Tuberculosis in a developed country

All 515 patients notified for tuberculosis for the first time in 1972, 1977 and 1982 in Copenhagen have been studied. Changes during the period and differences between Danes and immigrants were looked for. The percentage of immigrants increased during the period. The immigrants had a different age distribution, higher frequency of extrapulmonary tuberculosis with a distribution different from that of Danes, fewer complicating diseases and they drank less alcohol. No significant changes in the patient population took place in the decade studied, except for a decreasing number of Danes with tuberculosis, a decreasing number of abacillary patients and an increase in the percentage of extrapulmonary tuberculosis. At follow-up in 1983, none of the immigrants, but 147 of 407 Danes had died, mainly from complicating diseases. Life expectancy for the Danes, who survived the initial phase, was not significantly different from that for the population at large. None of the patients were bacillary at the time of the follow-up.

BMI and oral glucocorticoids as predictors of prognosis in COPD patients on long-term oxygen therapy

AIMS

The objectives of the study were to determine whether body mass index (BMI), and oral corticosteroid use predict survival and hospitalization in hypoxaemic chronic obstructive pulmonary disease (COPD) patients.

METHODS

The study was a prospective cohort study with analysis of a nationwide database (Danish Oxygen Register). We studied survival and hospitalization in 221 hypoxaemic COPD patients who were on long-term oxygen therapy (LTOT).

RESULTS

Low BMI was strongly associated with high mortality (P < 0.001). Maintenance treatment with steroids was only associated with higher mortality in overweight patients (BMI > or = 25 kg/m2), RR = 3.8 (1.4-10.5), P = 0.011. Whereas BMI had no influence on risk of any hospitalization in patients using oral steroids, high BMI was independently associated with reduced risk of any hospitalization in patients without oral steroids [the RR of any hospitalization for each 1 kg/m2 increase in BMI was 0.94 (CI: 0.90-0.99), P = 0.009]. Overall, the use of oral steroids was associated with increased risk of any hospitalization, RR = 1.7 (1.2-2.4), P = 0.002. This increase was especially pronounced in the group with BMI above 25 kg/m2, where steroid treatment increased the risk of any hospitalization with RR = 3.6 (1.5-8.7), P = 0.005.

CONCLUSIONS

In hypoxaemic patients on LTOT, low BMI is an independent risk factor of death and any hospitalization. Maintenance treatment with oral corticosteroids is associated with increased mortality and hospitalization in COPD patients with high BMI. Our findings suggest that loss of body weight should be avoided, and that oral corticosteroids should be used cautiously in patients on LTOT--especially those with high BMI. Further research on the role of changes in body composition as a prognostic factor is needed.

Standardised mortality rates in females and males with COPD and asthma

Mortality studies of males and females with chronic obstructive pulmonary disease (COPD) and asthma have suggested that females have a poorer prognosis than males, but the results are either not unanimous or based on poorly characterised patients. The current study analysed the mortality of 279 asthma patients and 869 COPD patients, who were seeking pension due to disability, and compared mortality rates with expected rates derived from the general population. The mean follow-up period was 13.3 yrs (range 2.5-22.4 yrs) during which time 96 (34.4%) and 671 (77.2%) deaths were identified among asthma and COPD patients, respectively. The average age at study entry was 46.8 and 56.6 yrs, and the average forced expiratory volume in one second (FEV1) was 68.8 and 44.1 % predicted in the two diagnostic groups. After adjustment for predictors of survival (age, FEV1 % predicted, chronic bronchitis, body mass index, smoking status, oral prednisolone, ischaemic heart disease, and cor pulmonale), the relative risk of death was 1.21 (95% confidence interval: 0.77-1.89) and 0.98 (0.83-1.16) in females compared with males, in asthma and COPD patients, respectively. The standardised mortality rate (SMR) for males was 1.54 (1.10-2.09) and 2.7 (2.5-3.0), and for females 1.91 (1.44-2.49) and 4.8 (4.2-5.4), in asthma and COPD patients, respectively. Direct comparison of the SMR of males and females showed that females had higher mortality than males, with a rate ratio of 1.24 (0.82-1.84) and 1.8 (1.5-2.0), in asthma and COPD patients, respectively. Poisson regression analysis with control for the confounders did not change this result. Females and males with the same level of obstructive lung disease appear to have the same level of mortality. However, using standardised mortality rates, females have a higher mortality than males, suggesting that the protective effect of being female is lost in chronic obstructive pulmonary disease patients.

Is there any association between inhaled ipratropium and mortality in patients with COPD and asthma?

BACKGROUND

To determine whether ipratropium was associated with premature death in patients with asthma and chronic obstructive pulmonary disease (COPD).

METHODS

A longitudinal cohort of 827 patients with COPD and 273 with asthma who were evaluated for compensation by two specialists in pulmonary medicine.

RESULTS

By June 1999, 538 of the patients with COPD and 77 of those with asthma had died. Atthe consultation, 77% ofthe COPD patients and 8.1% of the asthmatic patients were treated with inhaled ipratropium. Ipratropium was associated with mortality risk ratio (RR) of 2.0 (95% confidence interval: 1.5-2.6) for COPD and 3.6 (1.8-7.1) for asthma patients. After adjustment for confounding factors [forced expiratory volume 1 s (FEV1), smoking habits, asthma medication, and presence of cor pulmonale] the RR for COPD was 1.6 (1.2-2.1) and for asthma 24 (1.2-5.0).

CONCLUSIONS

The increased risk of premature death associated with ipratropium is of concern and necessitates further evaluation, e.g., in a randomised study.

Does long-term oxygen therapy reduce hospitalisation in hypoxaemic chronic obstructive pulmonary disease?

