Geographic variation in long-term oxygen therapy in Denmark : factors related to adherence to guidelines for long-term oxygen therapy.

STUDY OBJECTIVES: To evaluate regional differences in adherence to guidelines for long-term oxygen therapy (LTOT) in Denmark and to determine factors related to compliance with these guidelines. DESIGN: Cross-sectional study and analysis of a nationwide database (Danish Oxygen Register). SETTING: Denmark. PATIENTS: In November 1994, 1,354 COPD patients were receiving LTOT in Denmark. MEASUREMENTS AND RESULTS: Among 16 counties, the prevalence of LTOT for COPD varied from 14 to 53 per 100,000. The prevalence was highest in counties where general practitioners (GPs) were prescribing LTOT. Adherence to national guidelines for LTOT was found in 34.4% of the patients for the whole of Denmark and varied regionally from 14 to 63%. Mean compliance with guidelines was 5.3 (range, 2.9 to 9.1) times as likely if the oxygen was prescribed by a pulmonary department compared to LTOT initiated by a GP. CONCLUSIONS: Marked geographic variations in compliance with LTOT guidelines are present even in a small country as Denmark. In general, the adherence to the guidelines is poor, especially when non-chest physicians prescribe LTOT. We therefore recommend that local and national thoracic societies together with health organizations responsible for treatment should play a more forceful role in implementing the guidelines. This could be done by enhanced educational efforts, by monitoring of adherence, or even by centralizing the prescription right to departments with pulmonary physicians.

Multidrug-resistant tuberculosis in Denmark 1993-1995.

SETTING: All bacteriologically confirmed new cases of tuberculosis and treatment relapses in Denmark are examined for drug resistance. In the years 1993-1995, nine cases of multidrug-resistant tuberculosis (MDR-TB), all acquired outside Denmark, were identified among 1354 cases of tuberculosis. OBJECTIVE: To examine incidence, treatment and prognosis for patients with tuberculosis due to MDR Mycobacterium tuberculosis. DESIGN: Retrospective evaluation of routine data. RESULTS AND CONCLUSION: Multidrug resistance was present in less than one present of patients with tuberculosis. One patient died from tuberculosis without revision of treatment, and eight patients responded favourably to a regimen of pyrazinamide, streptomycin or amikacin, ofloxacin and cycloserine. In two patients, this regimen was supplemented with para-aminosalicylic acid and thiacetazone respectively. All patients needed prolonged hospitalization and had observed treatment. It is possible to cure such patients, but it is a lengthy and expensive process. It is expected that similar cases will be imported into the country and that they will occur within Denmark in the future.

Corticosteroids and tuberculosis.

Common for all older studies is the use of less potent anti-tuberculosis chemotherapy as compared with the present. The results of these studies cannot without reservation be used in the present setting. The newer, prospective, randomized placebo-controlled trials include rather few patients and their number is limited. The results must be interpreted carefully. There is no reason to give prophylactic isoniazide treatment to Mantoux-positive patients or patients with earlier tuberculosis who start treatment with corticosteroids. If allergic reactions to one of the antituberculous drugs emerge during therapy, the treatment can, if necessary, be continued if corticosteroids are added. Pericardial tuberculosis and atelectasis in children with endobronchial tuberculosis should be treated with corticosteroids, as can pleural disease with prolonged fever and exudation. Cases of severe pulmonary tuberculosis may be treated with supplementary steroids. The effect seems modest. Patients with tuberculous meningitis, stages II and III seem to benefit from corticosteroid-treatment.

Has the perception of disability among COPD patients applying for pension changed during the last 20 years?

