Comparison of pre- and post-bronchodilator lung function as predictors of mortality: The HUNT Study.

BACKGROUND AND OBJECTIVE: Post-bronchodilator (BD) lung function is recommended for the diagnosis of chronic obstructive pulmonary disease (COPD). However, often only pre-BD lung function is used in clinical practice or epidemiological studies. We aimed to compare the discrimination ability of pre-BD and post-BD lung function to predict all-cause mortality. METHODS: Participants aged ≥40 years with airflow limitation (n = 2538) and COPD (n = 1262) in the second survey of the Nord-Trøndelag Health Study (HUNT2, 1995-1997) were followed up until 31 December 2015. Survival analysis and time-dependent area under the receiver operating characteristic curves (AUC) were used to compare the discrimination ability of pre-BD and post-BD lung function (percent-predicted forced expiratory volume in the first second (FEV1 ) (ppFEV1 ), FEV1 z-score, FEV1 quotient (FEV1 Q), modified Global Initiative for Chronic Obstructive Lung Disease (GOLD) categories or GOLD grades). RESULTS: Among 2538 participants, 1387 died. The AUC for pre-BD and post-BD ppFEV1 to predict mortality were 60.8 and 61.8 (P = 0.005), respectively, at 20 years' follow-up. The corresponding AUC for FEV1 z-score were 58.5 and 60.4 (P < 0.001), for FEV1 Q were 68.7 and 70.1 (P = 0.002) and for modified GOLD categories were 62.3 and 64.5 (P < 0.001). Among participants with COPD, the AUC for pre-BD and post-BD ppFEV1 were 57.0 and 58.8 (P < 0.001), respectively. The corresponding AUC for FEV1 z-score were 53.1 and 55.8 (P < 0.001), for FEV1 Q were 63.6 and 65.1 (P = 0.037) and for GOLD grades were 56.0 and 57.0 (P = 0.268). CONCLUSION: Mortality was better predicted by post-BD than by pre-BD lung function; however, they differed only by a small margin. The discrimination ability using GOLD grades among COPD participants was similar.

The Prevalence and Symptom Profile of Asthma-COPD Overlap: The HUNT Study.

The concept of asthma and COPD as separate conditions has been questioned, and the term asthma-COPD overlap syndrome has been introduced. We assessed the prevalence, symptoms, and lifestyle factors of asthma-COPD overlap (ACO) in a large Norwegian population-based study. From 2006 to 2008, a total of 50,777 residents of Nord-Trøndelag participated in the Nord-Trøndelag Health Study, Norway. They completed questionnaires regarding respiratory symptoms, disease status, and medication use. We estimated the prevalence and 95% confidence intervals of ACO. Additionally, spirometry was used to estimate the prevalence of ACO in a subgroup. The prevalence of self-reported ACO was 1.9%, and in age groups <40, 40-60 and ≥60 years it was 0.7%, 1.4%, and 3.2%, respectively. Among those reporting COPD, the proportion of ACO was 0.56. In the spirometry subgroup when ACO was defined as doctor diagnosed asthma ever and FEV1/FVC < 0.70, the prevalence of ACO was 2.0%. All respiratory symptoms, separately or in combination, as well as medication use were reported most frequently in those with ACO compared to the other groups. Strikingly, we observed a two-fold higher proportion of allergic rhinitis in ACO compared to COPD only. In this Norwegian population, the prevalence of self-reported ACO was 1.9%, and the corresponding proportion of ACO among those with COPD was 0.56. Participants with ACO generally had the highest proportions of respiratory symptoms compared to asthma or COPD.

Physical activity and lung function decline in adults with asthma: The HUNT Study.

BACKGROUND AND OBJECTIVE: People with asthma may seek advice about physical activity. However, the benefits of leisure time physical activity on lung function are unclear. We investigated the association between leisure time physical activity and lung function decline in adults with asthma. METHODS: In a population-based cohort study in Norway, we used multiple linear regressions to estimate the annual mean decline in lung function (and 95% CI) in 1329 people with asthma over a mean follow-up of 11.6 years. The durations of light and hard physical activity per week in the last year were collected by questionnaire. Inactive participants did not report any light or hard activity, while active participants reported light or hard activity. RESULTS: The mean decline in forced expiratory volume in 1 s (FEV1 ) was 37 mL/year among inactive participants and 32 mL/year in active participants (difference: -5 mL/year (95% CI: -13 to 3)). The mean decline in forced vital capacity (FVC) was 33 mL/year among inactive participants and 31 mL/year in active participants (difference: -2 mL/year (95% CI: -11 to 7)). The mean decline in FEV1 /FVC ratio was 0.36%/year among inactive participants and 0.22%/year in active participants (difference: -0.14%/year (95% CI: -0.27 to -0.01)). The mean decline in peak expiratory flow (PEF) was 14 mL/year among the inactive participants and 10 mL/year in active participants (difference: -4 mL/year (95% CI: -9 to 1)). CONCLUSION: We observed slightly less decline in lung function in physically active than inactive participants with asthma, particularly for FEV1 , FEV1 /FVC ratio and PEF.