The aim of this study was to determine whether long-term oxygen therapy (LTOT) reduces hospitalisation in hypoxaemic patients with chronic obstructive pulmonary disease (COPD). The circumstances of initiation of LTOT (start during hospitalisation versus start as an outpatient) and compliance with oxygen were also investigated (continuous oxygen therapy (COT) > or = 15 h daily versus noncontinuous oxygen therapy (NCOT) <15 h daily). A total 246 COPD patients were studied, with each patient acting as their own control. Patients were divided into four groups: 125 patients on COT who started LTOT in conjunction with hospitalisation, 37 patients on COT who started LTOT as outpatients, 58 patients on NCOT who started LTOT in conjunction with hospitalisation and 26 patients on NCOT who started LTOT as outpatients. Admission rates, days spent in hospital and number of patients with at least one hospitalisation (ever hospitalised) were compared in two periods of 10 months before and after initiation of LTOT. Overall during the LTOT period, in comparison with the preoxygen period, the admission rates, hospital days and "ever hospitalised" were reduced by 23.8%, 43.5% and 31.2%, respectively. Among patients who started LTOT as outpatients, a tendency towards a higher effect in the compliant group was observed. This study shows that in hypoxaemic chronic obstructive pulmonary disease patients, long-term oxygen therapy is associated with a reduction in hospitalisation.

Non-continuous home oxygen therapy: utilization, symptomatic effect and prognosis, data from a national register on home oxygen therapy

About half of all patients on home oxygen therapy receive non-continuous oxygen therapy (less than 15 h daily) (NCOT). The goal of NCOT is to improve well-being during daily activities and to improve sleep quality. The aim of this study was to evaluate the effect of NCOT on pulmonary symptoms and sleep quality, and to determine whether patients with a subjective beneficial effect differed from those without effect in terms of patients' characteristics, utilization of oxygen, hospitalization and survival. Furthermore, the relationship between the reported beneficial effect of NCOT on dyspnoea and physical activity during domestic activities was examined. During the period November 1994 to July 1995, 254 Danish patients were prescribed oxygen less than 12 h daily or 'on demand'. Of these patients, 142 (55.9%) answered a questionnaire on hours spent with oxygen and symptomatic effect of oxygen treatment. While on oxygen, 76.3% of the patients reported improved dyspnoea score (0-10) more than 0.5 points, 78.3% had improved quality of life, 59.5% improved sleep, 48.5% increased physical activity, 49.3% felt less tired and 40.0% reported improved thinking. Fifty-seven (43.2%) patients reported both improved dyspnoea and physical activity whereas seven (5.3%) patients reported that oxygen had no effect on dyspnoea but a beneficial effect on physical activity Only 11 (7.7%) patients reported no subjective improvement on oxygen. The subjective effect of NCOT was not significantly associated to hours spent with oxygen. the underlying disease, gender, hospitalization or survival. During daily activity and regardless of daily number of hours spent with oxygen, NCOT improved well-being in nearly all patients. The most pronounced improvement was reported on dyspnoea, sleep and quality of life. Very few patients sensed improved physical activity without relief in breathlessness.

[Reliability of recorded deaths from asthma in Denmark during a 1-year period 1994-1995]

INTRODUCTION

The aim of this study was to evaluate the accuracy of death certificates over a one-year period, where asthma was given as the cause of death.

METHODS

All medical information available was collected on 218 patients by reviewing hospital records, records from general practitioners, and sometimes by interviewing close relatives. A panel of four pulmonologists each examined the information and independently assessed the cause of death.

RESULTS

Thirty-nine were excluded, as the cause of death could not be validated. In 16 (9%) of the subjects, asthma was judged to be the definite cause of death and in 12 (7%) a possible cause. Of 151 non-asthma deaths, but registered as asthma, 109 were judged to have suffered or died from COPD and 14 from heart disease.

DISCUSSION

The accuracy of Danish death certification in asthma deaths is poor, especially in the elderly, where COPD is often classified as asthma. We conclude that the true mortality from asthma in Denmark is substantially lower than that officially recorded.

Are patients on long-term oxygen therapy followed up properly? Data from the Danish Oxygen Register

OBJECTIVES

The aim of the study was to assess the extent and quality of follow-up of patients on LTOT.

SETTING

The Danish Oxygen Register.

SUBJECTS

A total of 890 chronic obstructive pulmonary disease (COPD) patients who were on long-term oxygen therapy (LTOT) during the period from 1 November 1994 to 31 August 1995.

MAIN OUTCOME MEASURES

The extent and quality of follow-up.

RESULTS

Only 38.5% of the patients were followed up in the study period, and only 17.5% had a 'sufficient follow-up' defined as at least one follow-up visit within 10 months which included measurement of arterial blood gases or pulsoximetry with oxygen supply, verification that the patient used oxygen > or =15 h day-1 and was nonsmoker. Female gender, LTOT initiated 3-12 months ago, LTOT started by a chest physician at pulmonary department and LTOT prescribed > or =15 h day-1 were found to be significant predictors of 'sufficient follow-up' (odds ratio (OR): 1.7, 2.0, 3.7 and 1.9, respectively).

CONCLUSIONS

The extent and the quality of follow-up of patients on LTOT were poor, especially if a nonpulmonary physician initiated LTOT. We recommend that more attention should be paid on proper monitoring of LTOT, and that only chest physicians should be able to prescribe and re-evaluate LTOT.

Geographic variation in long-term oxygen therapy in Denmark : factors related to adherence to guidelines for long-term oxygen therapy

STUDY OBJECTIVES

To evaluate regional differences in adherence to guidelines for long-term oxygen therapy (LTOT) in Denmark and to determine factors related to compliance with these guidelines.

DESIGN

Cross-sectional study and analysis of a nationwide database (Danish Oxygen Register).

SETTING

Denmark.

PATIENTS

In November 1994, 1,354 COPD patients were receiving LTOT in Denmark.

MEASUREMENTS AND RESULTS

Among 16 counties, the prevalence of LTOT for COPD varied from 14 to 53 per 100,000. The prevalence was highest in counties where general practitioners (GPs) were prescribing LTOT. Adherence to national guidelines for LTOT was found in 34.4% of the patients for the whole of Denmark and varied regionally from 14 to 63%. Mean compliance with guidelines was 5.3 (range, 2.9 to 9.1) times as likely if the oxygen was prescribed by a pulmonary department compared to LTOT initiated by a GP.

CONCLUSIONS

Marked geographic variations in compliance with LTOT guidelines are present even in a small country as Denmark. In general, the adherence to the guidelines is poor, especially when non-chest physicians prescribe LTOT. We therefore recommend that local and national thoracic societies together with health organizations responsible for treatment should play a more forceful role in implementing the guidelines. This could be done by enhanced educational efforts, by monitoring of adherence, or even by centralizing the prescription right to departments with pulmonary physicians.

