The effectiveness of nationally implemented smoking interventions in Denmark.

OBJECTIVE: The present study aimed to investigate the effectiveness of smoking cessation interventions at a national level. METHOD: A systematic follow-up was made of 3628 adults who participated in smoking cessation groups or in individual interventions in different settings in Denmark from January 2001 to March 2002. RESULTS: The rates of continued abstinence from smoking were estimated as 18% and 16% after 6 and 12 months, respectively, for the 3628 participants from 101 smoking cessation units. Among participants, who accomplished at least 75% of the intervention, the rates of non-smokers after six and twelve months were 23% and 19%, respectively. Five of the investigated factors influenced continued abstinence after 12 months: gender, age, degree of nicotine dependence, the format and the setting of the cessation service. CONCLUSIONS: The study shows that it is possible to implement uniform smoking cessation interventions at a national level keeping the same abstinence rates as previously achieved in randomized clinical trials. The successful cessation interventions were run by nurses and equivalent staff that had received only 3 days of training and had no other particular therapeutic skills.

Diagnostic value of routine radioisotope bone scanning in a series of 63 patients with pulmonary sarcoidosis.

BACKGROUND AND AIM: Routine use of diagnostic radioisotope bone scanning in patients with sarcoidosis has not previously been evaluated. The aim of this study was to assess whether routine radioisotope bone scanning might be of value in the detection of osseous lesions in sarcoidosis. METHODS: 63 consecutive Caucasian patients (32 men) with a median age of 39 years (range 17-66) and biopsy proven pulmonary sarcoidosis were included. None had symptoms suggesting osseous sarcoidosis. Extrathoracic, non-osseous sarcoidosis was present in 24 patients; 13 patients were on oral steroids. Radioisotope bone scanning was performed with a gammacamera after intravenous injection of 99mTechnetium-methylenediphosphonate. An abnormal bone scan was followed by a radiograph of the region of interest. RESULTS: 39 patients (61.9%) had normal bone scans. Minor bone scan abnormalities were found in 24 patients (38.1%). Of these, 11 patients had bone foci (8 in the vertebral spine, 9 in the ribs, 1 in a finger). Radiographically only one of these 11 patients had a bony lesion being typical of sarcoidosis, located in the second finger. 17 patients had joint foci. Radiographs of the joints showed sequelae after a fracture in 1 patient, and degenerative osteoarthritis in 1 patient. There was no difference between clinical and paraclinical variables in patients with normal and abnormal bone scans. CONCLUSIONS: There appears to be no indication for routine radioisotope bone scanning in patients with sarcoidosis. Scanning should be restricted to patients with clinical suspicion of osseous sarcoidosis.

Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study.

The aim of this prospective, randomized study was to investigate the possibility of performing pleurodesis using a small percutaneous catheter (Cystofix catheter, CH10, 65 cm) inserted at bedside in patients with recurrent malignant pleural effusion and to compare this catheter with a conventional large bore chest tube (CH24) placed in connection with diagnostic thoracoscopy. After drainage pleurodesis was performed with tetracycline as sclerosing agent. Of 18 evaluable consecutive patients (mean age 67.8 years) nine were randomized for pleurodesis with the small and nine for the large catheter. In the former group, the majority (seven of nine) did not find insertion of the catheter more unpleasant than thoracentesis. In the latter group only a few (two of nine) found insertion comparable with thoracentesis (P < 0.05). All patients found the presence of the large catheter very or somewhat unpleasant (two and seven patients), whereas this was only the case for a few (no and two patients) treated with the small catheter (P < 0.05). In the former group three patients required new thoracentesis, whereas this was only the case for two patients in the latter group (P > 0.05). No complications were seen. We conclude that pleurodesis in patients with recurrent malignant pleural effusion can be performed with a small percutaneous catheter (Cystofix) with an effect similar to that obtained with a large-bore chest tube and with less discomfort for the patient.

Nurse-conducted smoking cessation with minimal intervention in a lung clinic: a randomized controlled study.

