COPD: Iron Deficiency and Clinical Characteristics in Patients With and Without Chronic Respiratory Failure.

Background: The prevalence of iron deficiency in patients with chronic obstructive pulmonary disease (COPD) varies in previous studies. We aimed to assess its prevalence according to 3 well-known criteria for iron deficiency, its associations with clinical characteristics of COPD, and mortality. Methods: In a cohort study consisting of 84 COPD patients, of which 21 had chronic respiratory failure, and 59 were non-COPD controls, ferritin, transferrin saturation (TSat), and mortality across 6.5 years were assessed. Associations between clinical characteristics and iron deficiency were examined by logistic regression, while associations with mortality were assessed in mixed effects Cox regression analyses. Results: The prevalence of iron deficiency in the study population was 10%-43% according to diagnostic criteria, and was consistently higher in individuals with COPD, peaking at 71% in participants with chronic respiratory failure. Ferritin < cutoff was significantly associated with forced expiratory volume in 1 second (FEV1) (odds ratio [OR] 0.33 per liter increase), smoking (OR 3.2), and cardiovascular disease (OR 4.7). TSat < 20% was associated with body mass index (BMI) (OR 1.1 per kg/m2 increase) and hemoglobin (OR 0.65 per g/dL increase). The combined criterion of low ferritin and TSat was only associated with FEV1 (OR 0.39 per liter increase). Mortality was not significantly associated with iron deficiency (hazard ratio [HR] 1.2-1.8). Conclusion: The prevalence of iron deficiency in the study population increased with increasing severity of COPD. Iron deficiency, defined by ferritin < cutoff, was associated with bronchial obstruction, current smoking, and cardiovascular disease, while TSat < 20% was associated with reduced levels of hemoglobin and increased BMI. Iron deficiency was not associated with increased mortality.

Low diffusion capacity of the lung predicts pneumothorax and chest drainage after CT-guided lung biopsy.

OBJECTIVES: Complications after CT-guided lung biopsy is a burden both for the individual patient and for the overall healthcare. Pneumothorax is the most common complication. This study determined the association between lung function tests and pneumothorax and chest drainage following CT-guided lung biopsy in consecutive patients in a large university hospital. RESULTS: We prospectively registered 875 biopsy procedures from 786 patients in one institution from January 27th 2012 to March 1st 2017 and recorded complications including pneumothorax with or without chest drainage. Lung function data from 637 patients undergoing 710 of the procedures were available. The association of lung function measures with pneumothorax with or without chest drainage was assessed using multivariable logistic regression analyses. Diffusion capacity for carbon monoxide (DLCO) below 4.70 mmol/min/kPa was associated with increased occurrence of pneumothorax and chest drainage after CT guided lung biopsy. We found no association between FEV1, RV and occurrence of pneumothorax and chest drainage. We found low DLCO to be a risk factor of pneumothorax and chest drainage after CT-guided lung biopsy. This should be taken into account in planning and performing the procedure.

It is unlikely that oxygen supplementation in COPD patients with chronic respiratory failure reduce cardiac troponin level.

BACKGROUND: Cardiac troponin T (cTnT) is a biomarker of myocardial injury frequently elevated in COPD patients, potentially because of hypoxemia. This non-randomised observational study investigates whether long-term oxygen treatment (LTOT) reduces the cTnT level. METHODS: We compared cTnT between COPD patients who were candidates for LTOT (n = 20) with two reference groups. Patients from both reference groups were matched with the index group using propensity score.Reference groups consists of institutional pulmonary rehabilitation patients (short-term group) (n = 105 after matching n = 11) and outpatients at a pulmonary rehabilitation clinic (long-term group)(n = 62 after matching n = 10). Comparison was done within 24 h after LTOT initiation in first reference group and within 6 months after inclusion in the second group. RESULTS: The geometric mean of (standard deviation in parentheses) cTnT decreased from 17.8 (2.3) ng/L (between 8 and 9 a.m.) to 15.4 (2.5) ng/L between 1 and 2 p.m. in the LTOT group, and from 18.4 (4.8) ng/L to15.4 (2.5) ng/L in group (1) The corresponding long-term results were 17.0 (2.9) ng/L at inclusion (between 10 and 12 a.m.) to 18.4 (2.4) ng/L after 3 months in the LTOT-group, and from 14.0 (2.4) ng/L to 15.4 (2.5) ng/L after 6 months in group (2) None of the differences in cTnT during the follow-up between the LTOT-group and their matched references were significant. CONCLUSION: Initiation of LTOT was not associated with an early or sustained reduction in cTnT after treatment with oxygen supplementation.