Has the perception of disability among COPD patients applying for pension changed during the last 20 years?

The aim is to examine the change in lung function, treatment and pulmonary symptoms in patients with chronic obstructive pulmonary disease (COPD) or chronic bronchitis (CB) applying for a pension during the period 1977-1996. In addition, we compared the perception of disability in males and females. From 1977 to 1996, 947 patients with COPD or CB were evaluated for obtaining economic support due to disability. In order to test the trend, the patients were divided into three periods: (1) 1977-1983, (2) 1984-1989 and (3) 1990-1996. Compared to females, males had substantial more pack-years of smoking (36 vs. 28, P<0.001), but their FEV1 was only slightly decreased (46.9% versus 49.6% predicted, P=0.047). Females reported significantly more often attacks of dyspnoea [OR: 1.5(1.00-2.2)] and any kind of dyspnoea during daytime [OR: 4.0(1.2-13.3)]. From period 1 to period 3, FEV1 increased significantly (45-53% predicted, P<0.001). Despite the increased FEV1, the use of inhaled corticosteroid had increased markedly (9-32% of the patients, P<0.001). The results did not change when patients with asthma were included. Our data suggest that both sexes, especially females, have become more aware of pulmonary symptoms and tend to react to them more actively by demanding evaluation and treatment.

[Tuberculosis in immigrants]

Three cases of tuberculosis in immigrants are described here. The manifestations of tuberculosis in this group are often different from those seen in Danes--in casu tuberculosis of the lymph nodes, skin, bone, and intestines. Diagnosis is difficult, as Danish doctors are not familiar with the clinical picture. Language problems are common and often necessitate the presence of an interpreter. Immigrants tend to move around without notifying the responsible doctor and the resources needed to find them may not be readily available. These factors may cause a considerable delay--from months to years--in the diagnosis and treatment. Doctors examining immigrants from Africa and Asia should be aware of tuberculosis as a possible cause of disease. Secretion and biopsies from fistulae, chronic ulcerations, lymph nodes, and abscesses should always be cultured for Mycobacterium tuberculosis. The Mantoux reaction can be misleadingly negative in patients suffering from severe tuberculosis. Identification of Mycobacterium tuberculosis is not necessary for treatment--that decision is made on the clinical picture. On the other hand material for a bacteriological diagnosis should always be obtained, because of possible resistance problems.

Accuracy of recorded asthma deaths in Denmark in a 12-months period in 1994/95

Many studies of asthma mortality rely on official registration. The aim of this study was to evaluate the accuracy of death certificates, where asthma was coded as cause of death. In a 12-month period, medical information on all subjects with asthma officially coded as the underlying cause of death in Denmark, was obtained by reviewing hospital records, contacting general practitioners and sometimes close relatives. A panel of four pulmonologists each examined the obtained information and independently assessed the cause of death. Of a total of 218 death certificates, 39 were excluded as the cause of death could not be validated. In 16 (9%) of the subjects death from asthma was judged to be the definite cause of death and in 12 (7%) death from asthma was possible. Of 151 non-asthma deaths coded as due to asthma, 109 were judged to have suffered or died from COPD and 14 from heart disease. The accuracy of Danish death certification in asthma deaths is poor, especially in the elderly, where COPD is often classified as asthma. We conclude that the true asthma mortality in Denmark is substantially lower than officially recorded.

[Long-term effect of inhaled budesonide in patients with mild to moderate chronic obstructive lung disease. The Osterbro Study]

We compared the effect of inhaled budesonide with placebo on decline in lung function and respiratory symptoms in a three-year study of patients with chronic obstructive pulmonary disease (COPD). We used a parallel-group, randomized, double-blind, placebo-controlled design, nested in an ongoing epidemiological survey. Patients were non-asthmatic subjects with a decreased ratio between forced expiratory volume in one second (FEV1) and vital capacity (VC); i.e., FEV1/VC < or = 0.7. All included patients had an FEV1 which was irreversible to both inhaled terbutaline and prednisolone. Two hundred and ninety patients were randomized to receive either budesonide, 1200 mcg. daily for six months followed by 800 mcg. daily for 30 months, or placebo for 36 months. Patients had a mean age of 59 years and their mean FEV1 was 2.37 liters or 86% of predicted. Crude FEV1 declines were 41.8 ml/year in the placebo group and 45.1 ml/year in the budesonide group. Using a regression model in the intention-to-treat population, patients in the placebo group had an FEV1 decline of 49.1 ml/year in contrast to 46.0 ml/year in the budesonide group; the estimated difference 3.1 ml/year (95% confidence interval--12.8-19.0) was statistically insignificant, p = 0.70. No effect of inhaled budesonide was seen on respiratory symptoms or number of exacerbations. These findings question the role of longterm inhaled corticosteroids in the treatment of mild-moderate COPD.

Diagnostic and therapeutic process and prognosis in suspected lung cancer

Survival rates of patients with lung cancer are poor in Denmark and worse than in the other Nordic countries. The study focuses on the diagnostic process, the selection for operation, prognostic factors and outcome in lung cancer. The study comprised 467 consecutive patients with cancer-suspect lesions. In 40% of cases the diagnostic delay exceeded 30 days. Fibreoptic bronchoscopy and fine-needle biopsy (FNB) were the most important diagnostic tests, with approximately 90% accuracy in central and peripheral lesions. FNB of peripheral lesions diagnosed benign histology or small cell lung cancer (SCLC) in 16 patients, and due to that procedure a thoracotomy was prevented. Surgery was performed on 83 (33%) of 252 patients with non-small cell lung cancer. Three-year survival was 37% in all surgically treated patients and 64% after radical operation; 59% of the patients with stage I tumours were alive after three years, but none with stage IV at diagnosis. Among patients operated on, preoperated forced expiratory volume (FEV1) was related to survival rate. Survival rates were higher in women than in men with or without surgery. Of 43 patients with SCLC, 32 received chemotherapy, and half of these were alive after one year. Conclusions from the study were that diagnosis should be speeded up and that diagnostic FNB of peripheral lesions is of value for preventing unnecessary operations. Standard registration of tumour, node, metastasis (TNM) classification, resection, FEV1 (% of predicted) and gender could increase the validity of international comparisons.

