Impact of the metabolic syndrome on cardiopulmonary morbidity and mortality in individuals with lung function impairment: a prospective cohort study of the Danish general population.

Background: Whether the metabolic syndrome plays a role for the prognosis of individuals with lung function impairment (preserved ratio impaired spirometry (PRISm) or airflow limitation) is unclear. We hypothesised that the metabolic syndrome in individuals with lung function impairment is associated with increased cardiopulmonary morbidity and mortality. Methods: The Copenhagen General Population Study was initiated in 2003 based on a random sample of white men and women aged 20-100 years drawn from the Danish general population. The risk of ischemic heart disease/heart failure, respiratory disease, and all-cause mortality was analysed with Cox models adjusted for age, sex, current smoking, and asthma during 15 years of follow-up. Findings: Among 106,845 adults, 86,159 had normal lung function, 6126 had PRISm, and 14,560 had airflow limitation. We observed 10,448 hospital admissions for ischemic heart disease/heart failure, 21,140 for respiratory disease, and 11,125 deaths. Individuals with versus individuals without the metabolic syndrome generally had higher 5-year absolute risk of all outcomes, including within those with normal lung function, mild-moderate-severe PRISm, and very mild-mild-moderate-severe airflow limitation alike. Compared to individuals without the metabolic syndrome and with normal lung function, those with both the metabolic syndrome and severe PRISm had hazard ratios of 3.74 (95% CI: 2.53-5.55; p < 0.0001) for ischemic heart disease/heart failure, 5.02 (3.85-6.55; p < 0.0001) for respiratory disease, and 5.32 (3.76-7.54; p < 0.0001) for all-cause mortality. Corresponding hazard ratios in those with both the metabolic syndrome and severe airflow limitation were 2.89 (2.34-3.58; p < 0.0001) for ischemic heart disease/heart failure, 5.98 (5.28-6.78; p < 0.0001) for respiratory disease, and 4.16 (3.50-4.95; p < 0.0001) for all-cause mortality, respectively. The metabolic syndrome explained 13% and 27% of the influence of PRISm or airflow limitation on ischemic heart disease/heart failure and all-cause mortality. Interpretation: The metabolic syndrome conferred increased risk of cardiopulmonary morbidity and mortality at all levels of lung function impairment. Funding: Danish Lung Foundation, Danish Heart Foundation, Capital Region of Copenhagen, and Boehringer Ingelheim. JV is supported by the NIHR Manchester BRC.

The airway microbiota and exacerbations of COPD.

AIM: The aim of this study was to investigate whether the compositionality of the lower airway microbiota predicts later exacerbation risk in persons with COPD in a cohort study. MATERIALS AND METHODS: We collected lower airways microbiota samples by bronchoalveolar lavage and protected specimen brushes, and oral wash samples from 122 participants with COPD. Bacterial DNA was extracted from all samples, before we sequenced the V3-V4 region of the 16S RNA gene. The frequency of moderate and severe COPD exacerbations was surveyed in telephone interviews and in a follow-up visit. Compositional taxonomy and α and ß diversity were compared between participants with and without later exacerbations. RESULTS: The four most abundant phyla were Firmicutes, Bacteroidetes, Proteobacteria and Fusobacteria in both groups, and the four most abundant genera were Streptococcus, Veillonella, Prevotella and Gemella. The relative abundances of different taxa showed a large variation between samples and individuals, and no statistically significant difference of either compositional taxonomy, or α or ß diversity could be found between participants with and without COPD exacerbations within follow-up. CONCLUSION: The findings from the current study indicate that individual differences in the lower airway microbiota in persons with COPD far outweigh group differences between frequent and nonfrequent COPD exacerbators, and that the compositionality of the microbiota is so complex as to present large challenges for use as a biomarker of later exacerbations.

Complications and discomfort after research bronchoscopy in the MicroCOPD study.