Treatable Traits in Misdiagnosed Chronic Obstructive Pulmonary Disease: Data from the Akershus Cardiac Examination 1950 Study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is often misdiagnosed. We aimed to estimate the prevalence of misdiagnosed COPD in middle-aged Norwegians, and to assess potentially treatable clinical traits in over- and undiagnosed individuals. METHODS AND FINDINGS: The Akershus Cardiac Examination (ACE) 1950 Study is a population-based study of the 1950 birth cohort of Akershus county including 3706 participants aged 62-65 years at baseline. COPD was defined as a forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio < lower limit of normal (LLN). Misdiagnosed COPD was defined according to self-reported COPD. A total of 259 (7.1%) participants had spirometry confirmed COPD. Of these, only 72 (28%) reported having COPD, thus 187 (72%) were undiagnosed. A total of 92 (2.5%) of the 164 particpants who reported having COPD had an FEV1/FVC ratio ≥ LLN and were overdiagnosed. They had lower lung function, and more respiratory symptoms, self-reported asthma, eosinophils, and sleep apnea than other non-COPD participants . The main predictor of being overdiagnosed was overweight. Spirometry in participants reporting wheezing or cough and current smokers or participants with ≥20 tobacco pack-year history would have identified 85% of the undiagnosed cases. CONCLUSION: Both over- and underdiagnosis of COPD is frequent. Undiagnosed individuals have better lung function and less symptoms, but similar prevalence of comorbidities and systemic inflammation. Overdiagnosed individuals have treatable traits including asthma, eosinophilic inflammation, and sleep apnea. The main predictor of being overdiagnosed was being overweight.

Systemic inflammation induced by exacerbation of COPD or pneumonia in patients with COPD induces cardiac troponin elevation.

BACKGROUND: Troponin is a biomarker of myocardial injury. In chronic obstructive pulmonary disease (COPD), troponin is an important determinant of mortality after acute exacerbation. Whether acute exacerbation of COPD (AECOPD) causes troponin elevation is not known. Here, we investigated whether troponin is increased in AECOPD compared to stable COPD. METHODS: We included 320 patients with COPD in the stable state and 63 random individuals from Akershus University hospital's catchment area. All participants were ≥40 years old (mean 65·1 years, SD 7·6) and 176 (46%) were females. The geometric mean of high-sensitivity cardiac troponin T (hs-cTnT) was 6·9 ng/L (geometric-SD 2·6). They were followed regarding hospital admission for the subsequent 5 years. RESULTS: During the 5-year follow-up, we noted 474 hospitalisations: Totally, 150 and 80 admissions were due to AECOPD or pneumonia, respectively. The geometric mean ratio with geometric SE (GSE) between cTnT at admission and stable state in AECOPD and pneumonia was 1·27 (GSE=1.11, p=0·023) and 1·28 (GSE=1.14, p=0·054), respectively. After inclusion of blood leucocyte count and C reactive protein at hospitalisation, these ratios attenuated to zero. However, we estimated an indirect of AECOPD and pneumonia on the ratio between hs-cTnT at admission and the stable state to 1·16 (p=0·022) and 1·22 (p=0·008), representing 91% (95% CI 82% to 100%) and 95% (95% CI 83% to 100%) of the total effects, respectively. CONCLUSION: AECOPD and pneumonia in patients with COPD is associated with higher cTnT levels. This association appears to be mediated by systemic inflammation.

Predictors of pneumothorax and chest drainage after percutaneous CT-guided lung biopsy: A prospective study.

