Barriers to implementation of smoking cessation support among healthcare professionals in the secondary healthcare sector: A qualitative and quantitative evaluation.

INTRODUCTION: Smoking cessation support (SCS) in the hospital is essential; patients often struggle to maintain quit attempts, which necessitates assistance from healthcare professionals (HCPs). However, unknown barriers can obstruct the implementation of SCS in hospitals. This study aims to uncover barriers to the implementation of SCS in psychiatric, somatic, inpatient, and outpatient hospital settings. METHODS: In the period from June to September 2021, HCPs in a large secondary care hospital in the Region of Southern Denmark completed an online, cross-sectional study, providing sociodemographic details and listing potential barriers to SCS. They also shared additional barriers in the form of free-text responses. Descriptive statistics and thematic analysis of free-text responses were performed. RESULTS: Of 1645 HCPs surveyed, 409 elaborated their response in the free-text field assessing unlisted barriers. Top listed barriers, reported by more than one-third of participants, included: 'lack of time' (45.1%), 'lack of patient motivation' (34.3%), and 'insufficient knowledge on how to support' (32.2%). Free-text responses revealed three barrier-related, which we grouped under the themes of: 'Concerned about the patient', 'Not part of my job', and 'Inappropriate setting'. CONCLUSIONS: This quantitative and qualitative study identifies barriers to SCS on multiple levels in the hospital setting, i.e. on the patient, provider, and organizational levels. These results can inform healthcare organizations and professionals in the implementation of SCS in routine hospital care.

Trends in COPD mortality from 1983 to 2018: protocol for a population-based cohort study in Denmark.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide, which is partly contributed to the increasing prevalence of COPD owning to a demographic shift towards an older population. Conversely, recent studies on COPD mortality that take this demographic shift in age into account find decreasing overall age-standardised COPD mortality rates over time. This decrease in the age-standardised COPD mortality rate is contributed advances in COPD diagnostics and treatment, decreasing smoking prevalence and general advances in medical care particularly in western countries. However, it is unknown if patients with COPD have experienced a comparable relative increase in survival in line with the general population.Hence, there is a need for longitudinal studies comparing trends in mortality in patients with COPD compared with matched non-COPD individuals from the background population. METHODS AND ANALYSES: This is a cohort study with a matched non-COPD comparator cohort. Data are retrieved from the Danish national registers. Data from multiple registries from 1983 to 2018 will be merged on an individual level using the 10-digit Civil Registration numbers that are unique to each citizen in Denmark. Time trends in mortality in patients with COPD compared with the matched comparator cohort will be examined in three study periods: 1983-1993, 1994-2007 and 2008-2018. ETHICS AND DISSEMINATION: The study is entirely based on registry data and ethical approval is not required according to Danish Law and National Ethics Committee Guidelines. The results will be published in peer-reviewed journals and reported at appropriate national and international conferences.

COPD and Smoking Status - It Does Matter: Characteristics and Prognosis of COPD According to Smoking Status.

Background: Chronic obstructive pulmonary disease is a chronic, often progressive disease, which in most patients is caused by tobacco smoking. Our study focuses on differences in COPD-related outcomes between never smokers, former smokers, and current smokers. Methods: A nationwide, population-based cohort study utilizing Danish health registries. Clinical and socioeconomic variables including smoking status, comorbidities, and dyspnea were obtained. Poisson and Cox Regression were used to calculate the impact of these clinical parameters on the risk of moderate and severe exacerbations and mortality during 12 months of follow-up. Results: A total of 49,826 patients ≥40 years of age, with a hospital diagnosis of COPD in 2008-2017, were identified (mean age 69.2 years, 52% females). A total of 2127 (4%) were never smokers, 29,854 (60%) were former smokers and 17,845 (36%) current smokers. Compared to former and current smokers, never smokers reported a lower modified Medical Research Council score and had a milder COPD stage according to the Global Initiative for Chronic Obstructive Lung Disease classification. During follow-up, never smokers had a significantly lower risk of severe exacerbations (hazard ratio 0.87, 95% confidence interval [CI] 0.78-0.97) and a lower rate of death (mortality ratio 0.75, 95% CI 0.70-0.81) compared to patients with a smoking history. Discussion: Our nationwide study showed that COPD in never smokers is characterized by a lower level of dyspnea, milder lung function impairment, and a lower risk of exacerbations and death. At the same time, we found active smokers to have the highest risk. These findings highlight the need for campaigns to prevent smoking and may help general practitioners as well as other health care professionals to motivate patients with COPD to stop smoking.