BACKGROUND: Data on discomfort and complications from research bronchoscopy in chronic obstructive pulmonary disease (COPD) and asthma is limited. We present complications and discomfort occurring within a week after bronchoscopy, and investigate personal and procedural risk factors. METHODS: 239 subjects with COPD, asthma or without lung disease underwent research bronchoscopies as part of a microbiome study of the lower airways (the MicroCOPD study). Bronchoscopy was done in the supine position with oral scope insertion with the option of light conscious alfentanil sedation. Sampling consisted of protected specimen brushes, bronchoalveolar lavage, small volume lavage and for some, endobronchial biopsies. Bleeding, desaturation, cough, haemodynamic changes, dyspnoea and other events that required an unplanned intervention or early termination of bronchoscopy were prospectively recorded. Follow-up consisted of a telephone interview where subjects rated discomfort and answered questions about fever sensation and respiratory symptoms in the week following bronchoscopy. RESULTS: An unplanned intervention or early termination of bronchoscopy was required in 25.9% of bronchoscopies. Three subjects (1.3%) experienced potentially severe complications, of which all recovered without sequelae. COPD subjects experienced more dyspnoea than controls. Sedation and lower age was associated with less unplanned intervention or premature termination. About half of the subjects (47.7%) reported fever. Discomfort was associated with postprocedural fever, dread of bronchoscopy, higher score on the COPD Assessment Test and never-smoking. In subjects undergoing more than one bronchoscopy, the first bronchoscopy was often predictive for complications and postprocedural fever in the repeated bronchoscopy. CONCLUSION: Research bronchoscopies were not associated with more complications or discomfort in COPD subjects. 47.7% experienced postbronchoscopy fever sensation, which was associated with discomfort.

Risk factors for lung cancer in COPD - results from the Bergen COPD cohort study.

BACKGROUND: COPD patients have an increased risk of developing lung cancer, but the underlying mechanisms are poorly understood. We aimed to identify risk factors for lung cancer in patients from the Bergen COPD Cohort Study. METHODS: We compared 433 COPD patients with 279 healthy controls, all former or current smokers. All COPD patients had FEV1<80% and FEV1/FVC-ratio<0.7. Baseline predictors were sex, age, spirometry, body composition, smoking history, emphysema assessed by CT, chronic bronchitis, prior exacerbation frequency, Charlson Comorbidity Score, inhalation medication and 44 serum/plasma inflammatory biomarkers. Patients were followed up for 9 years recording incidence of lung cancer. Cox-regression models were fitted for the statistical analyses. The biomarkers were evaluated using principal component analysis. RESULTS: 28 COPD patients and 3 controls developed lung cancer, COPD patients had a significantly higher risk of developing lung cancer, (HR 5.0; 95% CI 1.5-17.1, p < 0.01, adjusted values). Among COPD patients, emphysema (HR 4.4; 1.7-10.8, p < 0.01) and obesity (HR 3.3; 1.3-8.5, p = 0.02) were associated with a higher cancer rate. Use of inhaled steroids was associated with a lower rate (HR 0.4; 0.2-0.9, p = 0.03). Smoking status, pack-years smoked or levels of systemic inflammatory markers, except for interferon gamma-induced protein 10, did not affect the lung cancer rate in patients with COPD. CONCLUSION: Patients with COPD have a higher lung cancer rate compared to healthy controls adjusted for smoking. The presence of emphysema and obesity in COPD predicted a higher lung cancer risk in COPD patients. Systemic inflammation was not associated with increased lung cancer risk.

Complications and discomfort of bronchoscopy: a systematic review.

OBJECTIVE: To identify bronchoscopy-related complications and discomfort, meaningful complication rates, and predictors. METHOD: We conducted a systematic literature search in PubMed on 8 February 2016, using a search strategy including the PICO model, on complications and discomfort related to bronchoscopy and related sampling techniques. RESULTS: The search yielded 1,707 hits, of which 45 publications were eligible for full review. Rates of mortality and severe complications were low. Other complications, for instance, hypoxaemia, bleeding, pneumothorax, and fever, were usually not related to patient characteristics or aspects of the procedure, and complication rates showed considerable ranges. Measures of patient discomfort differed considerably, and results were difficult to compare between different study populations. CONCLUSION: More research on safety aspects of bronchoscopy is needed to conclude on complication rates and patient- and procedure-related predictors of complications and discomfort.