OBJECTIVES: We present an analysis of predictors of pneumothorax, and pneumothorax requiring chest drainage after CT-guided lung biopsy, in one of the largest Scandinavian dataset presented. METHODS: We prospectively registered 875 biopsy procedures from 786 patients in one institution from January 27, 2012, to March 1, 2017, and recorded complications including pneumothorax with or without chest drainage, and multiple variables we assumed could be associated with complications. We performed multivariable logistic regression analysis to identify predictors of pneumothorax and pneumothorax requiring chest drainage. RESULTS: Of the biopsied lesions, 65% were malignant, 29% benign, and 6% inconclusive. Pneumothorax occurred in 39% of the procedures and chest drainage was performed in 10%. In multivariable analysis, significant predictors of pneumothorax were emphysema (OR 1.92), smaller lesion size (OR 0.83, per 1 cm increase in lesion size), lateral body position during procedure (OR 2.00), longer needle time (OR 1.09, per minute), repositioning of coaxial needle with new insertion through pleura (OR 3.04), insertion through interlobar fissure (OR 5.21), and shorter distance to pleura (OR 0.79, per 1 cm increase in distance). Predictors of chest drainage were emphysema (OR 4.01), lateral body position (OR 2.61), and needle insertion through interlobar fissure (OR 4.17). CONCLUSION: Predictors of pneumothorax were emphysema, lateral body position, needle insertion through interlobar fissure, repositioning of coaxial needle with new insertion through pleura, and shorter distance to pleura. The finding of lateral body position as a predictor of pneumothorax is not earlier described. Emphysema, lateral body position, and needle insertion through interlobar fissure were also predictors of chest drainage. KEY POINTS: • Pneumothorax is a frequent complication to CT-guided lung biopsy; a smaller fraction of these complications needs chest drainage. • Predictors for pneumothorax are emphysema, smaller lesion size, lateral body position, longer needle time, repositioning of coaxial needle with new insertion through pleura, needle insertion through the interlobar fissure, and shorter distance to pleura. • Predictors for requirement for chest drainage post CT-guided lung biopsy are emphysema, lateral body position, and needle insertion through the interlobar fissure.

Coping Patterns and Emotional Distress in Patients With Chronic Obstructive Lung Disease Who Are Undergoing Lung Transplant Evaluation.

OBJECTIVES: Living with severe lung disease like chronic obstructive pulmonary disease (COPD) is a very stressful situation. The way patients cope may impact their symptoms of anxiety and depression and physical function as well. We studied how ways of coping are associated with levels of emotional distress and lung function in patients with COPD being evaluated for lung transplantation. METHODS: Sixty-five (mean age 57 years, 46% females) patients completed the General Health Questionnaire-30 (GHQ-30) assessing emotional distress and the Ways of Coping Questionnaire. Measurements of lung function and 6-minute walk test were included. RESULTS: Seventeen (26%) patients had elevated emotional distress. Logistic regression of chronic GHQ score with gender, age, body mass index, lung function, and coping scales as covariates showed that escape avoidance and self-controlling coping and forced vital lung capacity were significantly associated with high emotional distress. Odds ratio of emotional distress increased with 5.2 per tertile (P = .011) in escape avoidance coping score. Moreover, we revealed that emotionally distressed patients cope with their current situation by refusing to believe the current situation and taking their distress out on other people. CONCLUSION: Among patients with COPD, a high level of emotional distress was uniquely associated with escape-avoidance coping and lung function. Future work should ascertain whether coping style predicts distress or whether distress increases the use of escape-avoidance coping. Nevertheless, our findings indicate that if either element is present, health care professionals should be attentive to the need for interventions to improve patients' well-being.

Annual decline in forced expiratory volume and airway inflammatory cells and mediators in a general population-based sample.

BACKGROUND: Few studies have examined the relationships between sputum inflammatory markers and subsequent annual decline in forced expiratory volume in 1 s (dFEV1). This study investigated whether indices of airway inflammation are predictors of dFEV1 in a general population-based sample. METHODS: The study, conducted from 2003 to 2005, included 120 healthy Norwegian subjects aged 40 to 70 years old. At baseline, the participants completed a self-administered respiratory questionnaire and underwent a clinical examination that included spirometry, venous blood sampling, and induced sputum examination. From 2015 to 2016, 62 (52%) participants agreed to a follow-up examination that did not include induced sputum examination. Those with a FEV1/forced vital capacity (FVC) ratio <  0.70 underwent a bronchial reversibility test. The levels of cytokines, pro-inflammatory M1 macrophage phenotypes were measured in induced sputum using bead-based multiplex analysis. The associations between cytokine levels and dFEV1 were then analysed. RESULTS: The mean dFEV1 was 32.9 ml/year (standard deviation 26.3). We found no associations between dFEV1 and the baseline indices of sputum inflammation. Seven participants had irreversible airflow limitation at follow-up. They had lower FEV1 and gas diffusion at baseline compared with the remaining subjects. Moreover, two of these individuals had a positive reversibility test and sputum eosinophilia at baseline. CONCLUSIONS: In this cohort of presumably healthy subjects, we found no associations between sputum inflammatory cells or mediators and dFEV1 during 10 years of follow-up.

