GOLD Classifications, COPD Hospitalization, and All-Cause Mortality in Chronic Obstructive Pulmonary Disease: The HUNT Study.

Purpose: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published three classifications of COPD from 2007 to 2017. No studies have investigated the ability of these classifications to predict COPD-related hospitalizations. We aimed to compare the discrimination ability of the GOLD 2007, 2011, and 2017 classifications to predict COPD hospitalization and all-cause mortality. Patients and Methods: We followed 1300 participants with COPD aged ≥40 years who participated in the HUNT Study (1995-1997) through to December 31, 2015. Survival analysis and time-dependent area under receiver operating characteristics curves (AUC) were used to compare the discrimination abilities of the GOLD classifications. Results: Of the 1300 participants, 522 were hospitalized due to COPD and 896 died over 20.4 years of follow-up. In adjusted models, worsening GOLD 2007, GOLD 2011, or GOLD 2017 categories were associated with higher hazards for COPD hospitalization and all-cause mortality, except for the GOLD 2017 classification and all-cause mortality (ptrend=0.114). In crude models, the AUCs (95% CI) for the GOLD 2007, GOLD 2011, and GOLD 2017 for COPD hospitalization were 63.1 (58.7-66.9), 60.9 (56.1-64.4), and 56.1 (54.0-58.1), respectively, at 20-years' follow-up. Corresponding estimates for all-cause mortality were 57.0 (54.8-59.1), 54.1 (52.1-56.0), and 52.6 (51.0-54.3). The differences in AUCs between the GOLD classifications to predict COPD hospitalization and all-cause mortality were constant over the follow-up time. Conclusion: The GOLD 2007 classification was better than the GOLD 2011 and 2017 classifications at predicting COPD hospitalization and all-cause mortality.

Impaired Respiratory Function in Women With PCOS Compared With Matched Controls From a Population-Based Study.

CONTEXT: Increased prevalence of asthma has been reported from epidemiological studies in women with polycystic ovary syndrome (PCOS). OBJECTIVE: To investigate respiratory function in women with PCOS compared with controls in a clinical setting. DESIGN: An 8-year clinical follow-up study including self-reported asthma diagnoses and spirometry of women with PCOS randomized to metformin or placebo during pregnancy in the original studies (the Pilot and the PregMet-study), compared with matched controls from a population-based cohort study (The HUNT Study). SETTING: Secondary and tertiary care centers. PARTICIPANTS: A total of 145 women with PCOS (54% of original cohort) were matched 1:3 to controls, on gender, age, and smoking-status. MAIN OUTCOMES AND MEASURES: Self-reported doctor-diagnosed asthma (DDA), percentage of predicted forced expiratory volume in the first second of expiration (FEV1 % predicted), percentage of predicted forced vital capacity (FVC % predicted). RESULTS: Women with PCOS reported more DDA compared with controls (19% vs 9%; P < 0.01). Spirometry indicated a combined obstructive (FEV1 % predicted, 93.7 vs 102.0; P < 0.01) and restrictive (FVC % predicted, 94.5 vs 103.7; P < 0.01) respiratory impairment in PCOS compared with controls. Metformin in pregnancy did not affect respiratory function at follow-up. CONCLUSION: Women with PCOS reported higher prevalence of DDA compared with controls matched for age and smoking status. In addition, respiratory function was decreased, with both obstructive and restrictive components. Further insight to the underlying pathogenesis of these observations is needed. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: The PregMet study: NCT00159536. The Pilot study: NCT03259919.

Comparison of procalcitonin, C-reactive protein, white blood cell count and clinical status in diagnosing pneumonia in patients hospitalized with acute exacerbations of COPD: A prospective observational study.