This study aimed to evaluate the effect of a motivational, minimal intervention approach to smoking cessation in an open, randomized design conducted by nurses as routine work in a lung clinic. Subjects who smoked less than 10 cigarettes x day(-1), and subjects who smoked > or = 10 cigarettes x day(-1) and who had refused to participate in a smoking cessation trial with nicotine replacement therapy, were randomly allocated to a motivational approach to smoking cessation or to a control group. The motivational approach consisted of a nurse-conducted 5 min consultation concerning reasons to quit smoking, brochures about smoking cessation and advice about how to quit. After 4-6 weeks, subjects in the motivational group received a letter encouraging them to quit smoking. After 1 year, all subjects were contacted by phone and smoking status reported. Subjects claiming to be abstinent attended the clinic for carbon monoxide verification. A total of 507 subjects were enrolled, 254 in the motivational group and 253 in the control group. The mean age of the motivational group was 51 yrs, 50% were males and they smoked a mean of 13 cigarettes x day(-1). The mean age of the control group was 53 yrs, 61% were males and they smoked a mean of 12 cigarettes x day(-1). At the 1 year follow-up, the success rate for point prevalence (no smoking at 1 year and during the preceding month) was 8, 7% in the motivational group versus 3.6% in the control group (p=0.025). The 12 months sustained success rate (no smoking at all during the year) was 3.1 versus 1.2% (p=0.22). The point prevalence for light smokers (<10 cigarettes x day(-1)) was 13.9% in the motivational group versus 6.3% in control group (p=0.12), and for heavy smokers (10 or more cigarettes x day(-1)) 5.2% versus 1.9% (p=0.20). In conclusion, the effect of this nurse-conducted, minimal intervention, motivational approach seems promising as the quit rate at 1 year follow-up had doubled.

Acute admissions to medical departments. A comparison between an urban and a rural district.

To compare hospitalization into medical departments, acute admissions into a city hospital and into a district hospital were compared prospectively over a two-week period. Patients referred to the city hospital were on average older, were more frequently living alone and they had a greater amount of social care attendance in their homes. On the other hand, distribution of referral diagnoses, overall patient activity, occupational status and contact with relatives were similar in the two areas. Sub-acute or acute illness was considered the main cause of admission in both areas; the amount of admissions for social reasons was 13 percent to the city hospital versus 3 percent to the district hospital. Relevant alternatives to hospitalization seemed to exist in 50 percent of the admissions to the city hospital versus only 3 percent to the district hospital. Since patients admitted for social reasons block hospital beds for a longer time period than those admitted for other reasons, these differences may to some extent explain why length of hospital stay is longer in city hospitals than in rural ones.

[Methotrexate treatment of patients with prednisolone dependent bronchial asthma]. / Methotrexatbehandling af patienter med prednisolonafhaengig asthma bronchiale.

In this review we went through eight placebo-controlled clinical trials of the folic acid antagonist methotrexate in the treatment of bronchial asthma. The studies, which differ in their methods and findings, are reviewed critically. Some studies seem to give documentation of methotrexate as an effective drug in reducing the corticosteroid requirements in patients with chronic corticosteroid-dependent asthma. Adverse effects are wellknown from the use of methotrexate in patients with rheumatoid arthritis and include nausea, diarrhoea, vomiting, transient increases in liver enzymes, alopecia and stomatitis. Rare but potentially life-threatening adverse effects are interstitial pneumonitis, opportunistic infections, bone marrow- and renal insufficiency. The role of methotrexate in patients with chronic corticosteroid-dependent asthma still needs to be clarified. Practical guide-lines in treating asthma patients with methotrexate are suggested.

[Oxygen therapy of chronic lung disease. Testing of a chemical oxygen generator--Vitaria]. / Iltbehandling til kronisk lungesyge. Afprøvning af en kemisk iltgenerator--Vitaria.