Introduction of a systematic examination framework for chronic cough: a before-after cohort study in a clinical setting.

Cough is a condition that can be caused by several different mechanisms. There are numerous guidelines for diagnosing the cause of cough, yet the effect of a well-constructed examination framework has not been investigated. At the Department of Internal Medicine, Lillebaelt Hospital, Vejle, a systematic examination framework for diagnosing cough was introduced. Two hundred consecutive patients referred to the pulmonary outpatient clinic with cough were included. The first 100 patients (Group 1) were included before implementation of the examination framework and diagnosed as usual. The next 100 patients (Group 2) were examined using the systematic framework. The primary endpoint was the number of appointments required to establish a diagnosis. A multivariable Poisson regression was performed, adjusting for age, sex, body mass index, pulmonary function (FEV1/FVC), duration of cough, and smoking status. A diagnosis was established within 1-2 visits in 47% in Group 1 compared to 83% in Group 2. When adjusting for confounders, fewer appointments was required to establish a diagnosis in Group 2 (Incidence rate ratio = 0.713 (95% confidence interval: 0.592-0.859), P = 0.000). Using a systematic examination framework for diagnosing cough may reduce the number of appointments required to establish a diagnosis, seemingly without compromising the diagnostic outcome.

Burden of Disease and Productivity Loss in the European Economic Area in Patients Affected by Fibrosing Interstitial Lung Disease.

INTRODUCTION: Progression of fibrosis in interstitial lung diseases (ILD) has been associated with poor prognosis, lower quality of life for patients and caregivers, and higher healthcare costs. This study estimated the burden of disease and productivity loss of progressively fibrosing ILD, focusing on progressive pulmonary fibrosis other than idiopathic pulmonary fibrosis (non-IPF PPF) and systemic sclerosis-associated ILD (SSc-ILD) in the European Economic Area (EEA). METHODS: An economic model was built to estimate the clinical burden of SSc-ILD and non-IPF PPF. The model was based on published data on disease prevalence and disease burden (in terms of comorbidities, exacerbations, and deaths) as well as on productivity loss (in terms of sick days, early retirement, permanent disability, and job loss). Aggregate income loss was obtained by multiplying productivity loss by the median daily income in each country/area of investigation. A sensitivity analysis was performed to test the impact of the variability of the model assumptions. RESULTS: In the whole EEA, a total of 86,794 and 13,221 individuals were estimated to be affected by non-IPF PPF and SSc-ILD, respectively. Estimated annual sick days associated with the diseases were 3,952,604 and 672,172, early retirements were 23,174 and 5341, permanently disabled patients were 41,748 and 4037, and job losses were 19,789 and 2617 for non-IPF PPF and SSc-ILD, respectively. Annual exacerbations were estimated to be 22,401-31,181 and 1259-1753, while deaths were 5791-6171 and 572-638 in non-IPF PPF and SSc-ILD, respectively. The estimated annual aggregate income loss in EEA, accounting for losses due to annual sick days, early retirements, and permanently disabled patients, was €1433 million and €220 million in non-IPF PPF and SSc-ILD, respectively. The productivity loss due to job losses was €194 million and €26 million in non-IPF PPF and SSc-ILD, respectively. The main driver of aggregate income loss variability was the prevalence. CONCLUSION: The impact of non-IPF PPF and SSc-ILD on society is definitely non-negligible. Actions to reduce the burden on our societies are highly needed.

Social prescribing to reduce polypharmacy in patients with COPD in general practice.