A randomized clinical trial of alpha(1)-antitrypsin augmentation therapy

We have investigated whether restoration of the balance between neutrophil elastase and its inhibitor, alpha(1)-antitrypsin, can prevent the progression of pulmonary emphysema in patients with alpha(1)-antitrypsin deficiency. Twenty-six Danish and 30 Dutch ex-smokers with alpha(1)-antitrypsin deficiency of PI*ZZ phenotype and moderate emphysema (FEV(1) between 30% and 80% of predicted) participated in a double-blind trial of alpha(1)-antitrypsin augmentation therapy. The patients were randomized to either alpha(1)-antitrypsin (250 mg/kg) or albumin (625 mg/kg) infusions at 4-wk intervals for at least 3 yr. Self-administered spirometry performed every morning and evening at home showed no significant difference in decline of FEV(1) between treatment and placebo. Each year, the degree of emphysema was quantified by the 15th percentile point of the lung density histogram derived from computed tomography (CT). The loss of lung tissue measured by CT (mean +/- SEM) was 2.6 +/- 0.41 g/L/yr for placebo as compared with 1.5 +/- 0.41 g/L/yr for alpha(1)-antitrypsin infusion (p = 0.07). Power analysis showed that this protective effect would be significant in a similar trial with 130 patients. This is in contrast to calculations based on annual decline of FEV(1) showing that 550 patients would be needed to show a 50% reduction of annual decline. We conclude that lung density measurements by CT may facilitate future randomized clinical trials of investigational drugs for a disease in which little progress in therapy has been made in the past 30 yr.

Long-term effect of inhaled budesonide in mild and moderate chronic obstructive pulmonary disease: a randomised controlled trial

BACKGROUND

Little is known about the long-term efficacy of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD). We investigated the efficacy of inhaled budesonide on decline in lung function and respiratory symptoms in a 3-year placebo-controlled study of patients with COPD.

METHODS

We used a parallel-group, randomised, double-blind, placebo-controlled design in a singlecentre study, nested in a continuing epidemiological survey (the Copenhagen City Heart Study). Inclusion criteria were as follows: no asthma; a ratio of forced expiratory volume in 1 s (FEV1) and vital capacity of 0.7 or less; FEV1 which showed no response (<15% change) to 1 mg inhaled terbutaline or prednisolone 37.5 mg orally once daily for 10 days. 290 patients were randomly assigned budesonide, 800 microg plus 400 microg daily for 6 months followed by 400 microg twice daily for 30 months, or placebo for 36 months. The mean age of the participants was 59 years and the mean FEV1 2.37 L or 86% of predicted. The main outcome measure was rate of FEV1 decline. Analyses were by intention to treat.

FINDINGS

The crude rates of FEV1 decline were slightly smaller than expected (placebo group 41.8 mL per year, budesonide group 45.1 mL per year). The estimated rates of decline from the regression model did not differ significantly (49.1 mL vs 46.0 mL per year; difference 3.1 mL per year [95% CI -12.8 to 19.0]; p=0.7). Before the study, the minimum relevant difference was defined as 20 mL per year; this difference was outside the 95% CI. No effect of inhaled budesonide was seen on respiratory symptoms. 316 exacerbations occurred during the study period, 155 in the budesonide group and 161 in the placebo group. Treatment was well tolerated.

INTERPRETATION

Inhaled budesonide was of no clinical benefit in COPD patients recruited from the general population by screening. We question the role of long-term inhaled corticosteroids in the treatment of mild to moderate COPD.

Compliance with LTOT and consumption of mobile oxygen

The aim of the study was to investigate compliance with long-term oxygen therapy (LTOT), the consumption of mobile oxygen and factors that might influence on these measures. The study included 182 patients with LTOT and 125 patients answered a questionnaire on daily activities. Information on arterial gas tension, lung function, and diagnosis was obtained from the medical file. Data on oxygen systems and the actual usage of oxygen were obtained from the oxygen suppliers. Seventy-six per cent of the patients had a concentrator and 35% had both stationary and mobile oxygen. Good compliance (use of oxygen > 15 h day-1) was seen in 65%. Of the tested factors, only mobile oxygen had an influence on the effective usage. Outdoor activity was reported in 65% of the patients. Only 48% of these patients had mobile units, while 21% of the home-bound patients had mobile units. Of the patients with mobile oxygen, only 39% used their mobile unit > 2 h week-1. Poorer usage of stationary oxygen was observed in patients with outdoor activity (2.4 hours day-1 less). Although only 16 (13%) patients reported a usage less than 15 h day-1, the actual consumption was less than 15 h day-1 in 29%. In conclusion, patients on LTOT tended to overestimate their oxygen usage. Acceptable compliance was observed in 65% of the patients. Only mobile oxygen had a significant impact on the overall compliance. As more patients had outdoor activities than expected, and as these activities had a negative impact on the usage of stationary oxygen, more attention must be paid on detecting outdoor activities. However, as fewer than half of the patients with outdoor activity and mobile oxygen used their mobile systems, there is a need for measures to improve compliance with mobile oxygen. Using lists referring to the actual usage and discussing the usage with the patients may improve the compliance and cost-benefit.

Fibrous pleural tumour producing 171 litres of transudate

Localized fibrous tumours of the pleura (or localized benign mesothelioma) are rare, and in most cases, asymptomatic. This report describes a 48 yr old female with a right-sided fibrous pleural tumour, which produced 171 L of transudate before a correct diagnosis was reached. The tumour was surgically removed and the transudation stopped immediately.

[Therapeutic strategies for patients with tuberculosis]

OBJECTIVES

To determine the effectiveness of strategies used to promote adherence to anti-tuberculosis treatment.

SEARCH STRATEGY

MEDLINE 1966-1996 (August), Cochrane Collaboration Trials Registers (October 1996), LILACS 1982-1996 (September); reference lists in articles on adherence, contact with experts in the fields of TB and adherence research.

SELECTION CRITERIA

Randomised or pseudo-randomised controlled trials of interventions to promote compliance with curative or preventive chemotherapy for TB, with at least one measure of adherence.