The aim is to examine the change in lung function, treatment and pulmonary symptoms in patients with chronic obstructive pulmonary disease (COPD) or chronic bronchitis (CB) applying for a pension during the period 1977-1996. In addition, we compared the perception of disability in males and females. From 1977 to 1996, 947 patients with COPD or CB were evaluated for obtaining economic support due to disability. In order to test the trend, the patients were divided into three periods: (1) 1977-1983, (2) 1984-1989 and (3) 1990-1996. Compared to females, males had substantial more pack-years of smoking (36 vs. 28, P<0.001), but their FEV1 was only slightly decreased (46.9% versus 49.6% predicted, P=0.047). Females reported significantly more often attacks of dyspnoea [OR: 1.5(1.00-2.2)] and any kind of dyspnoea during daytime [OR: 4.0(1.2-13.3)]. From period 1 to period 3, FEV1 increased significantly (45-53% predicted, P<0.001). Despite the increased FEV1, the use of inhaled corticosteroid had increased markedly (9-32% of the patients, P<0.001). The results did not change when patients with asthma were included. Our data suggest that both sexes, especially females, have become more aware of pulmonary symptoms and tend to react to them more actively by demanding evaluation and treatment.

Artificial pneumothorax by the Veress cannula: efficacy and safety.

In 16 patients with pulmonary fibrosis, an artificial pneumothorax was introduced using the Veress cannula and the Saugman water manometer. Atmospheric air was introduced by fractionated insufflation to a total volume of 800 ml (median). The interpleural space was found on the first attempt, and in all cases, fractionated insufflation of atmospheric air was conducted while the intrapleural pressure was controlled with the water manometer. In one case, the procedure was stopped because of a rise in the pleural pressure after insufflation of only 50 ml air. This was undoubtedly caused by pleural adhesions not visible on chest X-ray. The main concern with air insufflation is air embolism but this was not observed clinically in any of the present cases. The patients in the present study all suffered from pulmonary fibrosis judged by clinical examination, chest X-ray and pulmonary function tests. Despite a diffusion capacity (DCO/VA) with a median value of 48% expected, the procedure was well tolerated. It has previously been shown that artificial pneumothorax preceding thoracoscopy is well tolerated due to hyperventilation, with an increase in respiratory frequency and a fall in arterial CO2 concentration (PaCO2), while pH and arterial O2 concentration (PO2) remain constant. This probably also explains the tolerance of the patients in this material. Insufflation of air as described here should be restricted to senior pulmonologists because it is an infrequent procedure. The present authors found the procedure to be uncomplicated and easy to perform with little discomfort to the patients.

Is there any association between inhaled ipratropium and mortality in patients with COPD and asthma?

BACKGROUND: To determine whether ipratropium was associated with premature death in patients with asthma and chronic obstructive pulmonary disease (COPD). METHODS: A longitudinal cohort of 827 patients with COPD and 273 with asthma who were evaluated for compensation by two specialists in pulmonary medicine. RESULTS: By June 1999, 538 of the patients with COPD and 77 of those with asthma had died. Atthe consultation, 77% ofthe COPD patients and 8.1% of the asthmatic patients were treated with inhaled ipratropium. Ipratropium was associated with mortality risk ratio (RR) of 2.0 (95% confidence interval: 1.5-2.6) for COPD and 3.6 (1.8-7.1) for asthma patients. After adjustment for confounding factors [forced expiratory volume 1 s (FEV1), smoking habits, asthma medication, and presence of cor pulmonale] the RR for COPD was 1.6 (1.2-2.1) and for asthma 24 (1.2-5.0). CONCLUSIONS: The increased risk of premature death associated with ipratropium is of concern and necessitates further evaluation, e.g., in a randomised study.

Compliance with LTOT and consumption of mobile oxygen.