Premature Ventricular Complex is More Prevalent During Acute Exacerbated than Stable States of Chronic Obstructive Pulmonary Disease, and Is Related to Cardiac Troponin T.

During acute exacerbation of chronic obstructive pulmonary disease (AECOPD), myocardial stress may be aggravated. Sparse data exist concerning the prevalence and correlates of cardiac arrhythmias in the stable and exacerbated states of COPD. We hypothesized that AECOPD is associated with increased prevalence of cardiac arrhythmias independent of COPD-severity and co-morbidity, and explored possible mechanisms. A 24-hour Holter recording was obtained in 74 patients with stable COPD and 45 patients with AECOPD (mean age 54 years, 56% women). Any incidence of supraventricular tachycardia (SVT), frequent premature ventricular complex (PVC, >30/hour) and complex ventricular ectopy (bigeminy, trigeminy or non-sustained ventricular tachycardia) was recorded and compared between the two groups. Adjustments were made for by stable disease-related co-variates (demography, co-morbidity, COPD-severity) and by acute disease-related co-variates (heart rate, cardiac troponin T (cTnT), PO2, PCO2 and C-reactive protein (CRP)) in explorative analyses. The prevalence of SVT, frequent PVCs or complex ventricular ectopy was 40%, 27% and 33% in AECOPD, and 31%, 31% and 12% in stable COPD, respectively. Frequent PVC, but not SVT or complex ventricular ectopy, was significantly increased in AECOPD compared to stable COPD, odds ratio 3.03 (1.03-10.5, p = 0.039) when adjusted for stable disease-related co-variates. Higher heart rate, cTnT and CRP attenuated the association between AECOPD and frequent PVC to non-significant, while heart rate remained associated with frequent PVC. In conclusion, frequent PVC is more prevalent in exacerbated than in the stable states of COPD. Attenuation effects of cTnT, tachycardia and CRP suggest that cardiac stress or inflammation may be involved in mechanisms causing frequent PVC i AECOPD.

The prognostic value of measurement of high-sensitive cardiac troponin T for mortality in a cohort of stable chronic obstructive pulmonary disease patients.

BACKGROUND: Cardiovascular disease (CVD) is a common comorbidity in chronic obstructive pulmonary disease (COPD). Cardiac troponin (cTn) elevation, indicating myocardial injury, is frequent during acute COPD exacerbations and associated with increased mortality. The prognostic value of circulating cTnT among COPD patients in the stable state of the disease is still unknown. The purpose of the present study was to assess the association between circulating cTnT measured by a high sensitive assay (hs-cTnT) and all-cause mortality among patients with stable COPD without overt CVD. METHODS: In a prospective cohort study we included 275 patients from the Akershus University Hospital's outpatient clinic and from Glittre, a pulmonary rehabilitation clinic. COPD-severity and cardiovascular risk factors were assessed, and time to all-cause death was recorded during a mean follow-up time of 2.8 years. RESULTS: One hundred-eighty patients (65%) had hs-cTnT concentrations ≥ the level of detection (5.0 ng/L) and 66 patients (24%) had hs-cTnT above the normal range (≥14.0 ng/L). In total, 47 patients (17%) died. hs-cTnT concentrations in the ranges <5.0, 5.0-13.9 and ≥14 ng/L were associated with crude mortality rates of 2.8, 4.4 and 11.0 per 100 patient-years, respectively. In adjusted analyses the hazard ratios (95% confidence intervals) for death were 1.7 (0.8-3.9) and 2.9 (1.2-7.2) among patients with hs-cTnT concentrations 5.0-13.9 and ≥14 ng/L, respectively, compared to patients with hs-cTnT <5.0 ng/L. CONCLUSIONS: hs-cTnT elevation is frequently present in patients with stable COPD without overt CVD, and associated with increased mortality, independently of COPD-severity and other cardiovascular risk factors.