DATA COLLECTION AND ANALYSIS

Data on study methods, participants, interventions and outcomes were collected for each study and methodological quality was assessed. Estimates of effect were assessed for categorical outcomes using the Peto odds ratio, with 95% confidence intervals.

MAIN RESULTS

Strategies found to be of benefit were reminder cards sent to defaulters, assistance of patients by lay health workers, monetary incentives offered to patients, and increased supervision of TB clinic staff. It is not possible to determine from current trials whether health education by itself leads to better adherence to treatment. Even though directly-observed therapy (DOT) is widely advocated as the most cost-effective means of ensuring completion of TB treatment, no completed trials could be found which confirm or refute this view.

CONCLUSIONS

RCT evidence exists that certain strategies improve adherence to anti-tuberculous therapy, and these should be adopted into clinical practice depending on their appropriateness to practice circumstances. Further innovations should be tested to find solutions that will be useful in low income countries. Randomised trials evaluating the independent effects of directly-observed therapy (DOT) are awaited.

[Multiresistant tuberculosis in Denmark 1993-1996]

Infections with multiresistant tubercle bacilli have also become a problem in the rich part of the world. The reasons are lack of compliance in patients with life style problems and ineffectiveness of the health system due to lack of fundings. During a four year period, 1993-1996 ten patients were seen in Denmark with tuberculosis due to multiresistant Mycobacterium tuberculosis. Nine were infected abroad, one developed MDR-TB during treatment in Denmark. It is possible to cure these patients, but it is expensive and takes a long time. In the future more cases created within Denmark are likely to be seen due to lack of funding for the tuberculosis programme and, depending on immigration, further cases created abroad are expected.

[Diagnostic procedure in patients with suspected lung cancer. Results of combined evaluation by thoracic surgery and pulmonary medicine specialists]

During the last 50 years, the 5-year survival of lung cancer patients has been unchanged at 5%. As the prognosis for patients with operable nonsmall cell lung cancer (NSCLC) is much better, the diagnostic examination of tumour suspicious lesions with secondary judgement of operability in NSCLC is an important subject. This study focuses on the diagnostic process. During the years 1991-1993, 467 consecutive patients with pulmonary tumour suspicious lesions were prospectively followed at the Department of Pulmonary Medicine and the Department of Thoracic Surgery, Bispebjerg Hospital. In 40% of the patients, the diagnostic delay was longer than 30 days. Fiberbronchoscopy and fine needle biopsy were the most important diagnostic tests with an accuracy of approx. 90% for both central and peripheral lesions. Benign lesions comprised 19% of all, while the prevalence of squamous cell carcinoma, adenocarcinoma, small-cell carcinoma and large-cell carcinoma was respectively 21%, 26%, 15% and 18% of the malignant infiltrates. Histological diagnosis was not achieved in 104 patients. Histological diagnosis was achieved in most patients, but the diagnostic process was slow. A faster diagnostic process is to be aimed for and can, hopefully, be achieved by accomplishing diagnostic standards as just proposed by the Danish Lung Cancer Group.

[Therapeutic and prognostic course in patients with suspected lung cancer. Results of combined thoracic surgery-pulmonary medicine evaluation]

Survival of patients with lung cancer is poor in Denmark and worse than in the other Nordic countries. The study focuses on the treatment, the selection for operation, prognostic factors and the prognosis in lung cancer. During the years 1991-1993, 467 consecutive patients with pulmonary tumour suspicious lesions were prospectively followed at the Departments of Pulmonary Medicine and Thoracic Surgery, Bispebjerg Hospital, Copenhagen. Operation was performed in 83 (33%) of 252 patients with non-small-cell lung cancer. More than 70% of the 169 non-operated patients were judged inoperable on the basis of a clinical examination and a chest x-ray. The initial estimation of operability, done by the chest physician, was able to predict 91% of the inoperable patients. Therapeutic delay (diagnosis-operation) was on average 26 days and 95% were operated within 60 days. Three-year survival for all the operated patients was 36%, while 62% were alive when they were judged radically operated. For stage I tumours, 51% were alive after three years, while all with stage IV tumours were dead. In the operated patients, lung function was positively related to survival (p = 0.013). Females had a better survival than males (p = 0.01 for operated, p = 0.02 for non-operated). Among 43 with small-cell lung cancer, 32 were treated with chemotherapy, and half of these were alive after one year. Preoperative histology in peripheral lesions is of value in preventing unnecessary operations without significant losses. Mediastinoscopy should be performed before operation. Registration of TNM stage and lung function should become standard in order to make comparison from country to country more valid.

Risk of malignant neoplasms in patients with pulmonary sarcoidosis

BACKGROUND

For over 20 years the association between sarcoidosis and malignancy, particularly lymphoma and lung cancer, has been disputed with misclassification being the major concern. The aim of the present study was to analyse the incidence of malignancies in a cohort of patients with sarcoidosis by linkage to a nationwide population based cancer register.

METHODS

The cohort comprised 254 patients followed for a median of 25 years until death, emigration, or 31 December 1992, whichever came first. The expected number of cancer cases was calculated using the annual age and sex specific cancer rates from the Danish Cancer Registry.

RESULTS

Thirty six cancers were registered, three of which were misclassified as sarcoidosis, leaving 33 cancers compared with 23 expected (standardised incidence ratio (SIR) = 1.4; 95% CI 0.99 to 2.0). Five lung cancers were observed compared with 2.5 expected, yielding an SIR of 2.0 (95% CI 0.7 to 4.7). There was no incidence of lymphoma and only one case of leukaemia. There was a significant excess number of pharyngeal cancers based on two cases (SIR = 15.4; 95% CI 1.7 to 56).

CONCLUSIONS

This study does not support the theory of an association between sarcoidosis and malignancy, and the main reason other studies have shown such an association is most likely to have been due to selection bias and misclassification.