Diffusion capacity and CT measures of emphysema and airway wall thickness - relation to arterial oxygen tension in COPD patients.

BACKGROUND: Decreased diffusing capacity of the lung for carbon monoxide (DLCO) is associated with emphysema. DLCO is also related to decreased arterial oxygen tension (PaO2), but there are limited data on associations between PaO2 and computed tomography (CT) derived measures of emphysema and airway wall thickness. OBJECTIVE: To examine whether CT measures of emphysema and airway wall thickness are associated with level of arterial oxygen tension beyond that provided by measurements of diffusion capacity and spirometry. METHODS: The study sample consisted of 271 smoking or ex-smoking COPD patients from the Bergen COPD Cohort Study examined in 2007-2008. Emphysema was assessed as percent of low-attenuation areas<-950 Hounsfield units (%LAA), and airway wall thickness as standardised measure at an internal perimeter of 10 mm (AWT-Pi10). Multiple linear regression models were fitted with PaO2 as the outcome variable, and %LAA, AWT-Pi10, DLCO and carbon monoxide transfer coefficient (KCO) as main explanatory variables. The models were adjusted for sex, age, smoking status, and haemoglobin concentration, as well as forced expiratory volume in one second (FEV1). RESULTS: Sixty two per cent of the subjects were men, mean (SD) age was 64 (7) years, mean (SD) FEV1 in percent predicted was 50 (15)%, and mean PaO2 (SD) was 9.3 (1.1) kPa. The adjusted regression coefficient (CI) for PaO2 was -0.32 (-0.04-(-0.019)) per 10% increase in %LAA (p<0.01). When diffusion capacity and FEV1 were added to the model, respectively, the association lost its statistical significance. No relationship between airway wall thickness and PaO2 was found. CONCLUSION: CT assessment of airway wall thickness is not associated with arterial oxygen tension in COPD patients. Emphysema score measured by chest CT, is related to decreased PaO2, but cannot replace measurements of diffusion capacity in the clinical evaluation of hypoxaemia.

Oxygen desaturation in 6-min walk test is a risk factor for adverse outcomes in COPD.

The 6-min walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. We investigated oxygen desaturation during 6MWT as a risk factor for important COPD outcomes: mortality, frequency of exacerbations, decline in lung function and decline in lean body mass.433 COPD patients were included in the Bergen COPD Cohort Study 2006-2009, and followed-up for 3 years. Patients were characterised using spirometry, bioelectrical impedance measurements, Charlson comorbidity score, exacerbation history, smoking and arterial blood gases. 370 patients completed the 6MWT at the baseline of the study. Information on all-cause mortality was collected in 2011.Patients who experienced oxygen desaturation during the 6MWT had an approximately twofold increased risk of death (hazard ratio 2.4, 95% CI 1.2-5.1), a 50% increased risk for experiencing later COPD exacerbations (incidence rate ratio 1.6, 95% CI 1.1-2.2), double the yearly rate of decline in both forced vital capacity and forced expiratory volume in 1 s (3.2% and 1.7% versus 1.7% and 0.9%, respectively) and manifold increased yearly rate of loss of lean body mass (0.18 kg·m(-2) versus 0.03 kg·m(-2) among those who did not desaturate).Desaturating COPD patients had a significantly worse prognosis than non-desaturating COPD patients, for multiple important disease outcomes.

Participation in research bronchoscopy: a literature review.