Psychiatric disorders and psychological distress in patients undergoing evaluation for lung transplantation: a national cohort study.

OBJECTIVE: We sought to investigate type and prevalence of psychiatric disorders and psychological distress in patients being evaluated for lung transplantation. METHODS: One hundred eighteen patients were assessed [74% with chronic obstructive pulmonary disease (COPD)] with the MINI Neuropsychiatric Interview, the General Health Questionnaire (GHQ), and Hospital Anxiety Depression Scale (HADS). Spirometry and the 6-min walk test (6MWT) assessed lung function with data subject to multivariate regression analyses. RESULTS: Current and lifetime prevalence for mental disorders were 41.5% and 61.0% respectively, with anxiety (39.8% of patients), mood disorders (11.8%), and subsyndromal disorders (8.7%) identified. 15% of patients reported feelings of panic during the last week, 9% reported hopelessness, and 3% felt that life was not worth living. Statistically significant correlates were derived for HADS-depression with lung function (P=.0012) and 6MWT (P=.030) for the entire group (P=.012), and with lung function (P=.030) for COPD patients (P=.045), for whom higher chronic GHQ-scores correlated with poorer lung function (P=.009). In multivariate regression analysis, history of mental disorder was strongest predictor of current distress. CONCLUSIONS: Our findings underline the importance of assessing past, current, and sub-syndromal psychiatric disorders in addition to levels of distress in transplant candidates, with prospective studies needed to investigate impact on long-term outcome after transplantation.

Sputum neutrophils are elevated in smelter workers, and systemic neutrophils are associated with rapid decline in FEV1.

OBJECTIVES: In a previous study on smelter workers we, found significant relationship between exposure to dust and accelerated annual decline in forced expiratory volume in 1 s (FEV1). In this cross-sectional study at the end of a follow-up, we aimed to investigate the possible association between annual decline in FEV1 and markers of airways, and systemic inflammation in smelter workers. METHODS: Employees (n=76 (27 current smokers)) who had been part of a longitudinal study (9-13 years) that included spirometry (>6 measurements) and respiratory questionnaires, performed induced sputum, exhaled NO and had blood drawn. Participants with annual decline in FEV1≥45 mL were compared with participants with annual decline <45 mL; also 26 non-exposed controls were included. RESULTS: Compared with non-exposed controls, smelter workers demonstrated a significantly increased percentage of neutrophils (mean (SD)) (57% (17) vs 31% (15)) and matrix metalloproteinases 8 (MMP-8) levels in sputum, and MMP-9, surfactant protein D (SpD) and transforming growth factor ß (TGFb) levels in blood. A significant association in FEV1≥45 mL was found for blood neutrophils when controlling for smoking habits (OR=1.7 (95% CI 1.0 to 2.8), p=0.045). Airway and blood protein markers were not associated with annual decline in FEV1. CONCLUSIONS: All workers displayed airway and systemic inflammation characterised by increased levels of neutrophils and MMP-8 in sputum, and MMP-9, SpD and TGFß in blood compared with non-exposed controls. Blood neutrophils in particular were significantly elevated in those workers with the most rapid decline in lung function. A similar observation was not seen with airway neutrophils. In the present study, we were able to identify systemic but not airway inflammatory markers that can predict increased decline in FEV1 in smelter workers.

Annual decline in forced expiratory volume is steeper in aluminum potroom workers than in workers without exposure to potroom fumes.

BACKGROUND: Aluminum potroom exposure is associated with increased mortality of COPD but the association between potroom exposure and annual decline in lung function is unknown. We have measured lung volumes annually using spirometry from 1986 to 1996. The objective was to compare annual decline in forced expiratory volume in 1 s (dFEV1) and forced vital capacity (dFVC). METHODS: The number of aluminum potroom workers was 4,546 (81% males) and the number of workers in the reference group was 651 (76% males). The number of spirometries in the index group and the references were 24,060 and 2,243, respectively. RESULTS: After adjustment for confounders, the difference in dFEV1 and dFVC between the index and reference groups were 13.5 (P < 0.001) and -8.0 (P = 0.060) ml/year. CONCLUSION: Aluminum potroom operators have increased annual decline in FEV1 relative to a comparable group with non-exposure to potroom fumes and gases.