Does alpha1-antitrypsin augmentation therapy slow the annual decline in FEV1 in patients with severe hereditary alpha1-antitrypsin deficiency? Wissenschaftliche Arbeitsgemeinschaft zur Therapie von Lungenerkrankungen (WATL) alpha1-AT study group

Patients with severe hereditary alpha1-antitrypsin deficiency (alpha1-ATD) face a high risk of developing emphysema at a young age. Intravenous augmentation therapy with purified human alpha1-antitrypsin (alpha1-AT) is now available. However, a controlled trial to show its efficacy has never been carried out. The aim of this study was to compare the decline in forced expiratory volume in one second (deltaFEV1) between Danish patients who had never received augmentation therapy and German patients treated with weekly infusion of alpha1-AT. From the files of the Danish alpha1-ATD register, 97 exsmokers, with a PiZ phenotype and for whom results of at least two lung function measurements with an interval of at least 1 yr were available, were identified. From a German group of patients treated with weekly infusions of alpha1-AT, 60 mg x kg(-1) body weight, 198 exsmokers, with biannual lung function measurements were identified. The deltaFEV1 was compared between the two treatment groups by random effects modelling. The deltaFEV1 in the treated group was significantly lower than in the untreated group, with annual declines of 53 mL x yr(-1) (95% confidence interval (95% CI) 48-58 mL x yr(-1)) and 75 mL x yr(-1) (95% CI 63-87 mL x yr(-1)), respectively (p=0.02). The two groups differed with respect to gender and initial FEV1% predicted. Gender did not have any influence on the deltaFEV1. Stratification by initial FEV1% pred showed a significant effect of the treatment only in the group of patients with an initial FEV1% pred of 31-65%, and deltaFEV1 was reduced by 21 mL x yr(-1). This nonrandomized study suggests that weekly infusion of human alpha1-antitrypsin in patients with moderately reduced lung function may slow the annual decline in forced expiratory volume in one second.

Multidrug-resistant tuberculosis in Denmark 1993-1995

SETTING

All bacteriologically confirmed new cases of tuberculosis and treatment relapses in Denmark are examined for drug resistance. In the years 1993-1995, nine cases of multidrug-resistant tuberculosis (MDR-TB), all acquired outside Denmark, were identified among 1354 cases of tuberculosis.

OBJECTIVE

To examine incidence, treatment and prognosis for patients with tuberculosis due to MDR Mycobacterium tuberculosis.

DESIGN

Retrospective evaluation of routine data.

RESULTS AND CONCLUSION

Multidrug resistance was present in less than one present of patients with tuberculosis. One patient died from tuberculosis without revision of treatment, and eight patients responded favourably to a regimen of pyrazinamide, streptomycin or amikacin, ofloxacin and cycloserine. In two patients, this regimen was supplemented with para-aminosalicylic acid and thiacetazone respectively. All patients needed prolonged hospitalization and had observed treatment. It is possible to cure such patients, but it is a lengthy and expensive process. It is expected that similar cases will be imported into the country and that they will occur within Denmark in the future.

Artificial pneumothorax by the Veress cannula: efficacy and safety

In 16 patients with pulmonary fibrosis, an artificial pneumothorax was introduced using the Veress cannula and the Saugman water manometer. Atmospheric air was introduced by fractionated insufflation to a total volume of 800 ml (median). The interpleural space was found on the first attempt, and in all cases, fractionated insufflation of atmospheric air was conducted while the intrapleural pressure was controlled with the water manometer. In one case, the procedure was stopped because of a rise in the pleural pressure after insufflation of only 50 ml air. This was undoubtedly caused by pleural adhesions not visible on chest X-ray. The main concern with air insufflation is air embolism but this was not observed clinically in any of the present cases. The patients in the present study all suffered from pulmonary fibrosis judged by clinical examination, chest X-ray and pulmonary function tests. Despite a diffusion capacity (DCO/VA) with a median value of 48% expected, the procedure was well tolerated. It has previously been shown that artificial pneumothorax preceding thoracoscopy is well tolerated due to hyperventilation, with an increase in respiratory frequency and a fall in arterial CO2 concentration (PaCO2), while pH and arterial O2 concentration (PO2) remain constant. This probably also explains the tolerance of the patients in this material. Insufflation of air as described here should be restricted to senior pulmonologists because it is an infrequent procedure. The present authors found the procedure to be uncomplicated and easy to perform with little discomfort to the patients.

[Diagnostic invasive procedures in the diagnosis of primary lung cancer. Diagnostic value and complications]

The invasive procedures used in the diagnosis of primary lung cancer are reviewed based on the literature. The choice of method should be related to its diagnostic accuracy, complications and cost. The chest x-ray provides the background for the further choice of diagnostic method. In central tumors, bronchoscopy meets the requirements and in peripheral lesions percutaneous transthoracic needle biopsy fulfils the conditions. In some centres, mediastinoscopy is preferred in all cases preoperatively, while others only perform this examination if a CT-scan shows mediastinal lymph nodes larger than 1 cm in diameter. If the latter procedure is followed, 10-30% of the patients will have lymph node metastases. Thoracoscopy is used when a pleural effusion remains undiagnosed after pleuracentesis. A considerable amount of patients will be shown to have pleural neoplastic spread even though cytological examination of the pleural fluid did not demonstrate malignant cells. The complication rates in all methods are low.

Patient-administered sequential spirometry in healthy volunteers and patients with alpha 1-antitrypsin deficiency

The launching of cheap, pocket-sized spirometers, with data storage capability, has made patient-administered sequential spirometry (PASS) an attractive method of monitoring ventilatory capacity. At present, little information is available on the quality of PASS, compared to laboratory spirometry. The aim of this study was to investigate whether patients could perform PASS without loss of reliability and reproducibility as compared with traditional laboratory spirometry. Ten healthy volunteers performed spirometry for 1 month and 10 emphysematous patients with alpha 1-antitrypsin deficiency (type PiZ) performed spirometry twice daily for up to 2 yr. To fulfil Good Clinical Practice criteria on full data documentation, a traditional direct recording spirometer, the Vitalograph R-model, was used. A decompression device was used for calibration and a 3.8% annual drift in volume registration was noted. This drift was largest for the first year. After training, all patients were able to perform unsupervised spirometry, producing technically correct forced expiratory curves. Reproducibility of FEV1 and FVC obtained by PASS was found to be as good as for laboratory spirometry. After adjustment for the diurnal variation, the residual variation of FEV1 was 2.5% (range 1.6-4.2%) for healthy volunteers and 5.6% (range 4.2-7.7%) for emphysematous patients. Forced vital capacity showed the same pattern. In conclusion, PASS is possible in highly motivated individuals without loss of reliability and reproducibility when compared to laboratory spirometry.