Bronchoscopy is the preferred method for collecting biological samples from the lower airways of subjects in clinical research. However, ensuring participation in clinical research can be challenging when the research includes an invasive procedure. For this report we reviewed the literature to look for information on participation in research bronchoscopy studies to better design our own study, the Bergen COPD Microbiome study (MicroCOPD). We performed a systematic literature search on participation in research bronchoscopy studies in February 2014 using the search engines of PubMed and EMBASE. The literature search resulted in seven relevant papers. Motivation was an end point in six of the seven papers, but reasons for declining participation and recruitment strategies also seemed important. Human subjects participate in research bronchoscopy studies for personal benefit and altruistic reasons. Inconvenience associated with research, in addition to fear of procedures, is considered a barrier. Radio, especially news stations, generated the most inquiries for a clinical study involving bronchoscopy. There is a lack of information on participation in research bronchoscopy studies in the literature. A bronchoscopy study has been initiated at Haukeland University Hospital, Bergen, Norway, to examine the role of the microbiome in COPD, and participation will be explored as a substudy.

Predictors of health-related quality of life changes after lifestyle intervention in persons at risk of type 2 diabetes mellitus.

PURPOSE: To assess health-related quality of life (HRQOL) of subjects at risk of type 2 diabetes undergoing lifestyle intervention, and predictors for improved HRQOL. METHODS: The Finnish Diabetes Risk Score was used by general practitioners to identify individuals at risk. Low-intensity interventions with an 18-month follow-up were employed. HRQOL was assessed using the SF-36 at baseline and compared with results from a general Norwegian population survey and further at 6 and 18 months. Simple and multiple linear regression analyses were applied to identify predictors of changes in HRQOL of clinical importance. RESULTS: Two hundred and thirteen participants (50 % women; mean age: 46 years, mean body mass index: 37) were included: 182 returned for 18-month follow-up, of whom 172 completed the HRQOL questionnaire. HRQOL was reduced with clinical significance compared with general Norwegians. The mean changes in HRQOL from the baseline to the follow-up were not of clinical importance. However, one out of three individuals achieved a moderate or large clinical improvement in HRQOL. The best determinant for improved HRQOL was obtained for a composite, clinically significant lifestyle change, i.e. both a weight reduction of at least 5 % and an improvement in exercise capacity of at least 10 %, which was associated with an improvement in five out of the eight SF-36 domains. CONCLUSION: Subjects at risk of type 2 diabetes report a clinically important reduction in HRQOL compared with general Norwegians. The best predictor of improved HRQOL was a small weight loss combined with a small improvement in aerobic capacity.

Increased prevalence of chronic obstructive pulmonary disease in a general population.

BACKGROUND: Prevalence of COPD is increasing worldwide, and there is need for regularly updated estimates of COPD prevalence and risk factors. METHODS: In the Norwegian Hordaland County Cohort Study (HCCS), 1664 subjects aged 35-90 yrs answered questionnaires and performed spirometry in 2003-05. We estimated COPD prevalence and analysed risk factors for COPD with logistic regression. RESULTS: In a previous study phase, prevalence of GOLD-defined COPD was 7%. Eight years later, corresponding prevalence was 14%. Seventy % of the subjects experienced respiratory symptoms. Only 1 out of 4 had a physician's diagnosis. Significant risk factors for COPD were sex, age, smoking habits and pack-years. Men had 1.7 (OR, 95% CI 1.2, 2.3) higher odds for COPD than women. Subjects above 65 yrs had 10.3 (OR, 95% CI 6.4, 16.5) times higher odds for COPD than subjects below 40 yrs. Heavy smokers had 4.2 (OR, 95% CI 2.6, 6.7) times higher odds for COPD than subjects with <10 pack-years. When compared with the previous study phase, age and smoking status had roughly the same associations with COPD prevalence. Educational level and male gender, on the other hand, had less effect on COPD prevalence in 2005 than in 1997, while pack years were more important in 2005 than in 1997. CONCLUSIONS: Prevalence of GOLD defined COPD has increased from 7% to 14% in nine years. Although the risk factors remain the same, the strength of associations vary. There is still substantial under diagnosis in COPD, and better disease awareness and diagnostic routines are needed.