Lower respiratory tract infection is the most common cause of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of the present study was to compare the accuracy of procalcitonin (PCT), C-reactive protein (CRP) and white blood cell count (WBC) as single diagnostic tests and in combination with clinical signs and symptoms to diagnose pneumonia in patients hospitalized with AECOPD. This was a prospective, single centre observational study. Patients with spirometry-confirmed COPD who were hospitalized due to AECOPD were consecutively recruited at the hospital's Emergency Unit. Pneumonia was defined as a new pulmonary infiltrate on chest X-ray. The values of PCT, CRP and WBC were determined at admission. Receiver operating characteristic (ROC) curve analysis was used to study the accuracy of various diagnostic tests. Of the 113 included patients, 35 (31%) had pneumonia at admission. Area under the ROC curve (AUC) for PCT, CRP and WBC as a single test to distinguish between patients with and without pneumonia was 0.67 (95% CI 0.55-0.79), 0.73 (95% CI 0.63-0.84) and 0.67 (95% CI 0.55-0.79), respectively ( p = 0.42 for the test of difference). The AUC for a model of clinical signs and symptoms was 0.84 (95% CI 0.76-0.92). When biomarkers were added to the clinical model, the AUCs of the combined models were not significantly different from that of the clinical model alone ( p = 0.54). PCT had about the same accuracy as CRP and WBC in predicting pneumonia in patients hospitalized with AECOPD both as a single test and in combination with clinical signs and symptoms.

Prevalence and trend of COPD from 1995-1997 to 2006-2008: The HUNT study, Norway.

BACKGROUND: COPD is a major cause of morbidity and mortality across the world and new estimates of prevalence and trend are of great importance. We aimed to estimate the prevalence and trend of COPD from 1995-1997 to 2006-2008 in Norwegian adults ≥40 years from the Nord-Trøndelag Health Study. MATERIAL AND METHODS: COPD was assessed using a fixed-ratio and lower limit of normal (LLN) criteria. Pre-bronchodilator spirometry was performed during 1995-1997 (n = 7158) and 2006-2008 (n = 8788). The prevalence of COPD was weighted using the inverse probability of selection and predicted probability of response. RESULTS: The prevalence of pre-bronchodilator COPD was 16.7% in 1995-1997 and 14.8% in 2006-2008 using fixed-ratio criteria, and 10.4% in 1995-1997 and 7.3% in 2006-2008 using LLN criteria. The prevalence of LLN COPD was higher among men (13.0% in 1995-1997, 7.7% in 2006-2008) than women (8.0% in 1995-1997, 6.9% in 2006-2008). From 1995-1997 to 2006-2008, the prevalence decreased among men but remained relatively stable among women. Over the 11-year period, the cumulative incidence of pre-bronchodilator COPD using LLN criteria was 3.3% and 2.7% among men and women respectively. The prevalence of self-reported asthma and respiratory symptoms increased. CONCLUSIONS: The prevalence declined in men but not in women from 1995-1997 to 2006-2008, and was consistently higher among men than women.

Does an Integrated Care Intervention for COPD Patients Have Long-Term Effects on Quality of Life and Patient Activation? A Prospective, Open, Controlled Single-Center Intervention Study.

BACKGROUND: Implementation of the COPD-Home integrated disease management (IDM) intervention at discharge after hospitalizations for acute exacerbations of COPD (AECOPD) led to reduced hospital utilization during the following 24 months compared to the year prior to study start. AIMS: To analyze the impact of the COPD-Home IDM intervention on health related quality of life, symptoms of anxiety and depression, and the degree of patient activation during 24 months of follow-up and to assess the association between these outcomes. METHODS: A single center, prospective, open, controlled clinical study. Changes in The St. George Respiratory Questionnaire (SGRQ), the Hospital anxiety (HADS-A) and depression (HADS-D) and the patient activation measure (PAM) scores were compared between the patients in the integrated care group (ICG) and the usual care group (UCG) 6, 12 and 24 months after enrolment. RESULTS: The questionnaire response rate was 80-96%. There were no statistically significant differences in the change of the SGRQ scores between the groups during follow up. After 12 months of follow-up there was a trend towards a reduction in the mean HADS-A score in the ICG compared to the UCG. The HADS-D scores remained stable in the ICG compared with an increasing trend in the UCG. Clinically significant difference in the PAM score was achieved only in the ICG, 6.7 (CI95% 0.7 to 7.5) compared to 3.6 (CI95% -1.4 to 8.6) in the UCG. In a logistic regression model a higher HADS-D score and current smoking significantly increased the odds for a low PAM score. CONCLUSION: The COPD-Home IDM intervention did not result in any statistically significant changes in mean SGRQ, HADS-A, HADS- D or PAM scores during the 24 months of follow-up. TRIAL REGISTRATION: The ID number for the study in the Clinical.Trials.gov registration system is 17417. ClinicalTrials.gov Identifier: NCT 00702078.