Patients suffering from COPD are often treated with a substantial number of medications due to multimorbidity. The combination of multimorbidity and polypharmacy can make the treatment of individuals with COPD difficult. Although guidelines in recent years have focused on the reduction of inappropriate medication, there is still room for improvement. This review suggests an increased focus on smoking cessation and physical activity in terms of the use of social prescribing to prevent polypharmacy and thereby improve sustainability in patients with COPD.

Comorbidity and mortality in systemic sclerosis and matched controls: Impact of interstitial lung disease. A population based cohort study based on health registry data.

OBJECTIVE: This population-based, matched cohort study evaluates the impact of comorbidities on mortality among systemic sclerosis (SSc) patients with and without interstitial lung disease (ILD). METHOD: Patients with a first-time SSc diagnosis between 2002 and 2015 were identified in the Danish National Patient Registry, separated into two cohorts - with ILD (SSc-ILD) and without ILD (non-ILD SSc), and matched 1:4 with controls from the general population on age, sex, residency and marital status. Comorbidity and mortality data were obtained from national registries. The Deyo-Charlson comorbidity score (DCcs) was used for assessment of the burden of comorbidities. RESULTS: 1732 patients with SSc and 6919 controls were included; 258 (14.9%) patients had SSc-ILD. The hazard ratio (HR) for death was 2.8 (95% CI 2.4-3.3) in SSc, and especially increased in SSc-ILD (HR 4.2 (95% CI 3.2-5.4)), males (HR 3.1 95% CI 2.4-4.1) and younger adults (aged 18-40 (HR 6.9, 95% CI 3.4-14.2) and 41-50 (HR 7.7, 95% CI 3.8-15.6)). In non-ILD SSc, mortality increased with increasing DCcs. Cancer was the most frequent cause of death in SSc (24.9% of deaths) and in controls (33.5%), in SSc followed by musculoskeletal and connective tissue diseases (22.7%); the cause of only 0.8% of deaths among controls. CONCLUSION: The high prevalence of comorbidities in SSc had extensive impact on mortality. Mortality was increased in males, in young adults and in SSc-ILD, underlining the excess mortality associated with ILD. These findings emphasise the importance of timely diagnosis and optimal management of organ involvement and comorbidities in SSc.

A survey exploring the practices of smoking cessation support among hospital-based healthcare providers.

BACKGROUND: Hospital visits constitute a 'window of opportunity' for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs. METHODS: HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the "five As" framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis. RESULTS: All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs. CONCLUSION: Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed.

Pharmacological smoking cessation of adults aged 30-50 years with COPD.

The prevalence of active smokers has remained relatively stable around 20% for several years in Denmark despite knowledge of the harmful effects. Smoking cessation is the most effective way to limit progression and reduce mortality of chronic obstructive pulmonary disease (COPD). Therefore, smoking cessation is particularly important among adults with COPD. The aim of this study was to determine the extent to which adults 30-50 years of age with COPD redeem pharmacotherapy for smoking cessation, and to identify demographic factors that influence the use of smoking cessation medication. We conducted a national retrospective non-interventional registry study, including all Danish patients with COPD (ICD-10 code J.44: chronic obstructive pulmonary disease) aged 30-50 years in the period 2009-2015. We identified 7734 cases, who were matched with controls (15,307) 1:2 on age, sex, and geography. Smoking status was not registered. We found that 18% of cases (with an estimated smoking prevalence at 33-50%) redeemed pharmacological smoking cessation medication in the study period compared to 3% of the controls (with an estimated smoking prevalence at 23%). The OR for cases collecting pharmacological smoking cessation medication was 5.92 [95% CI 5.24-6.70]. Male sex, being unemployed, and receiving social benefits were factors associated with less probability of redeeming pharmacological smoking cessation medication. Our study indicates that attention is needed on smoking cessation in adults aged 30-50 years with COPD, especially if unemployed or receiving social benefits, as these individuals are less likely to redeem pharmacological smoking cessation medication.

[Smoking cessation and drug interactions].

