility of a small potentially clinically important effect, we can say that it appears unlikely that providing risk information will result in harm through false reassurance and the adoption of unhealthy behaviours. There was also either no change or an improvement in psychological well-being, anxiety, worry about future risk of heart attacks, or self-regulation in these studies. This is an important finding as screening programmes based on risk assessment such as the NHS Health Checks in the UK have the potential to cause harm and a key decision when considering implementation is the extent of that harm. Our review suggests that such screening programmes are safe when it comes to psychological well-being.The effect of the provision of risk information on intermediate measures of CVD and modelled CVD risk was more consistent with studies consistently showing reductions in cholesterol, SBP and DBP, and modelled CVD risk. While the effect sizes are small, they may be of clinical significance at the population level and those studies including only high-risk participants showed significant reductions in cholesterol and SBP. It is possible these effects are mediated through changes in prescribing: although only on the border of statistical significance, patients were 1.4–1.5 times more likely to have a change of lipid-lowering or blood pressure medication when risk information was provided to their physicians and this increased to over twice as likely when only those with a CVD risk >20% were included. This difference in prescribing is not unexpected. Guidelines for prescribing lipid-lowering and blood pressure medication are based on assessment of CVD risk. The increased prescribing for those at high risk therefore likely reflects a greater number of physicians following existing guidance and the smaller effect in those studies including low-risk participants, the effect of including participants in whom no change in treatment would be expected.Trends towards small reductions in cholesterol and blood pressure were also seen in studies in which risk information was only provided to patients. This highlights the central role patients have in making decisions about their treatment and the impact their risk perception and views about preventive medicine have on the outcomes: while some may be risk averse and start medication at low-risk levels, we know from existing literature that many patients are reluctant to start medication with 5% of people on the streets of London stating that they would not take a statin even if it gave them another 5 years of life,While this review shows that provision of risk information to patients and physicians improves accuracy of risk perception, increases prescribing and reduces levels of CVD risk factors and modelled CVD risk without causing changes in psychological well-being or anxiety, no studies included actual CVD events as an outcome, and so we are unable to comment on the effect of risk information on CVD morbidity or mortality. Additionally, while there is some suggestion that the effects may be greater in those at higher risk, with such a small number of studies that could simply reflect regression to the mean. There is, therefore, a need for further research with adequately powered trials with objective outcomes and longer follow-up to understand how best to communicate risk information to increase understanding, enhance shared decision-making and encourage behaviour change.We are also unable to comment on the cost-effectiveness of provision of risk information and whether risk information delivered directly to patients is comparable to physician-led risk assessment. In the current age of increasing demand for healthcare and rising costs of treatment, ways of stratifying the population to enable delivery of interventions to those most likely to benefit are of increasing interest, but with such small changes observed in these studies, the question remains as to whether greater benefit could be derived from investment in population-wide prevention strategies