Vitamin D and Lung Function Decline in Adults With Asthma: The HUNT Study.

We investigated whether low 25-hydroxyvitamin D (25(OH)D) levels were associated with more lung function decline in adults with asthma and whether this association was modified by smoking status or inhaled corticosteroid (ICS) use. We analyzed data on 395 adults with asthma from the Nord-Trøndelag Health Study (1995-2008), Norway. Plasma 25(OH)D and lung function were measured at baseline, and lung function measurements were repeated at follow-up, approximately 11 years later. Linear regression was used to estimate lung function decline. Participants with low 25(OH)D (<50 nmol/L) had more decline in lung function measurements for forced expiratory volume in 1 second (FEV1) (388 mL), forced vital capacity (298 mL), and the FEV1/forced vital capacity ratio (3.7%) over the follow-up, compared with those with high 25(OH)D (≥50 nmol/L) who declined 314 mL, 246 mL, and 3.0%, respectively (P = 0.08, 0.30, and 0.23, respectively). The associations were stronger in never smokers and non-ICS users. In never smokers, low 25(OH)D levels were associated with more decline in FEV1 (445 vs. 222 mL) (P = 0.01). In non-ICS users, low 25(OH)D levels were associated with more decline in FEV1 (467 vs. 320 mL) (P = 0.02). Low serum 25(OH)D levels were weakly associated with more lung function decline in adults with asthma, and stronger associations were observed in never smokers and non-ICS users.

Neutrophil CD64 Expression as a Diagnostic Marker in Patients Hospitalized with Exacerbations of COPD: A Prospective Observational Study.

PURPOSE: The expression of the neutrophil high-affinity Fc-gamma receptor (CD64) can be used as a diagnostic marker for bacterial infection and sepsis. The aims of this study were to determine the diagnostic accuracy of CD64 compared to C-reactive protein (CRP) and white blood cell count (WBC) in patients hospitalized with acute exacerbations of COPD (AECOPD) and to investigate the kinetics of CD64 expression. METHODS: The present study is a prospective, single-centre observation study. Blood samples were collected from patients hospitalized with AECOPD at admission and after 6, 24 and 48 h. Retrospective reviews on the patients' medical records were performed blinded to the CD64 results. The CD64 was measured using the Leuko64 kit from Trillium Diagnostics, LLC (Maine, USA) with the CELL-DYN Sapphire Haematology System (Abbott Laboratories, Illinois, USA). Diagnostic accuracy of the CD64, CRP and WBC was compared using a receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 113 patients were included. Thirty-six patients (32 %) had pulmonary infiltrate on chest X-ray at admission (PI). The CD64 was higher in samples from patients with AECOPD and PI than those without PI at admission (median 1.25 vs. 0.60, p = 0.002) and during 48 h of follow-up. The area under the ROC curve of CD64, CRP and WBC was 0.69, 0.73 and 0.64, respectively, (p = 0.42 for the test of difference). CONCLUSION: Neutrophil CD64 expression has about the same diagnostic accuracy as CRP in diagnosing pneumonia in patients hospitalized with AECOPD, but does not add to the diagnostic accuracy of CRP and WBC count.

Long term effects of an integrated care intervention on hospital utilization in patients with severe COPD: a single centre controlled study.