Tobacco smoke can cause drug interactions by induction of CYP1A2, which metabolizes drugs like clozapine, olanzapine and theophylline. This means that smokers need higher doses to achieve the same plasma concentrations as non-smokers. Furthermore, smoking cessation can cause an increase in plasma concentrations of drugs metabolised by CYP1A2, which in turn may lead to adverse effects. Of the drugs used for smoking cessation only bupropione has clinically relevant interactions. All of these situations may be handled by dose adjustment.

Changes in systemic inflammation after pulmonary rehabilitation in patients with COPD and severe physical inactivity - an exploratory study.

BACKGROUND: Severe physical inactivity (SPI) in patients with COPD is associated with a poor prognosis. It is unknown whether there is a link between SPI and systemic inflammation, and if systemic inflammation in SPI changes following pulmonary rehabilitation (PR). METHODS: A prospective, observational study of patients referred for at least 7 weeks of PR comprising 2 h of exercise therapy and education twice weekly. At baseline and after PR, daily physical activity level (PAL) was measured with a validated activity monitor, SenseWear® as well as systemic inflammation: b-eosinophils, p-fibrinogen, p-CRP, s-IL-6 and s-CD 163. SPI was defined as PAL <1.4. RESULTS: At baseline, SPI was present in 31 of the 57 patients included, and 23% (7/31) improved to non-SPI after PR. We observed no differences between patients with SPI and non-SPI, except baseline plasma fibrinogen level was slightly yet significantly higher in patients with SPI (median 13.3 [6.2-23.6] vs 11.2 [6.5-16.7] µmol/l) but change in fibrinogen levels differed insignificantly between patients who improved to non-SPI at follow-up compared to patients with persistent SPI (-0.6 [-16.9-9.9] vs -0.4 [-11.2-1.2] µmol/l). CONCLUSION: SPI in COPD appears not to be associated with a distinct inflammatory profile compared to less sedentary COPD patients attending pulmonary rehabilitation. Currently biomarkers have no role in the detection of SPI in COPD.

A progressing inflammatory pulmonary infiltrate in a patient with hyper IgE syndrome.

A young man known with autosomal dominant hyper IgE syndrome and changes on his chest radiograph was presumed to be infected with Aspergillus and treated with antifungal medicine for 11 months without effect. Positron emission tomography/computed tomography imaging was suggestive of Aspergilloma but bronchoalveolar lavage cultures, cytology as well as biochemistry were negative for Aspergillus. Finally, a transthoracic computed tomography-guided biopsy did not support the diagnosis of fungal infection as only chronic inflammatory changes were found. The patient was treated with Prednisolone after which the changes on his chest X-ray regressed.

Complete Spontaneous Regression of Squamous-Cell Lung Cancer: A Case Report.

Spontaneous regression of cancer is an extremely rare phenomenon, and it has been described in only a few cases of pulmonary cancer. We report a case of complete spontaneous regression of squamous-cell lung cancer (SCLC) following a core needle biopsy in a 67-year-old female patient with two previous lung cancers and concomitant follicular lymphoma. The patient was diagnosed with SCLC after 4 core needle biopsies from a nodule in the left upper lobe and at the same time suspected of having follicular lymphoma. Treatment for the lung cancer was delayed by approximately 8 weeks because the diagnosis of lymphoma was both challenging and time-consuming. A computed tomography scan was performed in relation to the scheduled treatment for SCLC, showing that the pulmonary nodule had disappeared completely. Most other cases of spontaneous regression of lung cancer hint at the involvement of immunological factors, and this case possibly involves a combination of mechanical and local immunological factors. Genetic and immunological analysis of patients showing spontaneous regression of cancers could provide valuable information.

Parental COPD as a Risk Factor for the Development of COPD and Disease Severity in Offspring: A Systematic Scoping Review.

