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David Gillespie,1,2 Nick Francis,3 Haroon Ahmed,4 Kerenza Hood,2 Carl Llor,5 Patrick White,6 Emma Thomas-Jones,2 Helen Stanton,2 Bernadette Sewell,7 Rhiannon Phillips,8 Gurudutt Naik,4 Hasse Melbye,9 Rachel Lowe,2 Nigel Kirby,2 Ann Cochrane,10 Janine Bates,2 Mohammed Fasihul Alam,11 Christopher Butler1 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UK; 2Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, Wales, UK; 3Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK; 4Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK; 5University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain; 6School of Population Health and Environmental Sciences, Kings College London, London, England, UK; 7Swansea Centre for Health Economics, Swansea University, Swansea, Wales, UK; 8Cardiff School of Sport & Health Science, Cardiff Metropolitan University, Cardiff, Wales, UK; 9General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 10York Trials Unit, Department of Health Sciences, University of York, York, England, UK; 11Department of Public Health, College of Health Sciences, QU-Health, Qatar University, Doha, QatarCorrespondence: David Gillespie, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, England, OX2 6GG, UK, Email david.gillespie@phc.ox.ac.ukBackground: It has been demonstrated that antibiotic prescribing for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) can be safely reduced in primary care when general practitioners have access to C-reactive protein (CRP) rapid testing.Aim: To investigate the factors associated with post-consultation COPD health status in patients presenting with AECOPD in this setting.Design and Setting: A cohort study of patients enrolled in a randomised controlled trial. Patients aged 40+ years with a clinical diagnosis of COPD who presented in primary care across England and Wales with an AECOPD were included.Methods: Participants were contacted for follow-up at one- and two-weeks by phone and attended the practice four weeks after the index consultation. The outcome of interest was the Clinical COPD Questionnaire (CCQ) score. Multivariable multilevel linear regression models fitted to examine the factors associated with COPD health status in the four-weeks following consultation for an AECOPD.Results: A total of 649 patients were included, with 1947 CCQ total scores analysed. Post-consultation CCQ total scores were significantly higher (worse) in participants with diabetes (adjusted mean difference [AMD]=0.26; 95% confidence interval (CI) 0.08– 0.45), obese patients compared to those with normal body mass index (AMD = 0.25, 95% CI 0.07– 0.43), and those who were prescribed oral antibiotics in the prior 12 months (AMD = 0.26; 95% CI 0.11– 0.41), but only the two latter associations remained after adjusting for other sociodemographic variables.Conclusion: COPD health status was worse in the four weeks following primary care consultation for AECOPD in patients with obesity and those prescribed oral antibiotics in the preceding year.Keywords: chronic obstructive, health status, Primary Health Care, pulmonary disease, symptom exacerbation

Sarah Cook,1– 3 Anne Elise Eggen,1 Laila A Hopstock,1 Sofia Malyutina,4,5 Marina Shapkina,4 Alexander V Kudryavtsev,1,6 Hasse Melbye,1,* Jennifer K Quint3,* 1Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway; 2Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; 3National Heart and Lung Institute, Imperial College London, London, UK; 4Research Institute of Internal and Preventive Medicine, Branch of Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russian Federation; 5Novosibirsk State Medical University, Russian Ministry of Health, Novosibirsk, Russian Federation; 6Northern State Medical University, Arkhangelsk, Russian Federation*These authors contributed equally to this workCorrespondence: Sarah Cook Email sarah.cook@lshtm.ac.ukBackground: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Despite a high prevalence of smoking and respiratory symptoms, two recent population-based studies in Russia found a relatively low prevalence of obstructive lung function. Here, we investigated the prevalence of both obstructive lung disease and respiratory symptoms in a population-based study conducted in two Russian cities and compared the findings with a similar study from Norway conducted in the same time period.Methods: The study population was a sub-sample of participants aged 40– 69 years participating in the Know Your Heart (KYH) study in Russia in 2015– 18 (n=1883) and in the 7th survey of the Tromsø Study (n=5271) carried out in Norway in 2015– 16 (Tromsø 7) who participated in spirometry examinations. The main outcome was obstructive lung function (FEV1/FVC ratio< lower limit of normal on pre-bronchodilator spirometry examination) with and without respiratory symptoms (chronic cough and breathlessness). In those with obstructive lung function, awareness (known diagnosis) and management (use of medications, smoking cessation) were compared.Results: The age-standardized prevalence of obstructive lung function was similar among men in both studies (KYH 11.0% vs Tromsø 7 9.8%, p=0.21) and higher in the Norwegian (9.4%) than Russian (6.8%) women (p=0.006). In contrast, the prevalence of obstructive lung function plus respiratory symptoms was higher in Russian men (KYH 8.3% vs Tromsø 7 4.7%, p< 0.001) but similar in women (KYH 5.9% vs Tromsø 7 6.4%, p=0.18). There was a much higher prevalence of respiratory symptoms in Russian than Norwegian participants of both sexes regardless of presence of obstructive lung function.Conclusion: The prevalence of respiratory symptoms was strikingly high among Russian participants but this was not explained by a higher burden of obstructive lung function on spirometry testing in comparison with Norwegian participants. Further work is needed to understand the reasons and health implications of this high prevalence of cough and breathlessness.Keywords: COPD, Russian Federation, Norway, respiratory symptoms

