[Hepatopulmonary syndrome]. / Hepatopulmonaalinen oireyhtymä.

Hepatopulmonary syndrome (HPS) is characterized by the triad of liver disease, intrapulmonary vascular dilatation and arterial deoxygenation. Mediating factors are tumor necrosis factor a, endothelin 1 and nitric oxide. Typical symptom is an increase in dyspnea while in standing position, orthodeoxia. In orthodeoxia hypoxemia accentuates while the partial pressure of oxygen in arterial blood decreases by 5% or more. The blood flow distribution to the lungs is changed as the pulmonary vascular tone is altered. Diagnosis is based on the evidence of liver disease, hypoxemia and pulmonary vascular shunt detected by the so-called bubble test. Liver transplantation is currently the only efficient therapeutic option.

High hospital burden in overlap syndrome of asthma and COPD.

BACKGROUND: Overlap syndrome of asthma and chronic obstructive pulmonary disease (COPD) is a common condition, which is not well understood. This study describes the characteristics and hospital impact of patients suffering from this condition. METHODS: The data are comprised of the hospital discharge registry data maintained by National Institute for Health and Welfare [Terveyden ja hyvinvoinnin laitos (THL)] between 1972 and 2009 covering the entire Finnish population (5.35 million inhabitants in 2009). In THL, treatment periods for patients with the primary or secondary diagnosis of asthma or COPD were selected. From that data, patients over 34 years and their treatment periods starting and ending 2000-2009 with a principal or secondary diagnosis of asthma [International Classification of Diseases (ICD) 10: J45-J46] or COPD (ICD 10: J41-J44) were picked up. There were 105 122 such patients who had 343 420 treatment periods altogether. RESULTS: Patients with asthma were younger than patients with COPD and overlap syndrome, while COPD and overlap syndrome patients' age distribution was very similar. Patients with both asthma and COPD had 30.4% of all treatment periods, even though the percentage of all patients in this group was only 16.1%. These patients had an increased number of hospitalisation episodes across all age groups. Average number of treatment periods during 2000-2009 was 2.1 in asthma, 3.4 in COPD and 6.0 in overlap syndrome. Hospital impact of the same period in asthma was 939 900 days in COPD 1 517 308 and 1 000 724 days in overlap syndrome. CONCLUSION: Overlap syndrome of asthma and COPD is a common condition with high hospital impact for patients with this condition.

The 10-year COPD Programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality.

BACKGROUND: The Finnish National Programme for Chronic Bronchitis and Chronic Obstructive Pulmonary Disease (COPD) 1998-2007 was set up to reduce the prevalence of COPD, improve COPD diagnosis and care, reduce the number of moderate to severe cases of the disease, and reduce hospitalisations and treatment costs due to COPD. Over 900 events for 25,000 participating healthcare workers were arranged. The major strengths of this programme included multidisciplinary strategies and web-based guidelines in nearly all primary health care centres around the country. METHODS: Data from national registries, epidemiological studies and questionnaires were used to measure whether the goals had been reached. RESULTS: The prevalence of COPD remained unchanged. Smoking decreased in males from 30% to 26% (p<0.001) and in females from 20% to 17% (p<0.001). Significant improvements in the quality of spirometry were obtained. Hospitalisation decreased by 39.7% (p<0.001). COPD costs were 88% lower than had been anticipated from earlier investigations. No increase in COPD mortality was observed. CONCLUSIONS: In combination with other efforts, the Finnish 10-year COPD Programme had significant positive consequences: no further increases in COPD prevalence, reduced smoking prevalence, improved quality of diagnosis, and reduction in COPD-related hospitalisations.

Differences in COPD-related readmissions to primary and secondary care hospitals.