[Sarcoidosis. Dependence of life expectancy on lung function, respiratory symptoms, roentgenologic stage and age at diagnosis and significance of extrapulmonary manifestations]

Patients with intrathoracic sarcoidosis have - during prolonged observation (27 years) - the same survival as the general population. A higher mortality from sarcoidosis as well as from diseases not related to sarcoidosis is found among persons who at the time of diagnosis of sarcoidosis had respiratory symptoms and a low FEV1, TLC and Tiffeneau. Our knowledge of the prognosis for extrapulmonary manifestations and their influence on survival is sporadic. Symptoms from heart and CNS have in studies of selected patients been connected with an elevated mortality.

[Long-term prognosis of pulmonary sarcoidosis. 1. Prognostic value of lung function and symptoms]

A follow-up of 254 patients with intrathoracic sarcoidosis has been carried out after a median of 27 years from diagnosis. All patients could be traced. No excess mortality was found (80 deaths observed versus 66 expected). The causes of death were related to sarcoidosis in 41%. X-ray stage was related to survival with a significant excess mortality for stage 3. Early clearing of X-ray changes gave a favourable vital prognosis. Survival was related to lung function, especially forced expiratory volume in 1 second (FEV1) and total lung capacity (TLC). All deaths from sarcoidosis were seen among patients with respiratory symptoms at presentation. For sarcoidosis & sarcoidosis-related deaths (N = 33), presence of one or more of the respiratory symptoms increased the risk significantly. For overall mortality respiratory symptoms were also significant predictors; this was the case even after adjusting for age, sex, x-ray stage and lung function (FEV1 & TLC) at presentation. In conclusion, no excess mortality was observed after a median of 27 years follow-up. Lung function, respiratory symptoms and to some extent X-ray stage at time of diagnosis influenced long-term mortality in patients with intrathoracic sarcoidosis.

[Long-term prognosis of pulmonary sarcoidosis. 2. Cardiac sarcoidosis and other extrapulmonary manifestations]

Frequency and prognostic importance of extrapulmonary manifestations have been examined in 254 patients with intrathoracic sarcoidosis. A follow-up was carried out after a median of 27 years from diagnosis. All patients could be traced. Extrapulmonary manifestations were found in 119 patients (47%), mostly occurring within the first years after diagnosis of intrathoracic sarcoidosis; skin manifestations were most frequently seen. ECG-abnormalities were found in 35 patients (14%); in 17 cases in the form of sinus tachycardia. No excess mortality was found (80 deaths observed versus 66 expected). The causes of death were related to sarcoidosis in 41%. Only tachycardia was associated with an unfavourable prognosis and this association vanished after adjusting for decreased lung function. None of the other extrapulmonary manifestations were associated with an unfavourable vital prognosis. Erythema nodosum was of no prognostic significance concerning survival. In conclusion, extrapulmonary manifestations are frequent in patients with intrathoracic sarcoidosis but do not influence vital prognosis.

[Exposure to passive smoking of hospital employees and attitude to smoking at workplaces in 1992]

The aim of the study was to investigate exposure to passive smoking at work and the attitudes towards smoking at work among Danish hospital employees. It was carried out as a cross-sectional questionnaire study in collaboration with Bispebjerg Hospital and Tobaksskaderådet, to which 3154 (84%) employees responded. Results showed that 40% of the employees were exposed to passive smoking at work. Fifty-seven percent of the non-smokers and 14% of the smokers had symptoms associated with exposure to tobacco smoke. Every third employee complained of headache, coughing, eye irritation or breathlessness, and most were worried about the possible long term impact on health of passive smoking. In conclusion, surprisingly many employees are unwillingly exposed to the effects of passive smoking during working hours. Rules on smoking restriction are needed at the Danish health institutions to ensure the right to work in an environment free of tobacco smoke.

[Smoking habits among hospital employees in 1992]

The aim of the study was to investigate the smoking habits of employees of a Danish hospital on the basis of a questionnaire given in October 1992 and compare the results with two similar previous studies of smoking habits among the Danish population (1991) and physicians and nurses (1989). It was performed as a cross-sectional questionnaire study in collaboration with Bispebjerg Hospital and Tobaksskaderådet. Three thousand one hundred and fifty-four (84%) employees responded. The results showed that 37% of male and 33% of female employees were daily smokers. The prevalence of smokers and the distribution of smoking habits according to social class of the employees were equal to the general population except for male physicians and female nurses where the prevalence of smokers was lower than the corresponding social classes. Female doctors smoked as much as class I from the population study. Twenty-two percent of male and 17% of female employees smoked 15 cigarettes a day or more (heavy smokers). Eighty-seven percent of the smokers smoked at work, and one-third smoked more than five cigarettes on each workday. It is concluded that the smoking habits of Danish hospital employees correspond to the smoking habits of the general population. Rules on smoking restriction in Danish hospitals are needed. The smoking habits of female doctors calls for attention.

Electrocardiographic changes in patients with intrathoracic sarcoidosis: influence on prognosis

A retrospective evaluation of 244 electrocardiograms obtained at rest at time of diagnosis from a population of 254 patients with intrathoracic sarcoidosis was carried out. Thirty-five (14%) were abnormal. Sinus tachycardia was present in 17 (7%), the rest encompassing various degrees of right-sided bundle branch, atrioventricular first degree block, ventricular extrasystolia and ST-depression. At follow-up after a median time of 27 years we found a significantly higher mortality risk in the group with ECG-changes compared to those without. Excess mortality was increased when comparing patients with tachycardia to those without. However, when adjusted for FEV1, the risk of death was not significantly different between the two groups.