Nick A Francis,1 David Gillespie,2 Mandy Wootton,3 Patrick White,4 Janine Bates,2 Jennifer Richards,3 Hasse Melbye,5 Kerenza Hood,2 Christopher C Butler6 1Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK; 2Centre for Trials Research, Cardiff University, Cardiff, Wales, UK; 3Specialist Antimicrobial Chemotherapy Unit, Microbiology Cardiff, Public Health Wales, Cardiff, Wales, UK; 4School of Population Health and Environmental Sciences, King’s College London, London, England, UK; 5Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 6Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UKCorrespondence: Nick A FrancisPrimary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UKEmail nick.francis@soton.ac.ukIntroduction: Identifying predictors of bacterial and viral pathogens in sputum from patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) may help direct management.Methods: We used data from a trial evaluating a C-reactive protein (CRP) point of care guided approach to managing COPD exacerbations in primary care. We used regression analyses to identify baseline clinical features, including CRP value in those randomized to testing, associated with bacterial, viral or mixed infections, defined by the presence of bacterial and viral pathogens in sputum, detected by culture or polymerase chain reaction (PCR), respectively.Results: Of 386 participants with baseline sputum samples, 79 (20.5%), 123 (31.9%), and 91 (23.6%) had bacterial, viral/atypical, and mixed bacterial/viral/atypical pathogens identified, respectively. Increasing sputum purulence assessed by color chart was associated with increased odds of finding bacterial and mixed (bacterial and viral/atypical) pathogens in sputum (area under the ROC curve (AUROC) for bacterial pathogens =0.739 (95% CI: 0.670, 0.808)). Elevated CRP was associated with increased odds of finding bacterial pathogens and mixed pathogens but did not significantly increase the AUROC for predicting bacterial pathogens over sputum color alone (AUROC for combination of sputum color and CRP = 0.776 (95% CI: 0.708, 0.843), p for comparison of models = 0.053). We found no association between the presence of sputum pathogens and other clinical or demographic features.Conclusion: Sputum purulence was the best predictor of sputum bacterial pathogens and mixed bacterial viral/atypical pathogens in patients with COPD exacerbations in our study. Elevated CRP was associated with bacterial pathogens but did not add to the predictive value of sputum purulence.Keywords: COPD, exacerbation, infection, bacteria, sputum, primary care

Hasse Melbye,1 Jon Helgeland,2 Øystein Karlstad,3 Inger Ariansen,3 Arnulf Langhammer,4 Torbjørn Wisløff,1 Per Nafstad,3 Wenche Nystad3 1General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 2Norwegian Institute of Public Health, Division of Health Services, Oslo, Norway; 3Norwegian Institute of Public Health, Department of Non-Communicable Diseases, Oslo, Norway; 4Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, NorwayCorrespondence: Hasse MelbyeGeneral Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø 9037, NorwayTel +4795213200Email hasse.melbye@uit.noBackground: Less smoking should lead to fewer COPD cases. We aimed at estimating time trends in the prevalence and burden of COPD in Norway from 2001 to 2017.Methods: We used pre-bronchodilator spirometry and other health data from persons aged 40– 84 years in three surveys of the Tromsø Study, 2001– 2002, 2007– 2008 and 2015– 2016. We applied spirometry lower limits of normal (LLN) according to Global Lung Initiative 2012. Age-standardized prevalence was determined. We defined COPD as FEV1/FVC1 Results: In the Tromsø Study, the age-standardized prevalence of daily smoking dropped from 29.9% to 14.1% among women and from 31.4% to 12.8% among men (P< 0.0001). The age-standardized prevalence of COPD dropped from 7.6% to 5.6% among women (P=0.2) and from 7.3% to 5.6% among men (P=0.003) and of moderate to severe COPD from 5.2% to 2.7% among women (P=0.0003) and from 4.6% to 3.2% among men (P=0.0008). Among men, the yearly age-standardized prevalence of hospitalization due to COPD exacerbation decreased from 3.6 to 3.0 per 1000 inhabitants aged 40– 84 years (P