Twenty patients (11 females, nine males, mean age: 70.6 years) with chronic obstructive pulmonary disease and hypoxaemia took part in a randomized single blinded placebo-controlled clinical trial, testing the efficacy of a new transportable oxygen delivery system (VITARIA). The system consists of a container and a sodium carbonate containing powder (75 mg). When the powder is stirred in water in the container pure oxygen with a max flow of 1 l/min is delivered over a period of approximately 15 minutes. All patients had been receiving home oxygen treatment of at least 0.5 l/min for at least one month. Their baseline oxygen levels in arterial blood were mean 7.66 kPa, with a mean oxygen response to 0.5 l/min of oxygen of 2.54 kPa. In the placebo group no oxygen responses were seen, while in the Vitaria group a small but insignificant rise in arterial PaO2 was seen. No side effects were seen. In conclusion we find the system handy and easy to use but the recommended dose of powder is insufficient.

Orally administered N-acetylcysteine may improve general well-being in patients with mild chronic bronchitis.

Oral N-acetylcysteine (NAC) exerts a beneficial action in chronic bronchitis by reducing the number of exacerbations. There have been few studies of the effect of NAC (or of any other drug) on general well-being in chronic bronchitis. We used an established psychiatric instrument (General Health Questionnaire; GHQ) and a visual analogue scale (VAS) to measure well-being in a 22-week, placebo-controlled, double-blind, parallel-group study of NAC administered as sustained release tablets 600 mg b.i.d., including during the winter months, to patients with mild chronic bronchitis. One hundred and fifty-three patients were accepted for randomized treatment, 129 finished the study (59 NAC, 70 placebo), and well-being was measured in 105 (46 NAC, 59 placebo). The number of observed exacerbations was unexpectedly low in both groups. The number was lowest in the NAC group, however, the difference did not reach statistical significance in the present study (P = 0.08). There were no statistically significant differences between NAC and placebo in subjective symptom scores, FEV1 or FVC. The distribution of GHQ score at baseline was uneven, but NAC was significantly superior to placebo in terms of a favourable effect on GHQ score. GHQ score correlated with the number of exacerbations, and VAS correlated with GHQ score. This study therefore demonstrates the validity of measuring general well-being in patients with mild chronic bronchitis. Future studies of the treatment of chronic bronchitis should use a battery of more specifically adapted instruments which are now becoming available to measure well-being.

Terbutaline inhalations by the Turbuhaler as replacement for domiciliary nebulizer therapy in severe chronic obstructive pulmonary disease.

Patients with chronic obstructive pulmonary disease (COPD) are often treated with high dose inhalations of beta 2-agonists. We compared domiciliary therapy with terbutaline administered by the Turbuhaler and by a jet nebulizer. Forty nebulizer users with severe COPD were included in the randomized, double-blind, cross-over study. Terbutaline was inhaled t.i.d. for 2 weeks as dry powder (5 doses = 2.5 mg) by Turbuhaler or as solution (2 ml = 5 mg) by jet nebulizer (Pari Inhalierboy). The mean age of the 25 completing patients was 66 years (range: 54-81), the mean FEV1 was 0.73 l or 29% of predicted (range: 11-55%). The period where the Turbuhaler delivered the active drug was preferred by 16 patients, the nebulizer period by seven (P = 0.09). The median score concerning feeling of control over the disease--according to the Chronic Respiratory Disease Questionnaire--was better after the Turbuhaler period (P = 0.01). Other scores concerning disease related quality of life, the daily peak expiratory flow rates, the additional use of a metered dose inhaler were not significantly different for the two types of treatment. It is concluded that high dose domiciliary terbutaline treatment by Turbuhaler can replace nebulizer treatment in most patients with severe COPD.

Bronchodilating effect of terbutaline powder in acute severe bronchial obstruction.