Reference values for within-breath pulmonary impedance parameters in asymptomatic elderly.

INTRODUCTION: A new application for the forced oscillation technique (FOT) has been described by Dellaca et al. using sinusoidal pressure variations at 5 Hz to detect expiratory flow limitation by measuring the within-breath reactance [termed difference between inspiratory and expiratory X5 (DX5)]. Few studies have been performed on respiratory phase differences in the elderly. OBJECTIVE: Our aim was to present reference values for within-breath impedance measurements and to examine how the earlier mentioned method performs in a study population of asymptomatic elderly. METHODS: An age- and sex-stratified random sample was drawn from the elderly population of Bergen, Norway. Among the healthy non-smoking responders from a postal questionnaire study, 148 were selected to perform FOT measurements using an impulse oscillometry system (IOS). Seventy five of these participants had a normal spirometry and were able to perform at least two valid FOT measurements. Predictive equations for men and women were created for FOT parameters by linear multiple regression analysis. DX5 was calculated from the within-breath variation of reactance at 5 Hz. RESULTS/CONCLUSION: This study presents reference values for whole-breath and within-breath impedance parameters in asymptomatic elderly aged >70 years using the IOS method. We found higher resistance measurements than what is reported in previous studies and significantly larger frequency dependence.

Chronic obstructive pulmonary disease is associated with low levels of vitamin D.

INTRODUCTION: COPD patients may be at increased risk for vitamin D (25(OH)D) deficiency, but risk factors for deficiency among COPD patients have not been extensively reported. METHODS: Serum 25(OH)D levels were measured by liquid chromatography double mass spectrometry in subjects aged 40-76 years from Western Norway, including 433 COPD patients (GOLD stage II-IV) and 325 controls. Levels <20 ng/mL defined deficiency. Season, sex, age, body mass index (BMI), smoking, GOLD stage, exacerbation frequency, arterial oxygen tension (PaO(2)), respiratory symptoms, depression (CES-D score≥16), comorbidities (Charlson score), treatment for osteoporosis, use of inhaled steroids, and total white blood count were examined for associations with 25(OH)D in both linear and logistic regression models. RESULTS: COPD patients had an increased risk for vitamin D deficiency compared to controls after adjustment for seasonality, age, smoking and BMI. Variables associated with lower 25(OH)D levels in COPD patients were obesity ( = -6.63), current smoking ( = -4.02), GOLD stage III- IV ( = -4.71, = -5.64), and depression ( = -3.29). Summertime decreased the risk of vitamin D deficiency (OR = 0.22). CONCLUSION: COPD was associated with an increased risk of vitamin D deficiency, and important disease characteristics were significantly related to 25(OH)D levels.

Explained variance for blood gases in a population with COPD.

INTRODUCTION: Variation of blood gas levels in chronic obstructive pulmonary disease (COPD) patients has not been extensively reported and there is limited knowledge about predictors of chronic respiratory failure in COPD patients. OBJECTIVES: The aim of this study was to identify predictors of hypoxemia, hypercapnia and increased alveolar-arterial oxygen difference in COPD patients. We hypothesized that prediction of arterial blood gases will be improved in multivariate models including measurements of lung function, anthropometry and systemic inflammation. METHODS: A cross-sectional sample of 382 Norwegian COPD patients, age 40-76, Global Initiative for Chronic Obstructive Lung Disease stage II-IV, with a smoking history of at least 10 pack-years, underwent extensive measurements, including medical examination, arterial blood gases, systemic inflammatory markers, spirometry, plethysmography, respiratory impedance and bioelectrical impedance. Possible predictors of arterial oxygen (PaO(2)), arterial carbon dioxide (PaCO(2)) and alveolar-arterial oxygen difference (AaO(2)) were analyzed with both bivariate and multiple regression methods. RESULTS: We found that various lung function measurements were significantly associated with PaO2, PaCO(2) and AaO(2). In addition, heart rate and Fat Mass Index were predictors of PaO(2) and AaO(2), while heart failure and current smoking status were associated with PaCO(2). The explained variance (R(2)) in the final multivariate regression models was 0.14-0.20. CONCLUSIONS: With a wide assortment of possible clinical predictors, we could explain 14-20% of the variation in blood gas measurements in COPD patients.