Johanna Laue,1 Hasse Melbye,1 Peder A Halvorsen,1 Elena A Andreeva,2 Maciek Godycki-Cwirko,3 Anja Wollny,4 Nick A Francis,5 Mark Spigt,6 Kenny Kung,7 Mette Bech Risør1 1Department of Community Medicine, General Practice Research Unit, University of Tromsø – The Arctic University of Norway, Tromsø, Norway; 2Department of Family Medicine, Northern State Medical University, Arkhangelsk, Russia; 3Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland; 4Institute of General Practice, University Medical Center Rostock, Rostock, Germany; 5Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK; 6CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands; 7The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Purpose: To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.Methods: Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.Results: Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities.Conclusion: Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations. Keywords: COPD exacerbation, antibiotics, oral corticosteroids, hospitalization, primary care, decision-making

Hasse Melbye,1 Salwan Al-ani,1 Mark Spigt1,2 1General Practice Research Unit, Department of Community Medicine, UIT The Arctic University of Norway, Tromsø, Norway; 2Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, the Netherlands Background: When assessing patients with exacerbation of asthma or COPD, it may be useful to know the drop in forced expiratory volume in 1 second (FEV1) compared with stable state, in particular when considering treatment with oral corticosteroids. The objective of the study was to identify indicators of drop in FEV1 during exacerbations. Methods: In this prospective multicenter study from primary care, patients diagnosed with asthma or COPD were examined at stable state and during exacerbations the following year. Symptoms, chest findings, and pulse oximetry were recorded, and spirometry was performed. A fixed drop in FEV1 (10% and ≥200 mL) and percentage change in FEV1 were outcomes when possible indicators were evaluated. Results: Three hundred and eighty patients attended baseline examination, and 88 with a subsequent exacerbation were included in the analysis. Thirty (34%) had a significant drop in FEV1 (10% and 200 mL). Increased wheezing was the only symptom associated with this drop with a likelihood ratio of 6.4 (95% confidence interval, 1.9–21.7). Crackles and any new ausculta­tion finding were also associated with a significant drop in FEV1, as was a ≥2% drop in oxygen saturation (SpO2) to ≤92% in the subgroup diagnosed with COPD. Very bothersome wheezing and severe decrease in SpO2 were also very strong predictors of change in FEV1 in linear regression adjusted for age, gender, and baseline FEV1% predicted. Conclusion: Increased wheezing, as experienced by the patient, and a decreased SpO2 value strongly indicated a drop in lung function during asthma and COPD exacerbations and should probably be taken into account when treatment with oral corticosteroids is considered. Keywords: bronchial obstruction, systemic corticosteroids, diagnostic tests, primary care

Signe Elise Danielsen,1 Maja-Lisa Løchen,1 Astri Medbø,1 Monica Linea Vold,2 Hasse Melbye3 1Department of Community Medicine, The Arctic University of Norway, 2Department of Respiratory Medicine, University Hospital of North Norway, 3General Practice Research Unit, Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway Background: Patients with COPD have had a lower tendency to quit smoking compared to patients with coronary heart disease (CHD). We wanted to investigate if this is still true in a Norwegian population.Methods: Our data came from the fifth and sixth Tromsø surveys, which took place in 2001–2002 and 2007–2008. The predictors of smoking cessation were evaluated in a cohort of 4,497 participants who had stated their smoking status in both surveys.Results: Of the 4,497 subjects in the cohort, 1,150 (25.6%) reported daily smoking in Tromsø 5. In Tromsø 6, 428 had quit (37.2%). A new diagnosis of obstructive lung disease (asthma or COPD) and CHD were both associated with increased quitting rates, 50.6% (P=0.01) and 52.1% (P=0.02), respectively. In multivariable logistic regression analysis with smoking cessation as outcome, the odds ratios (ORs) of a new diagnosis of obstructive lung disease and of CHD were 1.7 (1.1–2.7) and 1.7 (1.0–2.9), respectively. Male sex had an OR of 1.4 (1.1–1.8) compared to women in the multivariable model, whereas the ORs of an educational length of 13–16 years and ≥17 years compared to shorter education were 1.6 (1.1–2.2) and 2.5 (1.5–4.1), respectively.Conclusion: The general trend of smoking cessation in the population was confirmed. Increased rates of smoking cessation were associated with a new diagnosis of heart or lung disease, and obstructive lung disease was just as strongly linked to smoking cessation as was CHD. This should encourage the pursuit of early diagnosis of COPD.Keywords: smoking cessation, cohort study, COPD, asthma, coronary heart disease