UNLABELLED: Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality globally. In Trondheim in 2008 an integrated care model (COPD-Home) consisting of an education program, self-management plan, home visits and a call centre for patient support and communication was developed. The objective was to determine the efficacy of an intervention according to the COPD-Home model in reducing hospital utilization among patients with COPD stage III and IV (GOLD 2007) discharged after hospitalization for acute exacerbations of COPD (AECOPD). METHODS: A single centre, prospective, open, controlled clinical study comparing COPD-Home integrated care (IC) with usual care (UC). RESULTS: Ninety-one versus 81 patients mean age 73.4 ± 9.3 years (57% women) were included in the IC group (ICG) and the UC group (UCG) respectively, and after 2 years 51 and 49 patients were available for control in the respective groups. During the year prior to study start there were 71 hospital admissions (HA) in the ICG and 84 in the UCG. There was a 12.6% reduction in HA in the ICG during the first year of follow-up and a 46.5% reduction during the second year (p = 0.01) compared to an 8.3% increase during the first year and no change during the second year in the ICG. During the year prior to study start, the number of hospital days (HD) was 468 in the ICG and 479 in the UCG. In the IC group, the number of HD was reduced by 48.3% during the first year (p = 0.01), and remained low during the second year of follow-up (p=0.02). In the UC group, the number of HD remained unchanged during the follow-up period. There was a trend towards a shorter survival time among patients in the ICG compared to the UCG, hazard ratio 1.33 [95% CI 0.77 to 2.33]. CONCLUSION: Intervention according to the COPD-Home model reduced hospital utilization in patients with COPD III and IV with a persisting effect throughout the 2 years of follow-up. However, there was a trend towards a shorter survival time in the intervention group.

The development of an integrated care model for patients with severe or very severe chronic obstructive pulmonary disease (COPD): the COPD-Home model.

BACKGROUND: Adherence to guidelines for managing stable chronic obstructive pulmonary disease (COPD) and its exacerbations is inadequate among healthcare workers and patients. An appropriate care model would meet patient needs, enhance their coping with COPD and improve their quality of life (QOL). AIM: This study aims to present the 'COPD-Home' as an integrated care model for patients with severe or very severe COPD. MODEL: One principle of the COPD-Home model is that hospital treatment should lead to follow up in the patient's home. The model also includes education, improved coordination of levels of care, improved accessibility and a management plan. One of the main elements of the COPD-Home model is the clear role of the home-care nurse. Model development is based on earlier research and clinical experience. It comprises: (i) education provided through an education programme for patients and involved nurses, (ii) joint visits and telephone checks, (iii) a call centre for support and communication with a general practitioner and (iv) an individualised self-management plan including home monitoring and a plan for pharmacological and nonpharmacological interventions. CONCLUSION: The COPD-Home model attempts to cultivate competences and behaviours of patients and community nurses that better accord with guidelines for interventions. The next step in its development will be to evaluate its ability to assist both healthcare workers and planners to improve the management of COPD, reduce exacerbations and improve QOL and coping among patients with COPD.

Anxiety and depression following pulmonary rehabilitation.

AIM: The aim of this study was to evaluate changes and predictive factors of anxiety and depression in patients with chronic obstructive pulmonary disease (COPD) before and up to 3 months after pulmonary rehabilitation (PR). METHODS: A single group longitudinal design of patients with COPD underwent a PR programme. The measurements took place at baseline (T1: N=100), immediately before (T2: N=66), immediately after (T3: N=54) and 3 months after (T4: N=43) the programme. The programme was a 6-week outpatient programme, including education, psychosocial support and training sessions. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale, self-efficacy by the COPD self-efficacy scale, lung function by spirometry and exercise capacity by incremental shuttle walking test. Mixed effect model analyses were used. RESULTS: Results showed a tendency of less anxiety and depression immediately after (T3) compared with immediately before (T2) the PR programme, but the changes were not significant. Results also showed that female reported significantly more anxiety than male (p=0.019), better exercise capacity predicted significantly less depression (p=0.049), and higher self-efficacy predicted both significantly less anxiety (p=0.001) and less depression (p=0.005). CONCLUSIONS: A tendency of less anxiety and depression during the PR programme was found, but the changes were not significant. Higher level of self-efficacy and better exercise capacity are suggested to relieve anxiety and depression.

The Norwegian version of the chronic obstructive pulmonary disease self-efficacy scale (CSES): a validation and reliability study.