The aim of the study was to investigate compliance with long-term oxygen therapy (LTOT), the consumption of mobile oxygen and factors that might influence on these measures. The study included 182 patients with LTOT and 125 patients answered a questionnaire on daily activities. Information on arterial gas tension, lung function, and diagnosis was obtained from the medical file. Data on oxygen systems and the actual usage of oxygen were obtained from the oxygen suppliers. Seventy-six per cent of the patients had a concentrator and 35% had both stationary and mobile oxygen. Good compliance (use of oxygen > 15 h day-1) was seen in 65%. Of the tested factors, only mobile oxygen had an influence on the effective usage. Outdoor activity was reported in 65% of the patients. Only 48% of these patients had mobile units, while 21% of the home-bound patients had mobile units. Of the patients with mobile oxygen, only 39% used their mobile unit > 2 h week-1. Poorer usage of stationary oxygen was observed in patients with outdoor activity (2.4 hours day-1 less). Although only 16 (13%) patients reported a usage less than 15 h day-1, the actual consumption was less than 15 h day-1 in 29%. In conclusion, patients on LTOT tended to overestimate their oxygen usage. Acceptable compliance was observed in 65% of the patients. Only mobile oxygen had a significant impact on the overall compliance. As more patients had outdoor activities than expected, and as these activities had a negative impact on the usage of stationary oxygen, more attention must be paid on detecting outdoor activities. However, as fewer than half of the patients with outdoor activity and mobile oxygen used their mobile systems, there is a need for measures to improve compliance with mobile oxygen. Using lists referring to the actual usage and discussing the usage with the patients may improve the compliance and cost-benefit.

Non-continuous home oxygen therapy: utilization, symptomatic effect and prognosis, data from a national register on home oxygen therapy.

About half of all patients on home oxygen therapy receive non-continuous oxygen therapy (less than 15 h daily) (NCOT). The goal of NCOT is to improve well-being during daily activities and to improve sleep quality. The aim of this study was to evaluate the effect of NCOT on pulmonary symptoms and sleep quality, and to determine whether patients with a subjective beneficial effect differed from those without effect in terms of patients' characteristics, utilization of oxygen, hospitalization and survival. Furthermore, the relationship between the reported beneficial effect of NCOT on dyspnoea and physical activity during domestic activities was examined. During the period November 1994 to July 1995, 254 Danish patients were prescribed oxygen less than 12 h daily or 'on demand'. Of these patients, 142 (55.9%) answered a questionnaire on hours spent with oxygen and symptomatic effect of oxygen treatment. While on oxygen, 76.3% of the patients reported improved dyspnoea score (0-10) more than 0.5 points, 78.3% had improved quality of life, 59.5% improved sleep, 48.5% increased physical activity, 49.3% felt less tired and 40.0% reported improved thinking. Fifty-seven (43.2%) patients reported both improved dyspnoea and physical activity whereas seven (5.3%) patients reported that oxygen had no effect on dyspnoea but a beneficial effect on physical activity Only 11 (7.7%) patients reported no subjective improvement on oxygen. The subjective effect of NCOT was not significantly associated to hours spent with oxygen. the underlying disease, gender, hospitalization or survival. During daily activity and regardless of daily number of hours spent with oxygen, NCOT improved well-being in nearly all patients. The most pronounced improvement was reported on dyspnoea, sleep and quality of life. Very few patients sensed improved physical activity without relief in breathlessness.

Inhaled salmeterol in the treatment of patients with moderate to severe reversible obstructive airways disease--a 3-month comparison of the efficacy and safety of twice-daily salmeterol (100 micrograms) with salmeterol (50 micrograms).

Three-hundred and fifty patients with moderate to severe reversible obstructive airways disease (forced expiratory volume in 1 s or peak expiratory flow rate < or = 50% predicted, a 15% reversibility to inhaled salbutamol and symptomatic) were recruited into a multi-centre, multinational, double-blind, parallel-group randomized study. Two-hundred and eighty-three patients were randomized to receive 50 micrograms salmeterol twice daily or 100 micrograms salmeterol twice daily administered from a metered-dose inhaler for 3 months. Salbutamol (100 micrograms per metered actuation) was provided for symptomatic relief. Morning and evening peak expiratory flow rate (PEFR), day-time and night-time asthma symptoms and additional bronchodilator usage were recorded by the patient on a daily basis. Lung function and patient/physician assessment of treatment efficacy were recorded at scheduled clinic visits. Safety was determined by monitoring adverse events and standard biochemical, haematological and cardiovascular parameters. Salmeterol 100 micrograms twice daily was consistently superior to salmeterol 50 micrograms twice daily in morning and evening PEFR measurements (mean differences between the treatments: 10-14 l min-1 for morning, 95% CI-0, 22 l min-1, P = 0.047; and 10-15 l min-1 for evening, 95% CI 2, 22 l min-1, P = 0.023). The improvement in PEFR was independent of concurrent steroid usage, with the most marked improvement being seen in the more severe asthmatics requiring concurrent oral corticosteroids (mean differences between the treatments: 27-31 l min-1, 95% CI: 3,55 l m-1, P = 0.027).(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of recorded asthma deaths in Denmark in a 12-months period in 1994/95.