Excessive costs of COPD in ever-smokers. A longitudinal community study.

AIM: We aimed to estimate the societal treatment-related costs of COPD in hospital- and population-based subjects with spirometry defined COPD, relative to a control group. METHODS: 81 COPD cases and 132 controls without COPD were randomly recruited from a general population, as were 205 COPD patients from a hospital register. All participants were ever-smokers of at least 40 years of age, followed for 12 months. Data on comorbid conditions and spirometry were collected at baseline. Standardized telephone interviews every third month gave information on use of healthcare services and exacerbations of respiratory symptoms. RESULTS: The increased (excessive) median annual costs per case having stage II, stage III and stage IV COPD were € (95% CI) 400 (105-695), 1918 (1268-2569) and 1870 (1031-2709), respectively, compared to the population-based controls. Costs increased with €81 (95% CI 50-112) per exacerbation of respiratory symptoms and €461 (95% CI 354-567) per comorbid condition. Excessive costs for hospital COPD patients were threefold that of the population-based COPD cases. CONCLUSION: The excessive treatment-related cost of COPD stage II+ in ever-smokers of at least 40 years was estimated to €105 million for Norway. Comorbidity was a dominant predictor of excessive cost in COPD.

Case-control studies on risk factors for chronic obstructive pulmonary disease: how does the sampling of the cases and controls affect the results?

INTRODUCTION: Sampling is regarded as crucial to the validity of case-control studies. Ideally, cases and controls should be selected from the same source population, but deviations from this approach are often seen. OBJECTIVE: Our objective was to examine how exposure-disease relationships in a study on chronic obstructive pulmonary disease (COPD) were affected by the sampling sources of cases and controls. METHODS: A Norwegian case-control study on COPD including 1909 subjects used three sources of recruitment for cases (general population, hospital registry and volunteers) and two sources for controls (general population and volunteers). This resulted in six sampling combinations of cases and controls (groups A-F). We examined how the risk factors gender, age, smoking, educational level and comorbidity were associated with COPD in these six sampling groups. RESULTS: Several exposure-disease associations were dependent on variation in sampling source, thereby demonstrating the possibility of selection bias. The theoretically most ideal sampling group is likely group A, where both cases and controls are recruited from a general population. When using group A as a reference, the groups containing either voluntary controls and/or hospital-based cases deviated the most, suggesting higher susceptibility to selection bias in these groups. CONCLUSION: Recruitment from several sources made our study design vulnerable to selection bias. Our findings should bring about increased awareness to the sampling process, and encourage sampling of cases and controls from the same source population in future studies.

HRQoL changes, mood disorders and satisfaction after treatment in an unselected population of patients with lung cancer.

OBJECTIVES: This study intended to explore the impact of the first treatment modality on health-related quality of life (HRQoL), mood disorders and mastery in an unselected population of patients with primary lung cancer and to judge patient satisfaction with treatment. MATERIALS AND METHODS: An unselected group of 479 patients with newly diagnosed lung cancer in Southern Norway (Agder counties) were included prospectively from June 2002 to June 2005, collecting data on histology, treatment options, HRQoL, mood disorders and mastery at baseline as well as satisfaction with treatment, and changes in HRQoL and mood disorders after finishing the first treatment modality. RESULTS: After finishing the first treatment modality, patients experienced a worsening of nine HRQoL parameters and an improvement in one. Patients in good performance status experienced reduced physical and role function, and if in reduced performance, improved emotional and role function. Patients with mood disorders experienced reduced anxiety and depression, anxious patients experienced reduced neuropathies, and depressed patients experienced improved social functioning and appetite. Half of the patients treated actively were definitely positive to repeat the same treatment again compared with only 15% in the best supportive care group. Surgery was associated with reduced role function and increased dyspnoea, radiation was associated with increased fatigue, and chemotherapy in small cell lung cancer (SCLC), to a larger extent, was associated with alopecia than in non-SCLC (NSCLC). CONCLUSION: The development of many HRQoL parameters after the first treatment modality in an unselected population of patients with primary lung cancer seemed, at large, well correlated to general disease progression and to well-known treatment side effects. However, reduced role function after lung surgery, and reduced anxiety and depression in patients with mood disorders at baseline might be surprising. Patient satisfaction with treatment was surprisingly good. Several findings in this study may help clinicians to improve their handling of patients with lung cancer.