Collaboration between municipal and specialist public health care in tuberculosis screening in Norway.

BACKGROUND: About 90% of new tuberculosis (TB) cases in Norway appear among immigrants from high incidence countries. There is a compulsory governmental tuberculosis screening programme for immigrants; immigrants with positive screening results are to be referred from municipal health care to the specialist health care for follow-up. Recent studies of the screening programme have shown inadequate follow-up. One of the main problems has been that patients referred for follow-up have not attended their appointment at the specialist health care.TB screening in the municipality of Trondheim is done by two different teams: the Refugee Healthcare Centre (RHC) screens refugees and the Vaccination and Infection Control Office (VICO) screens all the other groups. Patients with positive findings on screening are referred to the hospital's Pulmonary Out-patient Department (POPD). The municipal and referral level public health care initiated a project aiming to improve follow-up through closer collaboration. METHODS: An intervention group and a pre-intervention control group were established for each screening group. During meetings between staff from the municipality and the POPD, inadequacies in the screening process were identified, and changes in procedures for summoning patients, and time and place for tests were implemented. For both the intervention group and the control group, time from referral until consultation at the POPD and number of patients that attended their first appointment were registered and compared. RESULTS: In the VICO group, 97/134 (72%) of the controls and 109/123 (89%) of the intervention group attended their first appointment at the POPD after 30 weeks (median) and 10 weeks, respectively. In the RHC group 28/46 (61%) of the controls and 55/59 (93%) in the intervention group attended their first appointment after 15 and 8 weeks (median) respectively. CONCLUSION: Increased collaboration between the municipal and specialist health care can improve the follow-up of positive TB screening results.

Changes in and predictors of pain and mortality in patients with chronic obstructive pulmonary disease.

This longitudinal study of patients with chronic obstructive pulmonary disease (COPD) aimed to investigate changes in pain characteristics (i.e., occurrence, intensity, and interference) and covariates associated with pain from study enrollment to 12 months, and to investigate if the different pain characteristics were associated with 5-year mortality. In total, 267 patients with COPD completed questionnaires five times over 1 year. The mean age of the patients was 63 years (standard deviation: 9.0), 53% were women, and 46% had very severe COPD. Median number of comorbidities was 2.0 (range: 0-11) and 47% of patients reported back/neck pain. Mixed models and Cox regression models were used for analyses. In total, 60% of the patients reported pain at baseline, and 61% at 12 months. The mixed model analyses revealed that those with better forced expiratory volume in 1 s (% predicted), more comorbidities, only primary school education, and more respiratory symptoms reported significantly higher average pain intensity. Moreover, those with more comorbidities, more respiratory symptoms, and more depression reported higher pain interference with function. At the 5-year follow-up, 64 patients (24%) were deceased, and the cumulative 5-year mortality rate was 22% (95% confidence interval [19-25]). Older age, lower forced expiratory volume in 1 s (% predicted), and higher pain interference at enrollment were all independently and significantly associated with higher 5-year mortality. Our findings show that many patients with COPD have persistent pain, and awareness regarding comorbidities and how pain interferes with their lives is needed.

Hypogammaglobulinemia and Risk of Exacerbation and Mortality in Patients with COPD.