The bronchodilating effect of terbutaline dry powder inhaled via Turbuhaler was compared with terbutaline inhaled via a conventional, chlorofluorocarbon (CFC) inhaler and Nebuhaler (750 ml spacer) in 68 consecutive patients attending the emergency department with acute severe bronchial obstruction. The study was of an open, randomized, parallel group design with one study day. Patients were treated with 2.5 mg of terbutaline 15 min apart, either as dry powder via Turbuhaler or with a CFC inhaler in conjunction with Nebuhaler. Data from 62 patients were analyzed. The mean baseline FEV1 values were 0.81 L (SD, 0.64; range, 0.14 to 2.74 L) in the Turbuhaler group (n = 33), and 0.90 L (SD, 0.90; range, 0.27 to 2.60 L) in the Nebuhaler group (n = 29). The mean increases in FEV1 from baseline were 0.40 L (SD, 0.40; range, 0.06 to 2.36 L) and 0.21 L (SD, 0.25; range, -0.05 to 0.95 L) 10 min after the last inhalation via Turbuhaler and Nebuhaler, respectively. The difference between mean values of the increase in FEV1 after terbutaline treatment with Turbuhaler and the CFC inhaler and Nebuhaler was statistically significant (p = 0.0004, ANOVA). This study showed that inhalation of terbutaline via Turbuhaler produced a significantly greater increase in FEV1 compared with the same dose of terbutaline administered via the CFC inhaler and Nebuhaler in patients attending the emergency department with acute severe bronchial obstruction.

A seven-year follow-up study of 343 adults with bronchial asthma.

A study of 343 urban adult outpatients with a history of bronchial asthma was initiated in 1981. Asthma was verified by a reversibility in airflow obstruction of at least 0.5 1 in forced expiratory volume (FEV1) (70%). The rest of the 343 patients was included because of diurnal variations of at least 100 l/min in peak expiratory flow (PEF) (22%), or because of a characteristic history of asthma (8%). In 1988, a follow-up study was performed. Two hundred-fourteen patients replied (80%), 100 women and 114 men. Fifty-four did not respond, but were known to be alive. Twenty-one had emigrated; of these, the fate of five was unknown. The mortality rate was significantly raised among the men (Standard mortality rate (SMR) = 1.55). In 19%, the cause of death was pulmonary. Seventeen percent were found dead. In these, no cause of death was obvious, and they may have died from an exacerbation of their pulmonary disease. One hundred and forty-four had non-allergic and 69 allergic asthma verified retrospectively by positive skin prick test in 1988. One was not tested and not classified. Seventy-five percent of the whole group were smokers. An annual decline of approximately 90 ml per year in FEV1 was found in both groups and was only partially explained by smoking and ageing. The remaining observed decline in lung function may be caused by asthma. Reversibility of 0.5 l in FEV1 was only maintained in the allergic group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hypercalcemia during immobilization and prolonged anuria treated with disodium clodronate]. / Hyperkalcaemi ved immobilisation og protraheret anuri behandlet med dinatriumklodronat.

Severe hypercalcaemia was observed during prolonged anuria and prolonged immobilization in a previously healthy 34 years old male after a severe trauma caused by a traffic accident. Other causes of the hypercalcaemia were evaluated, and even though granulomas of unidentified nature were found in the liver after partial resection due to traumatic rupture the immobile state was concluded to be the major cause. A maximum calcium value of 4.44 mmol/l was seen after 10 weeks immobilization. The patient was treated with daily dialysis and, even though the calcium content in the dialysis fluid was reduced, only a minor effect was seen on the calcium level. After eight weeks of hypercalcaemia, the patient was treated with disodium clodronate intravenously 400 mg for daily five days. However, the calcium level was not normalized and the treatment was repeated with a further reduction in the calcium level. If immobilization is a major contributory factor to hypercalcaemia, disodium clodronate seems to be a safe and effective treatment.

N-acetylcysteine by metered dose inhaler in the treatment of chronic bronchitis: a multi-centre study.