Background: There is sparse literature on parental chronic obstructive pulmonary disease (COPD) as a risk factor for the development of COPD in adult offspring, and the impact on disease severity. We aimed to map the literature reporting on the prevalence of and/or association between parental COPD and COPD in offspring, and to evaluate whether or not the literature reports on the severity of COPD or other health-related outcomes in offspring with parental COPD. Methods: A systematic literature search in Embase and Ovid MEDLINE was performed in June 2021. Search terms revolved around COPD and predisposition. Results: Thirteen studies were identified: 10 case-control studies, two cross-sectional studies and one cohort study. Population size varied from 44 to 2668 offspring cases; the distribution of female cases varied from 5% to 80% and mean age ranged from 27 to 65. Nine studies used an antecedents approach and evaluated the prevalence of parental COPD in patients with COPD, which ranged from 19% to 58%. Four studies used a descendants approach, by identifying patients with COPD and subsequently evaluated prevalence of COPD in their offspring, and found a prevalence of 0% to 17%. Apart from one, all the studies found an increased odds ratio for COPD in individuals with parental COPD. Four studies reported on parental smoking history and nine studies reported on smoking history in offspring. Three studies evaluated the association between parental COPD and COPD-related outcomes in patients with COPD. Conclusion: This review indicates that parental COPD is associated with a higher risk of COPD in offspring. The literature is sparse, and we identified a knowledge gap on whether parental COPD is a risk factor for severe COPD and other health conditions in offspring.

Hyperammonaemic Encephalopathy Caused by Adult-Onset Ornithine Transcarbamylase Deficiency.

Hyperammonaemic encephalopathy in adults is a rare condition in the absence of liver disease and is associated with a high mortality and risk of permanent neurological deficits. Seldomly, the condition is caused by an inborn error of metabolism in the urea cycle, triggered by an exogenic factor such as gastrointestinal haemorrhage, gastric bypass surgery, starvation, seizures, vigorous exercise, burn injuries, or drugs hampering the elimination of ammonia. Here, we present a fatal case of an unrecognized genetic ornithine transcarbamylase deficiency (OTCD) presenting with a subacute progressive encephalopathy. We review the current literature and discuss the differential diagnosis and treatment options. As swift diagnosis and initiation of treatment is vital, awareness of hyperammonaemic encephalopathy and its possible causes can help improve the prognosis of this condition.

COPD - do the right thing.

A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.

[Persons with chronic non-malignant pulmonal disease may gain physical progress from home-based excercise].

Rehabilitation is an effective non-pharmacological treatment for persons with chronic non-malignant pulmonary disease. However, studies have demonstrated various obstacles resulting in low attendance rate among the candidates, thus highlighting the need for alternative solutions. Home-based exercise improve exercise capacity and decrease dyspnoea in people with chronic obstructive pulmonary disease, asthma and idiopathic pulmonary fibrosis as summarised in this review. In addition, home-based exercise demonstrates numerical but not statistically significant improvements in quality of life and lung function.

The Association between Use of ICS and Psychiatric Symptoms in Patients with COPD-A Nationwide Cohort Study of 49,500 Patients.

Psychiatric side effects are well known from treatment with systemic corticosteroids. It is, however, unclear whether inhaled corticosteroids (ICS) have psychiatric side effects in patients with COPD. We conducted a nationwide cohort study in all Danish COPD outpatients who had respiratory medicine specialist-verified COPD, age ≥40 years, and no previous cancer. Prescription fillings of antidepressants and risk of admissions to psychiatric hospitals with either depression, anxiety or bipolar disorder were assessed by Cox proportional hazards models. We observed a dose-dependent increase in the risk of antidepressant-use with ICS cumulated dose (HR 1.05, 95% CI 1.03-1.07, p = 0.0472 with low ICS exposure, HR 1.10, 95% CI 1.08-1.12, p < 0.0001 with medium exposure, HR 1.15, 95% CI 1.11-1.15, p < 0.0001 with high exposure) as compared to no ICS exposure. We found a discrete increased risk of admission to psychiatric hospitals in the medium and high dose group (HR 1.00, 95% CI 0.98-1.03, p = 0.77 with low ICS exposure, HR 1.07, 95% CI 1.05-1.10, p < 0.0001 with medium exposure, HR 1.13, 95% CI 1.10-1.15, p < 0.0001 with high exposure). The association persisted when stratifying for prior antidepressant use. Thus, exposure to ICS was associated with a small to moderate increase in antidepressant-use and psychiatric admissions.