The aim of this study was to evaluate the feasibility, internal consistency and face and construct validity of the Norwegian version of the Chronic Obstructive Pulmonary Disease Self-Efficacy Scale (CSES). The CSES was translated into Norwegian according to standard procedures for forward and backward translation, and administered to 100 patients with chronic obstructive pulmonary disease (COPD) (51% men, mean age 66.1 years, range 42-82) prior to their participation in an outpatient pulmonary rehabilitation programme. The CSES-N (translated version) consists of 34 items comprising five subscales describing negative affect, intense emotional arousal, physical exertion, weather/environment and behavioural risk factors. Each scale ranges from 1 to 5, with higher scores indicating better self-efficacy. For validation purposes, we measured lung function (FEV(1) , FEV(1) % predicted) and exercise capacity (ISWT), and administered the St. George's Respiratory Questionnaire (SGRQ) and Hospital Anxiety and Depression Scale (HADS). A pilot study confirmed that the CSES-N was clear, understandable and easy to self-administer. Cronbach's alpha was 0.98 for the total score (0.80-0.96 for subscales). Results showed small to medium negative correlations between all CSES-N scales and anxiety, depression (HADS), physical activity, psychosocial impact of disease and total health status (SGRQ) (-0.20 to -0.49). Small or negligible negative correlations between different CSES-N scales and respiratory symptoms (SGRQ) (-0.03 to -0.23) were found. Any correlations among exercise capacity, lung function and different socio-demographic variables (age, gender and education) and CSES-N were also small or negligible (0.00 to 0.23). This study shows acceptable feasibility, internal consistency and face and construct validity for the CSES-N in a sample of Norwegian COPD patients.

Self-efficacy as a predictor of improvement in health status and overall quality of life in pulmonary rehabilitation--an exploratory study.

OBJECTIVE: To evaluate developments in health status (HS) and overall quality of life (QOL), and the impact of self-efficacy on HS and QOL in relation to COPD pulmonary rehabilitation (PR). METHODS: A longitudinal study of 100 COPD patients before and up to 3 months after COPD PR. Self-efficacy was measured by the COPD self-efficacy scale, HS by the St. George Respiratory Questionnaire and QOL by the Quality of Life Scale. Mixed effect models were used. RESULTS: Patients reported significantly reduced psychosocial impact of disease (estimate=-4.05, p=0.019) immediately after the PR programme. Higher levels of self-efficacy at baseline predicted significantly reduced psychosocial impact of disease and improved physical activity, total HS and QOL (p<0.05). Better exercise capacity at baseline predicted significantly reduced psychosocial impact of disease, improved physical activity and QOL (p<0.05). Older age at baseline predicted significantly fewer respiratory symptoms and improved total HS (p<0.05). CONCLUSIONS: Patients reported significantly reduced psychosocial impact of disease immediately after a COPD PR, and better exercise capacity and higher self-efficacy at baseline predicted significantly improved HS and QOL. PRACTICE IMPLICATIONS: Increasing self-efficacy is suggested to be an important aim in relation to COPD PR.

Allergy related disorders among 2-yrs olds in a general population. The PACT Study.

Allergic disorders represent a major health problem in most developed countries, but few population-based studies have focused on these disorders in early childhood. The aims of the present study were to investigate the prevalence, gender differences and distribution of allergy related disorders and their association to sensitization among unselected children, 2 yrs of age, in a general population. A population-based study with parental self reported questionnaire data involving allergy related symptoms and results from allergy tests from 4783 two-yr-old children was conducted, and skin prick tests (SPT) of a randomly selected sample comprising 390 children were performed. In the total population the prevalence of reported wheeze was 26%, doctor diagnosed asthma (DDAsthma) 7.0%, atopic dermatitis (AD) 17% and allergic rhinoconjunctivitis (ARC) 3%. Of the 1008 (21%) allergy tested children 59% reported a positive test, but of the randomly selected children only 8% had a positive SPT. Children with AD were most frequently sensitized and children with ARC were most likely to have other allergy related disorders (70%). More boys than girls had an allergy related disorder or a positive allergy test. In conclusion, two in five had an allergy related disorder, but less than 10% had a positive SPT. Having one allergic disorder, especially ARC, increased substantially the risk of having another, and having AD was most strongly associated to a positive allergy test. Moreover, boys were more likely than girls to have an allergy related disorder or a positive SPT indicating a gender difference in the natural history of allergy related disorders.

What determines subjective health status in patients with chronic obstructive pulmonary disease: importance of symptoms in subjective health status of COPD patients.