Aspects of healthcare utilisation in self-reported obstructive lung disease.

INTRODUCTION: Utilisation of healthcare resources because of pulmonary diseases have previously been presented according to lung function or symptom severity. We aimed to compare the associations of symptoms and lung function to healthcare and social service utilisation in subjects with self-reported obstructive lung diseases (OLDs) (asthma, chronic obstructive pulmonary disease, chronic bronchitis, emphysema). MATERIALS AND METHODS: Of 2819 participants aged 27-82 years in the Hordaland County Respiratory Health Survey, 200 subjects (7.1%) self-reported OLD. They answered 13 questions on respiratory symptoms and 5 questions on use of healthcare and social services. Altogether, 161 participants (81%) completed post-bronchodilation spirometry. RESULTS: Use of anti-asthmatic drugs, regular physician's appointment, sick leave payment for the last 12 months, hospital admission for the last 12 months and disability pension were reported by 68%, 63%, 18%, 8% and 7% of those with self-reported OLD, respectively. Twenty per cent of subjects with self-reported OLD had not received any healthcare or social services. In adjusted multivariate logistic regression analyses, increase in the respiratory symptom score was significantly associated with more healthcare and social services. Lower forced expiratory volume in 1 s in % predicted, however, was not significantly associated with more use of healthcare and social services. CONCLUSION: The majority (80%) of subjects in a general population with self-reported OLD received healthcare services. The utilisation of healthcare and social services was strongly associated to the burden of respiratory symptoms, and, to a lesser degree, to the level and pattern of lung function.

Relationships between hand-rolled cigarettes and primary lung cancer: a Norwegian experience.

INTRODUCTION: Detailed smoking history of patients developing lung cancer is rarely known, especially not for users of hand-rolled cigarettes. In Norway, smoking hand-rolled tobacco is still popular, accounting for one-third of the total tobacco consume. METHODS: A questionnaire-based study revealing detailed information about tobacco consume with consecutive inclusion of all persons developing lung cancer in Southern Norway 2002-2005. RESULTS: In this unselected population with 479 patients with newly diagnosed lung cancer, 95% had a smoking history and 88% of ever-smokers had smoked primarily hand-rolled cigarettes. The hand-rolled cigarette smokers had smoked fewer cigarettes daily (15) and less pack-years of tobacco (34) than fabricated cigarette smokers (20, P < 0.0001 and 42, P = 0.021, respectively). Smoking hand-rolled cigarettes was considerably more frequent than expected from official sales statistics. Hand-rolled cigarette smoking revealed an odds ratio of 13 for developing lung cancer compared with smoking fabricated cigarettes. CONCLUSION: In this unselected population with newly diagnosed lung cancer, nine out of 10 ever-smokers had smoked primarily hand-rolled cigarettes. Patients smoking hand-rolled cigarettes had a smoking history of fewer daily cigarettes and less pack-years tobacco consumed than fabricated cigarette smokers. In this study, hand-rolled cigarettes are more frequently used than shown in national statistics. Smokers of hand-rolled cigarettes may have a greatly increased risk for lung cancer compared with smokers of fabricated cigarettes.