Many studies of asthma mortality rely on official registration. The aim of this study was to evaluate the accuracy of death certificates, where asthma was coded as cause of death. In a 12-month period, medical information on all subjects with asthma officially coded as the underlying cause of death in Denmark, was obtained by reviewing hospital records, contacting general practitioners and sometimes close relatives. A panel of four pulmonologists each examined the obtained information and independently assessed the cause of death. Of a total of 218 death certificates, 39 were excluded as the cause of death could not be validated. In 16 (9%) of the subjects death from asthma was judged to be the definite cause of death and in 12 (7%) death from asthma was possible. Of 151 non-asthma deaths coded as due to asthma, 109 were judged to have suffered or died from COPD and 14 from heart disease. The accuracy of Danish death certification in asthma deaths is poor, especially in the elderly, where COPD is often classified as asthma. We conclude that the true asthma mortality in Denmark is substantially lower than officially recorded.

Patient-administered sequential spirometry in healthy volunteers and patients with alpha 1-antitrypsin deficiency.

The launching of cheap, pocket-sized spirometers, with data storage capability, has made patient-administered sequential spirometry (PASS) an attractive method of monitoring ventilatory capacity. At present, little information is available on the quality of PASS, compared to laboratory spirometry. The aim of this study was to investigate whether patients could perform PASS without loss of reliability and reproducibility as compared with traditional laboratory spirometry. Ten healthy volunteers performed spirometry for 1 month and 10 emphysematous patients with alpha 1-antitrypsin deficiency (type PiZ) performed spirometry twice daily for up to 2 yr. To fulfil Good Clinical Practice criteria on full data documentation, a traditional direct recording spirometer, the Vitalograph R-model, was used. A decompression device was used for calibration and a 3.8% annual drift in volume registration was noted. This drift was largest for the first year. After training, all patients were able to perform unsupervised spirometry, producing technically correct forced expiratory curves. Reproducibility of FEV1 and FVC obtained by PASS was found to be as good as for laboratory spirometry. After adjustment for the diurnal variation, the residual variation of FEV1 was 2.5% (range 1.6-4.2%) for healthy volunteers and 5.6% (range 4.2-7.7%) for emphysematous patients. Forced vital capacity showed the same pattern. In conclusion, PASS is possible in highly motivated individuals without loss of reliability and reproducibility when compared to laboratory spirometry.

Pulmonary lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is an interstitial lung disease seen virtually only in women of childbearing age. The diagnosis, symptoms, paraclinical investigations including the use of CT and spirometry are reviewed. A hormonal dependency of LAM seems obvious, but the exact mechanism has never been understood. Oestrogen and Progesterone receptors may or may not be present in the myoma tissue in LAM. The receptor status seems to have no influence on the results of treatment with medroxyprogesterone or oophorectomy. In spite of the uncertain results of hormonal treatment a therapeutic trial with medroxyprogesterone 200 mg i.m. weekly is warranted. If no improvement is observed bilateral oophorectomy is recommended. Death due to respiratory insufficiency is common, but prognosis seems better than previously though, survivors for more than 20 years after diagnosis being described.

[Tuberculosis in immigrants]. / Tuberkulose hos indvandrere.