Sixty-five patients with chronic bronchitis were studied at five different centres in a double-blind, randomized trial. Two parallel groups were treated with either N-acetylcysteine or placebo by metered dose inhalers for 16 weeks. Following a 1-week run-in period, each patient recorded subjective impressions of the drug action on their bronchitic symptoms in a diary once a week. In addition, exacerbations were registered. Lung function testing and adverse effects were evaluated by four visits to the chest clinics during the 16 weeks. We could not demonstrate that N-acetylcysteine by metered dose inhalers had any significant effect on patients' feeling of well-being, sensation of dyspnoea, intensity of coughing, mucus production, or expectoration or lung function. Its effect in reducing exacerbations could not be estimated because of a very low number of exacerbations reported. N-acetylcysteine inhalation was safe when used over a 16-week period.

The effect of inhaled terbutaline on FEV1, FVC, dyspnoea and walking distance in patients with chronic obstructive lung disease.

This double-blind, placebo-controlled, crossover study was performed to evaluate the effect of terbutaline administered by a turbuhaler on spirometry, walking distance and dyspnoea during exercise in patients with chronic obstructive lung disease (COLD) and to evaluate relationships between changes in spirometry and working indices. The patients had a maximum reversibility in FEV1 of 15% predicted, and to ensure the option of studying correlations between changes in spirometry and working indices in patients with COLD a wide range of reversibility in FVC was ensured. Eighteen patients (M, 12; F, 6; mean age 68.5 years) were included in the trial. Mean baseline FEV1 was 0.921 and FVC 2.081. Six minutes unpaced walking distance on flat ground (WD) and Brog dyspnoea index scale (BS) were used as working indices. Baseline mean WD was 467.9 m, and median BS 3.2. No significant difference was found in the effect of terbutaline compared to placebo on the spirometry findings or WD. However, BS during exercise improved significantly on the terbutaline day. No significant correlation was found between changes in working indices and change in spirometry. Thus, the use of exercise testing and dyspnoea-scoring may reveal patients who benefit from acute bronchodilation without significant improvement in lung function.

Bronchodilator and corticosteroid reversibility in ambulatory patients with airways obstruction.

With the aim of characterising subgroups, we analysed reversibility tests from 1,048 patients with airways obstruction (baseline FEV1 less than 60% of predicted normal (%pred), and FEV1 to FVC ratio less than 0.6). Spirometry before and after inhalation of salbutamol 0.3 mg and ipratropium bromide 0.06 mg was performed before and after one week of treatment with prednisone 30 mg daily. The changes in FEV1 after bronchodilators showed unimodal distribution (mean = 7.0 %pred, st.dev. = 6.6 %pred). The responses to corticosteroid were more spread out (mean = 6.3 %pred, st.dev. = 13.8 %pred). The correlation between bronchodilator responses before and after corticosteroid treatment was poor (r = 0.30), although highly significant (p less than 0.000,001). The responses to bronchodilators were virtually independent of the steroid reversibility. The corticosteroid response was inversely related to age (r = -0.20, p less than 0.000,001) and smoking habits (r = -0.17, p less than 0.000,001), and moderately associated with blood eosinophilia (r = 0.34, p less than 0.000,001). The frequency distribution of the bronchodilator responses and the steroid response and combinations of the responses were all unimodal, making any distinction between nosologic subgroups arbitrary. It is clear from the study that criteria other than just response to therapy must be employed for distinction of subgroups among patients with airways obstruction.

[Pulmonary function and survival of patients with alpha 1-antitrypsin deficiency, residents of Copenhagen]. / Lungefunktion og overlevelse hos patienter med alfa 1-antitrypsinmangel bosiddende i København.

From 1976 to 1987 alpha 1-antitrypsine deficiency type PiZZ was diagnosed in 89 patients living in the Copenhagen urban area (mean age: 45 years). Spirometry was performed yearly in 66 of these patients (mean observation period was 50 months). At the time of diagnosis basic FEV1 was significantly lower in smokers and ex-smokers than in patients who had never smoked (45%, 44% and 84% of predicted normal, respectively). However, the decline in FEV1 was similar (3% per year) in all three categories of smokers. Our results indicate that both smokers and non-smokers are at risk of developing pulmonary emphysema, however, the disease usually appears later in life or not at all in non smokers.