OBJECTIVE: To study differences in readmissions to primary and secondary care hospitals for exacerbations of chronic obstructive pulmonary disease (COPD). DESIGN: A register-based study. SUBJECTS: The data were gathered from the hospital admissions register of the Finnish National Research and Development Centre for Welfare and Health. The data included all acute periods of treatment received by COPD patients aged over 44 years in 1996-2004 who had a principal or subsidiary diagnosis of COPD (ICD 10: J41-J44), respiratory infection (ICD 10: J00-J39, J85-J86) or cardiac insufficiency (ICD 10: I50), followed by an emergency readmission. Treatment had to have taken place in either a primary care hospital or a specialized ward for respiratory diseases or internal medicine in a secondary care hospital. MAIN OUTCOME MEASURES: The risk of readmission within a week of discharge, analysed by site of care. RESULTS: The risk of readmission within seven days of discharge is 1.74-fold for a patient treated in primary care compared with a patient treated in secondary care. CONCLUSIONS: COPD patients discharged from primary care hospitals have a greater risk of readmission, particularly within a week, than those discharged from secondary care. This risk may be attributed to differences in treatment procedures and arrangement of subsequent care. Thus, in the future, more attention should be paid to primary healthcare resources and staff training.

A bronchiectatic patient's risk of pneumonia and prognosis.

The objective of this study was to define the morbidity and mortality of bronchiectatic patients. All records from the years 1993-2004 of patients with asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis as the primary diagnosis were extracted from the Finnish Hospital Discharge Register. The data of these patients' deaths until the end of the year 2004 were acquired from Statistics Finland. These materials were analyzed in order to find each bronchiectatic patient of this period an asthma or COPD control subject who was of the same age and sex and had also been hospitalized in the same year. Their numbers of pneumonia and prognoses were compared with each other during the study period. 59.4% of all bronchiectasis treatment periods in absolute numbers were for people aged 65 years or over. The occurrence of pneumonia in bronchiectatic patients was 1.03 (95% CI 0.82-1.24) per follow-up year, while the corresponding rate in the COPD control subjects was 1.22 (95% CI 0.92-1.53) and in the asthma control subjects 0.38 (95% CI 0.22-0.54). The mean survival times for the bronchiectatic patients were 8.33 (95% CI 8.16-8.50), for the COPD control subjects 6.26 (95% CI 6.07-6.45) and for the asthma patients 8.93 (95% CI 8.76-9.10) years. Bronchiectasis-related hospitalization in Finland is primarily focused on aged people. A bronchiectatic patient has a higher risk of pneumonia and a worse prognosis than an asthmatic, while the situation is opposite when compared to a COPD patient.

Does place of treatment affect prognosis for chronic obstructive pulmonary disease (COPD)?

BACKGROUND: It has been shown previously that mortality from acute chronic obstructive pulmonary disease (COPD) is higher at small hospitals than at large teaching hospitals. OBJECTIVE: To examine mortality at this acute stage and referral for further treatment by specialities in Finland, and trends in these between the 1990s and 2000s. METHODS: Data on all periods of treatment for patients over 44 years of age with a principal or subsidiary diagnosis of COPD beginning and ending in 1995-2004 were extracted from the Finnish hospital discharge register. Particular attention was paid to acute-stage treatment periods managed by a general practitioner, pulmonary specialist, or specialist in internal medicine that had begun as emergency admissions and had a principal diagnosis of COPD, and to any further treatment immediately following these. RESULTS: General practitioners referred 5.1% of their acute-stage patients to a specialist in secondary care in 1995-2004. Of the total of 77,445 acute-stage treatment periods, 3% (2328) ended in the death of the patient, implying the loss of 8.3% of the patients involved. The age- and sex-adjusted risk of death attached to treatment periods managed by a general practitioner relative to those managed by a pulmonary specialist was 0.83 (95% CI 0.75-0.91). CONCLUSION: It is quite possible to treat acute exacerbations of COPD efficiently and safely in a health centre hospital ward. New treatment modalities and health service structures seem to have led to a decrease in acute exacerbations of COPD since the year 2000, even though the number of patients with this disease has increased as a consequence of ageing of the population. Further research is required on the efficacy of treatment by a general practitioner, e.g., with data on re-hospitalization.

The COPD-induced hospitalization burden from first admission to death.