Three cases of tuberculosis in immigrants are described here. The manifestations of tuberculosis in this group are often different from those seen in Danes--in casu tuberculosis of the lymph nodes, skin, bone, and intestines. Diagnosis is difficult, as Danish doctors are not familiar with the clinical picture. Language problems are common and often necessitate the presence of an interpreter. Immigrants tend to move around without notifying the responsible doctor and the resources needed to find them may not be readily available. These factors may cause a considerable delay--from months to years--in the diagnosis and treatment. Doctors examining immigrants from Africa and Asia should be aware of tuberculosis as a possible cause of disease. Secretion and biopsies from fistulae, chronic ulcerations, lymph nodes, and abscesses should always be cultured for Mycobacterium tuberculosis. The Mantoux reaction can be misleadingly negative in patients suffering from severe tuberculosis. Identification of Mycobacterium tuberculosis is not necessary for treatment--that decision is made on the clinical picture. On the other hand material for a bacteriological diagnosis should always be obtained, because of possible resistance problems.

[Corticosteroids as adjuvants in the treatment of tuberculosis]. / Kortikosteroid som adjuverende behandling ved tuberkulose.

The anti-inflammatory effect of corticosteroids has been known for a long time, as have their use in treating diseases with an inflammatory component. Corticosteroids have also been used as an adjunct in treating tuberculosis. We have reviewed the literature to evaluate the rationale for our present treatment strategy. We find no reason for the use of Isoniazide in routine prophylaxis of Mantoux positive or former tuberculosis patients who are treated with corticosteroids. Corticosteroids could be added when treating severe pulmonary tuberculosis. When treating tuberculous pericarditis and severe tuberculous pleurisy, corticosteroids should be used as an adjunct to the antituberculous chemotherapy. No controlled studies have been carried out in patients with tuberculous meningitis, but retrospective reports have shown a lower mortality in patients treated with steroids. In children with stenosis and atelectasis because of endobronchial obstruction due to tuberculosis in mediastinal lymphnodes, corticosteroids should be added to the usual antituberculous regimen.

[Heart-lung transplantation]. / Hjerte-lungetransplantation.

During recent years, lung transplantations have been performed as lung transplantations or heart-lung transplantations in approximately 300 patients with terminal pulmonary or pulmonary vascular disease where other forms of treatment were considered hopeless. Two of the patients were Danish and operation was undertaken in England. One and three year's survival are now so good that this form of treatment need no longer be regarded as being of experimental nature. The indications and contraindications for operation are described and the postoperative immuno-suppressive therapy and complications are reviewed. Employing strict criteria in selection, the annual number of patients in Denmark is estimated to be approximately 50 and this is an adequate basis for a transplantation centre. At present, the procedure for selection of patients for operation is still vague and random in Denmark.

[Long-term prognosis of pulmonary sarcoidosis. 1. Prognostic value of lung function and symptoms]. / Langtidsprognosen ved pulmonal sarkoidose. 1. Den prognostiske voerdi af lungefunktion og -symptomer.

A follow-up of 254 patients with intrathoracic sarcoidosis has been carried out after a median of 27 years from diagnosis. All patients could be traced. No excess mortality was found (80 deaths observed versus 66 expected). The causes of death were related to sarcoidosis in 41%. X-ray stage was related to survival with a significant excess mortality for stage 3. Early clearing of X-ray changes gave a favourable vital prognosis. Survival was related to lung function, especially forced expiratory volume in 1 second (FEV1) and total lung capacity (TLC). All deaths from sarcoidosis were seen among patients with respiratory symptoms at presentation. For sarcoidosis & sarcoidosis-related deaths (N = 33), presence of one or more of the respiratory symptoms increased the risk significantly. For overall mortality respiratory symptoms were also significant predictors; this was the case even after adjusting for age, sex, x-ray stage and lung function (FEV1 & TLC) at presentation. In conclusion, no excess mortality was observed after a median of 27 years follow-up. Lung function, respiratory symptoms and to some extent X-ray stage at time of diagnosis influenced long-term mortality in patients with intrathoracic sarcoidosis.

[2 cases of lymphangioleiomyomatosis treated by hormonal manipulation]. / To tilfaelde af lymfangioleiomyomatose behandlet med hormonal manipulation.