Introduction: Chronic obstructive pulmonary disease (COPD) may, in some patients, be characterized by recurring acute exacerbations. Often these exacerbations are associated with airway infections. As immunoglobulins (Ig) are important parts of the immune defence against airway infections, the aim of this study was to relate the levels of circulating immunoglobulins to clinical features in unselected patients with COPD included in a Norwegian multicenter study. Methods: Clinical and biological data, including circulating levels of immunoglobulins, were assessed in 262 prospectively included patients with COPD GOLD stage II-IV at five hospitals in south-eastern Norway. A revisit was done after one year, and survival was assessed after five years. Clinical features and survival of those with immunoglobulin levels below reference values were compared to those with normal levels. Results: In total, 11.5% of all COPD patients and 18.5% of those with GOLD stage IV had IgG concentrations below reference values. These patients were more likely to use inhaled or oral steroids, had lower BMI, and lower FEV1%. Moreover, they had significantly more COPD-related hospital admissions (2.8 vs 0.6), number of prednisolone courses (3.9 vs 1.2), and antibiotic treatments (3.7 vs 1.5) in the preceding year. Importantly, hypogammaglobulinemia was significantly associated with reduced survival in a log-rank analysis. In multivariate regression analysis, we found that the higher risk for acute exacerbations in these patients was independent of other risk factors and was associated with impaired survival. Conclusion: In conclusion, our study suggests that hypogammaglobulinemia may be involved in poor outcome in COPD and may thus be a feasible therapeutic target for interventional studies in COPD.

Serum 25-hydroxyvitamin D, vitamin D supplement and asthma control: The HUNT study.

Few studies have investigated the association between serum 25-hydroxyvitamin D (25[OH]D), vitamin D supplement and asthma control among adults. We aimed to examine whether low levels of serum 25(OH)D or not taking vitamin D supplement were associated with an increased risk of poorly controlled asthma among Norwegian adults with asthma. We used a definition of asthma control adapted from the Global Initiative for Asthma. We first examined cross-sectional associations between serum 25(OH)D (n = 806) or vitamin D supplement (n = 1179) and poorly controlled asthma. Next, among those with well controlled asthma at baseline, we examined prospective associations between serum 25(OH)D (n = 147) or vitamin D supplement (n = 208) and poorly controlled asthma at follow-up, approximately 11 years later. We estimated risk ratios (RR) and 95% confidence intervals (CI) with Poisson regression. The adjusted RR for poorly controlled asthma was 1.00 (95% CI, 0.89-1.13) for adults with serum 25(OH)D < 50 nmol/L in cross-sectional and 1.50 (95% CI, 0.46-4.95) in prospective analyses. The adjusted RR for poorly controlled asthma was 1.17 (95% CI 1.00-1.37) for non-users of vitamin D supplement in cross-sectional and 1.66 (95% CI 0.49-5.67) in prospective analyses. Our study did not show strong evidence that among adults with asthma, having a low serum 25(OH)D or being a non-user of vitamin D supplement was associated with an increased risk of poorly controlled asthma. Some point estimates indicated an increased risk, however our estimates were generally imprecise and further evidence is needed.

Distinct pain profiles in patients with chronic obstructive pulmonary disease.

Background: Few studies have examined changes in the pain experience of patients with COPD and predictors of pain in these patients. Objectives: The objectives of the study were to examine whether distinct groups of COPD patients could be identified based on changes in the occurrence and severity of pain over 12 months and to evaluate whether these groups differed on demographic, clinical, and pain characteristics, and health-related quality of life (HRQoL). Patients and methods: A longitudinal study of 267 COPD patients with very severe COPD was conducted. Their mean age was 63 years, and 53% were females. The patients completed questionnaires including demographic and clinical variables, the Brief Pain Inventory, and the St Georges Respiratory Questionnaire at enrollment, and 3, 6, 9, and 12 months follow-up. In addition, spirometry and the 6 Minute Walk Test were performed. Latent class analysis was used to identify subgroups of patients with distinct pain profiles based on pain occurrence and worst pain severity. Results: Most of the patients (77%) reported pain occurrence over 12 months. Of these, 48% were in the "high probability of pain" group, while 29% were in the "moderate probability of pain" group. For the worst pain severity, 37% were in the "moderate pain" and 39% were in the "mild pain" groups. Females and those with higher body mass index, higher number of comorbidities, and less education were in the pain groups. Patients in the higher pain groups reported higher pain interference scores, higher number of pain locations, and more respiratory symptoms. Few differences in HRQoL were found between the groups except for the symptom subscale. Conclusion: Patients with COPD warrant comprehensive pain management. Clinicians may use this information to identify those who are at higher risk for persistent pain.

Distinct symptom experiences in subgroups of patients with COPD.