[Corticosteroids as adjuvants in the treatment of tuberculosis]

The anti-inflammatory effect of corticosteroids has been known for a long time, as have their use in treating diseases with an inflammatory component. Corticosteroids have also been used as an adjunct in treating tuberculosis. We have reviewed the literature to evaluate the rationale for our present treatment strategy. We find no reason for the use of Isoniazide in routine prophylaxis of Mantoux positive or former tuberculosis patients who are treated with corticosteroids. Corticosteroids could be added when treating severe pulmonary tuberculosis. When treating tuberculous pericarditis and severe tuberculous pleurisy, corticosteroids should be used as an adjunct to the antituberculous chemotherapy. No controlled studies have been carried out in patients with tuberculous meningitis, but retrospective reports have shown a lower mortality in patients treated with steroids. In children with stenosis and atelectasis because of endobronchial obstruction due to tuberculosis in mediastinal lymphnodes, corticosteroids should be added to the usual antituberculous regimen.

[Should the presence of Mycobacterium tuberculosis be demonstrated before the treatment of patients with suspected pulmonary tuberculosis?]

In Denmark, treatment of tuberculosis is generally only recommended if the diagnosis is confirmed bacteriologically, which may cause a delay in treatment. We investigated the duration of the treatment delay, and if the delay would cause any serious health problems for the individual or risk of contact infections by a retrospective examination of 324 cases of pulmonary tuberculosis. The mean treatment delay was longer in older age groups. Regarding death due to delay, we found no risk for the patients who are not weakened by old age or another disease. Only 11 (3.6%) above the age of ten years were treated without bacteriological confirmation (1% for Danes). The infection risk from the smear negative, but culture positive patients was minimal, as only one subject was definitely infected from a smear negative subject. In conclusion, we find the epidemiologic and individual risk sufficiently low to continue our rather restrictive treatment policy.

[Extrapulmonary tuberculosis in Denmark. A review of the incidence, localization and therapy]

In Denmark, just under 20% of tuberculosis (TB) cases amongst Danes and 25-30% of cases amongst people of foreign nationalities are made up of isolated extrapulmonary (EP) TB. The incidence among Danes is falling, whereas an increasing amount of EP TB cases are found among foreigners due to continued immigration, and these now constitute 50% of all cases of EP TB. EP TB is found among older Danes and younger foreigners. The HIV/AIDS epidemic has not had any effect on the incidence of TB and EP TB in Denmark. EP TB is most frequently found in lymph nodes and the urogenital system. Since the disease is rare, it may be overlooked; it should be considered as a differential diagnosis in unresolved cases, particularly in immigrants from countries with a high prevalence of TB. Treatment is as for pulmonary TB, namely "four drug" therapy for six months. Surgical intervention is rarely required. Supplementation with oral steroids may be useful in very special cases.

Respiratory symptoms at presentation and long-term vital prognosis in patients with pulmonary sarcoidosis

A follow-up of 254 patients with pulmonary sarcoidosis has been carried out after a median of 27 years from the diagnostic admission. Information on respiratory symptoms at entry was available in 80% of the patients. Cough and chronic bronchitis was present in 39% and 37%, respectively, whereas 41% reported breathlessness when walking and 25% reported breathlessness when undressing. In total, 51% had at least one respiratory symptom. All patients could be traced; eighty patients (31.5%) died during follow-up. A total of 17 died of sarcoidosis and a further 16 died of sarcoidosis-related diseases. All deaths from sarcoidosis were seen among patients with respiratory symptoms at presentation. For sarcoidosis and sarcoidosis-related deaths (N = 33), presence of one or more of the respiratory symptoms increased the risk significantly. For overall mortality, respiratory symptoms were also significant predictors; this was the case even after adjusting for age, sex, x-ray stage and lung function (FEV1 & TLC) at presentation. In conclusion, respiratory symptoms at the time of diagnosis are independently related to vital prognosis in pulmonary sarcoidosis.

Corticosteroids and tuberculosis

Common for all older studies is the use of less potent anti-tuberculosis chemotherapy as compared with the present. The results of these studies cannot without reservation be used in the present setting. The newer, prospective, randomized placebo-controlled trials include rather few patients and their number is limited. The results must be interpreted carefully. There is no reason to give prophylactic isoniazide treatment to Mantoux-positive patients or patients with earlier tuberculosis who start treatment with corticosteroids. If allergic reactions to one of the antituberculous drugs emerge during therapy, the treatment can, if necessary, be continued if corticosteroids are added. Pericardial tuberculosis and atelectasis in children with endobronchial tuberculosis should be treated with corticosteroids, as can pleural disease with prolonged fever and exudation. Cases of severe pulmonary tuberculosis may be treated with supplementary steroids. The effect seems modest. Patients with tuberculous meningitis, stages II and III seem to benefit from corticosteroid-treatment.

Electrical impedance measured changes in thoracic fluid content during thoracentesis

In patients (seven females and 11 males) with pleural effusion due to pulmonary (n = 13) or cardiac disease (n = 5) the change in baseline transthoracic impedance (Z0) was measured by electrical impedance (BoMed's NCCOM-3, 70 kHz) during thoracentesis. Data were obtained before and after withdrawal of each 500 ml, and at the end of the thoracentesis. We found a close linear correlation (r = 0.97) between changes in Z0 and the volume of aspirated pleural effusion (y = 0.415.x+0.093). The variability of the estimated thoracic fluid volumes was analysed with a plot of the residuals from the regression line, and we found that changes in thoracic fluid volume estimated by impedance technique would be within +/- 302 ml (= 2 SD). However, the absolute value of Z0 before thoracentesis could not differentiate the group of patients with pleural effusion from normal subjects (n = 28).

[Lung cancer in 1993]

The incidence of lung cancer is increasing in Denmark, especially among women. Today, smoking is the most important risk factor for developing this disease. A review of the literature shows that the prognosis is still very poor regardless of histologic findings. Chemotherapy prolongs life moderately among patients with small cell carcinoma (SCLC). Furthermore, total resection of non small cell cancer (NSCLC) may improve survival over several years. In patients investigated for surgery, cancer dissemination should be determined, using radiologic and invasive investigations. A detailed spirometric investigation should also be performed, as lung function is a predictor of postoperative survival. Other kinds of treatment are available, and good coordination regarding information, supportive arrangements and symptomatic treatment is important.

The prognosis of extrapulmonary sarcoidosis

The frequency and functional prognosis of some major extrapulmonary manifestations (EPM) are reviewed using the literature and our own data. The influence of EPM on the vital prognosis is studied. Our knowledge of functional and vital prognosis in EPM is scanty.