BACKGROUND: Hospitalization periods at the exacerbation stage of COPD place a major burden on the health services and entail substantial costs. Little is known, however, about the corresponding burden on hospitals as the disease advances. We therefore set out to determine from hospital discharge and cause of death registers the overall burden on hospital resources occasioned by a COPD patient on a relative time scale from first admission to death, differentiated by age group, prognosis and sex. METHODS: Data on all subsequent hospital treatment periods after the first for patients with COPD who were over 44 years of age on admission were gathered from the Finnish National Research and Development Centre for Welfare and Health for the period 1991-2001. The actual material for this study consisted of the data on those patients who were alive after the first treatment period but had died by 2001. These were divided into three survival groups. RESULTS: The 8325 patients in this material had a total of 35,814 hospitalization periods in 1991-2001, of which men accounted for 73.6%. A total of 1895 of the patients (22.8%) had died within a year, 4257 (51.1%) within 1-5 years and 2173 (26.1%) after more than 5 years. Of those dying within a year, 20.9% had been in hospital care, while of those who lived on for over a year, 4.5% were in hospital when two-thirds of their remaining lifetime was still ahead of them and 7.3% when one-tenth of that time was still ahead. CONCLUSIONS: Almost one-fourth of the COPD patients had died within a year of first hospital admission for the disease. This group with a poor prognosis made abundant use of hospital services. The burden imposed on such services by severe COPD patients is U-shaped, with hospital use increasing towards the end of their lives.

Is the treatment of acute COPD exacerbations in Finland shifting to general practitioners?

OBJECTIVE: To examine changes in the numbers of inpatient episodes and inpatient days and length of stay in acute exacerbations of COPD (chronic obstructive pulmonary disease) by specialization and by age group and sex distribution relative to the total population in the years 1995-2001. DESIGN: A register-based study. SUBJECTS: Data on inpatient episodes for patients aged 45 years or over with a principal diagnosis of COPD beginning in 1995-2001 and lasting less than 90 days were extracted from the hospital discharge register of the Finnish National Research and Development Centre for Welfare and Health. MAIN OUTCOME MEASURES: Numbers of inpatient episodes and days by age and sex in the specialties of general practice, pulmonary medicine, and internal medicine. RESULTS: The annual number of inpatient episodes increased by 10.9% from 1995 to 2001. The number of emergency treatment episodes supervised by a general practitioner increased by 36.8% during the same period and the number of such episodes supervised by a pulmonary specialist by 17.8%. The increase in age-adjusted emergency treatment episodes for men was 0.8% and that for women 18.5%. The average hospital stay shortened from 8.0 (SD 8.0) to 6.5 (SD 6.2) for men and from 8.7 (SD 8.5) to 7.3 (SD 6.8) for women. CONCLUSIONS: The greater increase in inpatient episodes for exacerbations of COPD in relation to the total population among women than among men may be attributed to differences in smoking habits and ageing between the sexes. Responsibility for COPD cases is clearly shifting to general practitioners. This is due partly to the national programme for the treatment of obstructive pulmonary diseases and the associated in-service training provided for general practitioners and partly to financial reasons. More detailed investigations should be made into the quality of the treatment.

Length of stay and interval to readmission in emergency hospital treatment of COPD.

BACKGROUND: increasing attention has recently been attached to the length of hospital stay and related factors in the treatment of COPD. OBJECTIVES: to assess the trend in the duration of inpatient episodes following emergency admissions for COPD by age and sex, and the frequency of readmissions, as well as the correlations between the frequency and duration of inpatient episodes. DESIGN: retrospective study. SETTING: the Finnish hospital discharge register. SUBJECTS: the 72,672 inpatient episodes following emergency admissions of patients aged over 44 years that ended in 1993-2001 and had COPD as the principal diagnosis. RESULTS: the mean duration of inpatient episodes was 8.5 days (SD 8.2) in 1993, but 6.8 days (SD 6.6) in 2001. The figure for 45- to 64-year-old men was 6.5 days (SD 6.6) and that for men aged >64 years, 7.8 days (SD 6.8). The corresponding figures for women were 7.1 days (SD 6.8) and 8.8 days (SD 8.4). The average interval between the end of one inpatient episode and the beginning of the next was 195.4 days (SD 327.7). This interval was longest when the inpatient episode lasted for 7 days (interval 215 days). CONCLUSIONS: the length of hospital stay for COPD exacerbation seems to be decreasing, and elderly women have the longest inpatient episodes. With the current treatment modalities, a 1-week stay in hospital results in the longest interval to readmission. The situation may change if supported home care at exacerbation can be increased.