The influence of heart failure co-morbidity on high-sensitivity troponin T levels in COPD exacerbation in a prospective cohort study: data from the Akershus cardiac examination (ACE) 2 study.

CONTEXT: Troponin (hs-TnT) levels predict mortality after acute exacerbation of COPD (AECOPD). Whether this is independent of heart failure (HF) is not established. MATERIAL AND METHODS: Prospectively included AECOPD patients adjudicated for acute HF categorized into three groups: (A) AECOPD, but acute HF the primary cause for hospitalization; (B) AECOPD the primary cause, but co-existing myocardial dysfunction and (C) AECOPD without myocardial dysfunction. RESULTS: About 103 AECOPD patients; 18% A, 27% B and 54% C. Hs-TnT level differed between the groups: (ng/l, median) A: 41, B: 25 and C: 15, p = 0.03 for A versus B and p = 0.005 for B versus C. During a median 826 days, 47% died. In Cox analysis, hs-TnT levels remained associated with mortality (hazard ratio per 10 ng/l 1.3, p < 0.0001). CONCLUSION: hs-TnT levels are influenced by myocardial dysfunction/HF in AECOPD, but provide independent prognostic information. The prognostic merit of hs-TnT cannot be attributed to HF alone.

Increased Decline in Pulmonary Function Among Employees in Norwegian Smelters Reporting Work-Related Asthma-Like Symptoms.

OBJECTIVE: To investigate associations between work-related asthma-like symptoms (WASTH) and annual pulmonary function decline among employees of 18 Norwegian smelters. METHODS: A 5-year longitudinal study in which WASTH was defined as a combination of dyspnea and wheezing that improved on rest days and vacation. RESULTS: A total of 12,966 spirometry examinations were performed in 3084 employees. Crude annual decline in forced expiratory volume in 1 second (FEV1) (dFEV1) was 32.9 mL/yr (95% confidence interval, 30.5 to 35.3), and crude annual decline in forced vital capacity (FVC) (dFVC) was 40.9 mL/yr (37.8 to 43.9). After adjustment for relevant covariates, employees reporting WASTH showed higher dFEV1 by 16.0 m:/yr (3.4 to 28.6) and higher dFVC by 20.5 mL/yr (6.0 to 35.0) compared with employees not reporting WASTH. CONCLUSION: Work-related asthma-like symptom was associated with greater annual declines in FEV1 and FVC, indicating a restrictive pattern.

Construction of a Job Exposure Matrix to Dust, Fluoride, and Polycyclic Aromatic Hydrocarbons in the Norwegian Aluminum Industry using Prediction Models.

BACKGROUND: The Norwegian aluminum industry developed and implemented a protocol for prospective monitoring of employees' exposure using personal samplers. We analyzed these data to develop prediction lines to construct a job exposure matrix (JEM) for the period 1986-1995. METHODS: The protocol for personal monitoring of exposure was implemented in all seven Norwegian aluminum plants in 1986 and continued until 1995. Personal samplers were used to collect total dust, fluorides, and total polycyclic aromatic hydrocarbons (PAH). In addition, exposure could be categorized according to process, i.e. prebake, Søderberg, and 'other'. We constructed four-dimensional JEMs characterized by: Plant, Job descriptor, Process, and Year. Totally 8074, 6734, and 3524 measurements were available for dust, fluorides, and PAH, respectively. The data were analyzed using linear mixed models with two-way interactions. The models were assessed using the Akaike criterion (AIC) and unadjusted R (2). The significance level was set to 10% (two-sided) for retaining variables in the model. RESULTS: In 1986, the geometric mean (95% confidence interval in parentheses) for total dust, total fluorides, and PAH were 3.18 (0.46-22.2) mg m(-3), 0.58 (0.085-4.00) mg m(-3), and 33.9 (2.3-504) µg m(-3), respectively. During 10 years of follow-up, the exposure to total dust, fluorides, and PAH decreased by 9.2, 11.7, and 14.9% per year, respectively. Each model encompassed from 49 to 72 significant components of the interaction terms. The interaction components were at least as important as the main effects, and 65 to 91% of the significant components of the interaction terms were time-dependent. CONCLUSION: Our prediction models indicated that exposures were highly time-dependent. We expect that the time-dependent changes in exposure are of major importance for longitudinal studies of health effects in the aluminum industry.