BACKGROUND: In addition to their respiratory symptoms, patients with COPD experience multiple, co-occurring symptoms. OBJECTIVES: The aims of this study were to identify subgroups of COPD patients based on their distinct experiences with 14 symptoms and to determine how these subgroups differed in demographic and clinical characteristics and disease-specific quality of life. PATIENTS AND METHODS: Patients with moderate, severe, and very severe COPD (n=267) completed a number of self-report questionnaires. Latent class analysis was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of self-reported symptoms using the Memorial Symptom Assessment Scale. RESULTS: Based on the probability of occurrence of a number of physical and psychological symptoms, three subgroups of patients (ie, latent classes) were identified and named "high", "intermediate", and "low". Across the three latent classes, the pairwise comparisons for the classification of airflow limitation in COPD were not significantly different, which suggests that measurements of respiratory function are not associated with COPD patients' symptom burden and their specific needs for symptom management. While patients in both the "high" and "intermediate" classes had high occurrence rates for respiratory symptoms, patients in the "high" class had the highest occurrence rates for psychological symptoms. Compared with the "intermediate" class, patients in the "high" class were younger, more likely to be women, had significantly more acute exacerbations in the past year, and reported significantly worse disease-specific quality of life scores. CONCLUSION: These findings suggest that subgroups of COPD patients with distinct symptom experiences can be identified. Patients with a higher symptom burden warrant more detailed assessments and may have therapeutic needs that would not be identified using current classifications based only on respiratory function.

Impact of pneumonia on hospitalizations due to acute exacerbations of COPD.

BACKGROUND AND AIMS: Pneumonia is often diagnosed among patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aims of this study were to find the proportion of patients with pneumonia among admissions due to AECOPD and whether pneumonia has impact on the length of stay (LOS), usage of non-invasive ventilation (NIV) or the in-hospital mortality. METHODS: Retrospectively, all hospitalizations in 2005 due to AECOPD in the Departments of Internal and Respiratory Medicine in one Swedish and two Norwegian hospitals were analyzed. A total of 1144 admittances (731 patients) were identified from patient administrative systems. Pneumonic AECOPD (pAECOPD) was defined as pneumonic infiltrates on chest X-ray and C-reactive protein (CRP) value of ≥40 mg/L, and non-pneumonic AECOPD (npAECOPD) was defined as no pneumonic infiltrate on X-ray and CRP value of <40 at admittance. RESULTS: In admissions with pAECOPD (n = 237), LOS was increased (median 9 days vs 5 days, P < 0.001) and usage of NIV was more frequent (18.1% vs 12.5%, P = 0.04), but no significant increase in the in-hospital mortality (3.8% vs 3.6%) was found compared to admissions with npAECOPD. A higher proportion of those with COPD GOLD stage I-II had pAECOPD compared to those with COPD GOLD stage III-IV (28.2% vs 18.7%, P = 0.001). CONCLUSIONS: In-hospital morbidity, but not mortality, was increased among admissions with pAECOPD compared to npAECOPD. This may, in part, be explained by the extensive treatment with antibiotics and NIV in patients with pAECOPD.

A Scandinavian audit of hospitalizations for chronic obstructive pulmonary disease.

In Scandinavia no large audits of hospitalizations for chronic obstructive pulmonary disease (COPD) have been performed, and data on adherence to national guidelines are scarce. The aims of the present study were to audit hospitalizations for COPD exacerbations in three Scandinavian hospitals with respect to incidence, patient population and standards of hospital care. Retrospectively all hospitalizations in the Departments of Internal and Respiratory Medicine in Ostersund Hospital (Sweden), Aalesund Hospital (Norway) and Trondheim University Hospital (Norway) from Jan 1 to Dec 31, 2005, with discharge ICD-10 diagnoses J43-J44, J96 + J44 or J13-18 + j44 were registered. A total of 1144 admissions (731 patients) were identified from patient administrative systems and medical charts. Among the admitted patients 27% were >80 years old, >50% had COPD stage III or IV, and 14% had respiratory acidosis at admittance. Patients with 3 or more admissions (13%) during 2005 accounted for 36% of all hospitalizations. One third of the patients were current smokers. Non-invasive ventilation was used in 14% of the admissions, with large variation between centres. In-hospital mortality was 3.7%. In this first large Scandinavian audit of COPD-hospitalizations, all centres had low in-hospital mortality. We consider this as an indication of good clinical practice in the three studied centres and possibly due to the frequent use of non-invasive ventilation.