[New therapeutic possibilities in alpha 1-antitrypsin deficiency]. / Nye behandlingsmuligheder ved alfa 1-antitrypsinmangel.

The alpha-1-antitrypsin gene is localized to chromosome 14. Numerous genetic variations may occur and some of these result in severely reduced concentration in the serum. The commonest cause of severe deficiency of alpha-1-antitrypsin is the gene-variant Z in the homozygotic form which occurs in one out of 2,000 Danes. Severe deficiency in alpha-1-antitrypsin results in liver symptoms in approximately 10% of the children. Some of these will develop cirrhosis of the liver. In adults at the ages of about 30 to 40 years, gradual development of emphysema occurs and this is earliest and most pronounced in smokers. Adults have also increased frequency of cirrhosis but this is much less pronounced than the development of emphysema. In addition to a number of theoretical therapeutic possibilities, liver transplantation is now possible and this is employed particularly in children with cirrhosis. In young persons with terminal pulmonary insufficiency with anticipated survival for less than one year, heart/lung transplantation or possibly isolated lung transplantation may be considered. An alpha-1-antitrypsin concentrate has been produced. Intravenous dosage once monthly can provide a concentration in the serum for three to four weeks which, as a rule, suffices to prevent emphysema. It is not yet known whether this treatment has any prophylactic effect in cases of developed emphysema. It is to be anticipated that treatment instituted prior to development of emphysema will prevent development of pulmonary disease but the treatment is rather expensive and must, probably, continue throughout life. No controlled investigation of the effect of treatment is available and the range of indications is not defined.

[Measurement of the quality of life or general health status in chronic obstructive lung diseases]. / Måling af livskvalitet eller generel helbredstilstand ved kronisk obstruktive lungesygdomme.

During recent years, in assessment of the therapeutic effect of medicinal treatment, measurement of the general condition of health or quality of life has been extensively employed. This holds true particularly in patients with chronic disease, including patients with chronic obstructive pulmonary disease. In this patient category, several controlled investigations have been carried out in which one or more questionnaires concerning general health have been employed. The questionnaires employed and reviewed are the Sickness impact profile (SIP), Mcmaster's chronic respiratory disease questionnaire (CRQ), Quality of well-being scale (QWB), General health questionnaire (GHQ), Minnesota multiphasic personality inventory (MMPI) and Profile of mood states (POMS). The questionnaires contain questions regarding many aspects of the existence of the patients and have been tested to varying extents for reproducibility, sensitivity and validity. No patent method exists for measurement of quality of life. It is therefore important for interpretation of investigations that the aspects of quality of life which have been measured are clearly defined and that the questionnaire method employed is quoted.

Decline in pulmonary function in patients with alpha 1-antitrypsin deficiency.

Sixty-five patients with severe alpha 1-antitrypsin (AAT) deficiency (phenotype PiZ) were followed with spirometry at regular intervals of one year and a median observation period of four years. The annual decline in pulmonary function was adjusted for sex, age and height by division with the predicted normal pulmonary function. The median decline in FEV1 was 1.9% predicted/year. The rate of decline was independent of age and pulmonary function, except for patients with FEV1 below 25% of predicted normal. There was a tendency towards a slower median decline in FEV1 in ex-smokers (1.7% predicted/year) compared to smokers (3.8% predicted/year) and never-smokers (3.7% predicted/year), however, this difference was not significant (p greater than 0.01). At the time of diagnosis smokers and ex-smokers had a lower FEV1 (44 and 38% predicted) than never-smokers (85% predicted) (p less than 0.02), and smokers and ex-smokers were generally younger (median age 44 and 42 years, respectively) than never smokers (median age 55 years) (p greater than 0.1). Our data indicate that smokers as well as nonsmokers with severe AAT deficiency are at risk of developing pulmonary emphysema. The disease seems to appear later in nonsmokers, though once initiated it progresses at the same rate.