The course of disease in two women with bioptically verified lymphangioleiomyomatosis (LAM) is demonstrated. One was oestrogen- and progesterone-receptor negative, but responded promptly to hysterosalpingo-oophorectomy and has had no symptoms later. The other was receptor positive, but in spite of hysterosalpingo-oophorectomy and hormonal manipulation with tamoxifen and medroxyprogesterone, has had a complicated course of the disease with symptoms for ten years. LAM is a hormone dependent disease, but our knowledge is still incomplete. Hormonal manipulation should be tried in receptor positive as well as negative patients. Tamoxifen seems to have deleterious effects on the course of disease.

[Extrapulmonary tuberculosis in Denmark. A review of the incidence, localization and therapy]. / Ekstrapulmonal tuberkulose i Danmark. En oversigt over forekomst, lokalisation og behandling.

In Denmark, just under 20% of tuberculosis (TB) cases amongst Danes and 25-30% of cases amongst people of foreign nationalities are made up of isolated extrapulmonary (EP) TB. The incidence among Danes is falling, whereas an increasing amount of EP TB cases are found among foreigners due to continued immigration, and these now constitute 50% of all cases of EP TB. EP TB is found among older Danes and younger foreigners. The HIV/AIDS epidemic has not had any effect on the incidence of TB and EP TB in Denmark. EP TB is most frequently found in lymph nodes and the urogenital system. Since the disease is rare, it may be overlooked; it should be considered as a differential diagnosis in unresolved cases, particularly in immigrants from countries with a high prevalence of TB. Treatment is as for pulmonary TB, namely "four drug" therapy for six months. Surgical intervention is rarely required. Supplementation with oral steroids may be useful in very special cases.

[Primary malignant pleural neoplasms. Diagnostic code 163.09]. / Primaer malign neoplasme i pleura. Diagnosekode 163.09.

The code 163.09 indicates a primary malignant pleural neoplasma-malignant mesothelioma. We have reinvestigated 173 patients, who were discharged from a department of pulmonary medicine with this code number during a 8 1/2 year period. A revision during which repeated biopsies, course of the disease and, in some cases, autopsy were considered, revealed that 63 were confirmed as having a malignant mesothelioma, 94 had neoplastic disease secondary to malignancy elsewhere, 13 had benign changes and in three cases the records were missing. Malignant mesothelioma entitles the patient to compensation if he has worked with asbestos. An occupational history was present in 94% of those suffering from mesothelioma and in 71% of the remaining patients. Among patients with mesothelioma a history of asbestos exposure was obtained in 44%, a history of no exposure in 22% and no specific mention of asbestos in 34%. In the group of patients who did not have mesothelioma 14% had known exposure to asbestos, eight none and in 78% no specific information concerning asbestos was available. Twenty-three of the 63 patients with mesothelioma had been notified to the workmens' compensation board. Retrospectively, we found that 12 more patients should have been notified. Eight patients who did not fulfil the criteria for malignant mesothelioma had erroneously been notified to the board for compensation. We find that code 163.09 frequently has been used as a working diagnosis, which could not invariably be substantiated. Although malignant mesothelioma had been suspected, previous history concerning asbestos exposure was often incomplete or absent. A correct occupational history and aggressive bioptical procedures are essential in all cases where malignant mesothelioma is suspected.(ABSTRACT TRUNCATED AT 250 WORDS)

[Alternative treatment of lung diseases]. / Alternativ behandling af lungesygdomme.

A total of 671 patients attending two outpatient clinics for pulmonary medicine received a questionnaire about possible alternative treatment of the pulmonary disease for which they were receiving treatment. Six hundred and five questionnaires were answered anonymously. Among the 605 patients, 75 (12%) had received alternative treatment. No differences in the frequencies were observed between men and women. Employment of alternative treatment was most frequent in the age groups 20-29 and 50-59 years. Prolonged illness without definite prospects of cure such as chronic bronchitis and asthma resulted in employment of alternative treatment more frequently than briefer illness without possibility of cure (cancer of lung) or with the possibility of cure (tuberculosis, pneumonia). The patients had practically always consulted their general practitioner before the alternative therapist (94%). Half of the patients had improved, half were unchanged and only a few per cent had deteriorated. In the majority of cases, the expenses were moderate but isolated patients had, however, paid more than 10,000 Danish crowns (approximately pounds 1,000) for the alternative treatment.