BACKGROUND: Subjective health status is the result of an interaction between physiological and psychosocial factors in patients with chronic obstructive pulmonary disease (COPD). However, there is little understanding of multivariate explanations of subjective health status in COPD. The purpose of this study was to explore what determines subjective health status in COPD by evaluating the relationships between background variables such as age and sex, predicted FEV1%, oxygen saturation, breathlessness, anxiety and depression, exercise capacity, and physical and mental health. METHODS: This study had a cross-sectional design, and included 100 COPD patients (51% men, mean age 66.1 years). Lung function was assessed by predicted FEV1%, oxygen saturation by transcutaneous pulse oximeter, symptoms with the St George Respiratory Questionnaire and the Hospital Anxiety and Depression Scale, physical function with the Incremental Shuttle Walking Test, and subjective health status with the SF-36 health survey. Linear regression analysis was used. RESULTS: Older patients reported less breathlessness and women reported more anxiety (p < 0.050). Women, older patients, those with lower predicted FEV1%, and those with greater depression had lower physical function (p < 0.050). Patients with higher predicted FEV1%, those with more breathlessness, and those with more anxiety or depression reported lower subjective health status (p < 0.050). Symptoms explained the greatest variance in subjective health status (35%-51%). CONCLUSION: Symptoms are more important for the subjective health status of patients with COPD than demographics, physiological variables, or physical function. These findings should be considered in the treatment and care of these patients.

Atopic dermatitis among 2-year olds; high prevalence, but predominantly mild disease--the PACT study, Norway.

Atopic dermatitis is often the first and most prevalent manifestation of atopic disease in preschool children. The objectives of the present study were to determine the prevalence and severity of atopic dermatitis in 2-year-old children. Questionnaire data from a total population of 4784 two-year olds and data from a clinical investigation of a sub-sample of 390 children were obtained from a comprehensive prospective study (Prevention of Atopy among Children in Trondheim). The severity of the atopic dermatitis was scored both according to the Nottingham Eczema Severity Score and the Severity Scoring of Atopic Dermatitis. In the total population the prevalence of this disease, defined as any eczema and itchy rash was 16.5% (95% CI: 15.5-17.6). In the subsample, the corresponding prevalence was 20.6% (95% CI: 16.6-24.6) and 15.9% (95% CI: 12.3-19.5) when diagnosed by the UK Working Party's Criteria. More than 70% of the children with UK-diagnosed atopic dermatitis had mild disease according to both the Nottingham Eczema Severity Score and the Severity Scoring of Atopic Dermatitis. The prevalence of atopic dermatitis among 2-year olds was high. However, more than two-thirds of the children had mild disease, which may imply that the impact of atopic dermatitis as a risk factor for future atopic disease is limited.

A study of the association between exercise-induced wheeze and exercise versus methacholine-induced bronchoconstriction in adolescents.

Among asthmatics, exercise-induced wheeze (EIW) is a frequent symptom, and 40-77% of asthmatics demonstrate exercise-induced bronchoconstriction (EIB). In the North-Trøndelag population-based survey of 8,571 adolescents (YOUNG-HUNT), 26% reported wheeze during the previous 12 months (current wheeze). Of those subjects, 50% reported EIW. The aim of the present study was to investigate the association between EIW and EIB in randomly selected adolescents with EIW as the only or predominant asthma-like symptom, and to relate our findings to results from methacholine bronchoprovocation tests (MT) and measurements of exhaled nitric oxide (ENO). Sixty-three subjects with current wheeze induced by exercise, but not by allergen exposure, were investigated using a treadmill exercise test (ET) and measurements of ENO. Fifty-eight subjects completed a MT on a separate study day. EIB was defined as a fall of >or= 10% in the forced expiratory volume in 1 second (FEV1) after exercise (DeltaFEV1%ex). Twenty-one subjects (33%) had EIB and 33 (57%) had a positive MT. The degree of reported dyspnea during the ET was not correlated to the DeltaFEV1%ex. The correlation between EIB and methacholine-induced bronchoconstriction (MIB) was poor, and the DeltaFEV1%ex was more pronounced in smokers than in non-smokers. Moreover, ENO was not increased in subjects with positive vs. negative ET. Hence, EIW, when reported as the only or predominant asthma-like symptom, was linked to EIB in only one-third of the patients. We conclude that EIW is a poor predictor of EIB in epidemiological studies. The poor correlation between EIB and MIB indicates that these two tests measure different mechanisms of bronchial hyper-responsiveness.