Diagnosis of biopsy verified usual interstitial pneumonia by computed tomography.

OBJECTIVE: To identify the combination of clinical data and high resolution computed tomography (HRCT) features that best identified biopsy verified usual interstitial pneumonia (UIP). METHODS: The study included 91 patients with a tentative diagnosis of interstitial lung disease. All underwent clinical investigation, surgical lung biopsy and HRCT. Two independent readers assessed the HRCT images for the extent and pattern of abnormality. On the basis of the biopsy result the patients were categorized in three groups: 1) Usual interstitial pneumonia, 2) Other idiopathic interstitial pneumonias (IIPs) and hypersensitivity pneumonitis and 3) Other interstitial lung diseases. The diagnostic value of HRCT was investigated using likelihood ratio to estimate the post-test probability of UIP. RESULTS: We found that UIP was associated with significantly higher scores for reticular pattern and for bronchiectasis than the remaining patients (p < 0.001). Moreover, these scores showed a steeper cranial-caudal increase in patients with histologically verified UIP than in the remaining patients (p < 0.001). UIP was associated with lower scores for ground glass opacities (p < 0.001). Using Bayes theorem and likelihood ratio estimation we found that UIP could be diagnosed with 90% certainty in patients 60 years or older and restrictive pattern in spirometry provided that HRCT demonstrated at least 15% reticular pattern and no ground glass opacities. CONCLUSION: In older patients with a restrictive spirometry in whom HRCT demonstrates a reticular pattern without ground glass opacities surgical lung biopsy is not warranted for the diagnosis of UIP.

The clinical value of serial measurement of high-sensitivity cardiac troponin T in acute exacerbations ofchronic obstructive pulmonary disease.

OBJECTIVE: To assess the prevalence and long-term prognostic value of a dynamic (rise/fall) pattern of cardiac troponin T (hs-cTnT) elevation during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) compared with a stable hs-cTnT elevation. METHODS: Prospective cohort study of unselected patients admitted with AECOPD to the emergency room of a university hospital. Serial hs-cTnT measurements were made during admission. Survival after a median of 1.8 years was recorded. RESULTS: 83 patients with a mean age of 72 years and a mean forced expiratory volume in 1 s (FEV1) of 0.9 L. The mortality rate was 62%. The median hs-cTnT at admission was 27 ng/L (IQR 13.4-51)). 65 patients (78%) had at least one hs-cTnT measurement ≥14 ng/L, and among these the median change in hs-cTnT was 50.7% (IQR 25.2-89.4). Of the patients with serial hs-cTnT measurements, 53 (82%) had a dynamic pattern (ie, ΔTnT ≥20%). In multivariate analysis, stable hs-cTnT elevation was associated with increasing age (OR per 5 years with 95% CI 1.9 (1.01 to 3.7), p=0.045) and low Hb (OR 7.3 (1.1 to 49), p=0.039). Stable hs-cTnT elevation was associated with increased mortality with an HR of 2.4 (95%CI 1.1 to 5.3, p=0.027) in the multivariate Cox regression analysis. CONCLUSIONS: Among the patients with at least one hs-cTnT above the 99th centile, 82% had a rise/fall pattern, as requested to make a diagnosis of myocardial infarction. Compared to a dynamic rise/fall pattern of hs-cTnT, a stable and moderately elevated hs-cTnT during AECOPD is associated with poor long-term prognosis.

Respiratory disorders in aluminum smelter workers.

OBJECTIVES: Summarizing the knowledge status, including the morphology, possible etiological factors, and clinical expression of aluminum potroom asthma and chronic obstructive pulmonary disease related to aluminum potroom exposure. METHODS: A review of the literature from the last two decades as it appears in PubMed. RESULTS: There is substantial evidence for the existence of potroom asthma, although the incidence seems to decline over the last 10 years. Increased mortality from chronic obstructive pulmonary disease and longitudinal decline in forced expiratory volume in the first second of expiration has been shown in aluminum potroom workers. Morphological manifestations in bronchial biopsies and the inflammatory markers NO and eosinophils in airway tissue and blood are consistent with asthma in general. The causative agent(s) is (are) not known. CONCLUSIONS: Reduction of exposure and cessation of smoking seem to be the major preventive measures to avoid respiratory disorders in the aluminum industry.