Monica Linea Vold,1,3 Ulf Aasebø,1,2 Hasse Melbye3 1Department of Respiratory Medicine, University Hospital of North Norway, 2Department of Clinical Medicine, 3Department of Community Medicine, University of Tromsø, Tromsø, Norway Background: Worsening of pulmonary diseases is associated with a decrease in oxygen saturation (SpO2). Such a decrease in SpO2 and associated factors has not been previously evaluated in a general adult population. Aim: We sought to describe SpO2 in a sample of adults, at baseline and after 6.3 years, to determine whether factors predicting low SpO2 in a cross-sectional study were also associated with a decrease in SpO2 in this cohort. Methods: As part of the Tromsø Study, 2,822 participants were examined with pulse oximetry in Tromsø 5 (2001/2002) and Tromsø 6 (2007/2008). Low SpO2 by pulse oximetry was defined as an SpO2 ≤95%, and SpO2 decrease was defined as a ≥2% decrease from baseline to below 96%. Results: A total of 139 (4.9%) subjects had a decrease in SpO2. Forced expiratory volume in 1 second (FEV1)

Katja Oshaug, Peder A Halvorsen, Hasse Melbye General Practice Research Unit, University of Tromsø, Tromsø, Norway Background: Although proven to be associated with bronchial obstruction, chest signs are not listed among cues that should prompt spirometry in the early diagnosis of chronic obstructive pulmonary disease (COPD) in established guidelines. Aims: We aimed to explore how chest findings add to respiratory symptoms and a history of smoking in the diagnosis of COPD. Methods: In a cross-sectional study, patients aged 40 years or older, previously diagnosed with either asthma or COPD in primary care, answered questionnaires and underwent physical chest examination and spirometry. Results: Among the 375 patients included, 39.7% had forced expiratory volume in 1 second/forced vital capacity

Hasse Melbye1, Elin Drivenes1, Lene G Dalbak2, Tone Leinan1, Svein Høegh-Henrichsen2, Anders Østrem21General Practice Research Unit, Department of Community Medicine, University of Tromsø, 2General Practice Research Unit, Department of Health and Society, University of Oslo, NorwayAims: To describe symptoms and lung function in patients registered with asthma or chronic obstructive pulmonary disease (COPD) in primary care and to examine how spirometry findings fit with general practitioners’ (GPs) diagnoses.Methods: Patients aged ≥40 years with a diagnosis of asthma or COPD registered in the electronic medical record during the previous 5 years were recruited at seven GP offices in Norway in 2009–2010. Registered diagnosis, spirometry results, comorbidity, and reported symptoms were compared.Results: Among 376 patients, 62% were women. Based on Global Initiative for Chronic Obstructive Lung Diseases criteria, a spirometry diagnosis of COPD could be made in 68.1% of the patients with a previous COPD diagnosis and in 17.1% of those diagnosed with asthma only (P < 0.001). The κ agreement between last clinical diagnosis of COPD and COPD based on spirometry was 0.50. A restrictive spirometry pattern was found in 19.4% and more frequently in patients diagnosed with both asthma and COPD (23.9%) than in patients diagnosed with COPD only (6.8%, P = 0.003).Conclusion: The ability of GPs to differentiate between asthma and COPD seems to have considerably improved during the last decade, probably due to the dissemination of spirometry and guidelines for COPD diagnosis. A diagnosis of COPD that cannot be confirmed by spirometry represents a challenge in clinical practice, in particular when a restrictive pattern on spirometry is found.Keywords: asthma, COPD, diagnosis, primary care

Background. Chronic obstructive pulmonary disease (COPD) is an under-diagnosed condition. General practitioners meet and examine the patients in early stages of the disease, and symptoms represent the starting point of the diagnostic process. Aim. To evaluate the diagnostic value of respiratory symptoms in the diagnosis of airflow limitation. Methods. Spirometry was performed in a cross-sectional population-based study of 3954 subjects 60 years and older (54.5% women), who also filled in a questionnaire on symptoms. Results. The prevalence of any airflow limitation was 15.5% and 20.8%, in women and men, respectively, whereas the corresponding prevalence of severe airflow limitation (FEV1<50% predicted) was 3.4% and 4.9%. The positive predictive value of chronic cough with phlegm for any airflow limitation was 37.0% in women and 40.4% in men, and 17.3% and 14.2%, respectively, for severe airflow limitation. Wheezing was a symptom which persisted despite smoking cessation, whereas coughing was considerably less common in ex-smokers than in current smokers. Wheezing, dyspnoea on unhurried walking, dyspnoea on quick walking, and coughing with phlegm were independent predictors of any airflow limitation, OR 1.5, 1.8, 1.4, and 1.6 respectively. (The ORs for severe airflow limitation were 2.4, 2.4, 2.4, and 1.6 respectively.) To be an ex-smoker (OR 2.4) or a current smoker (OR 5.8) was of greater importance. In never- and ex-smokers the chance of having airflow limitation was almost doubled when having two or more, compared with one, of the three symptoms: wheezing, dyspnoea, and coughing with phlegm. Ex-smokers reporting two symptoms had a similar risk of airflow limitation to current smokers not reporting any symptoms. Conclusion. Respiratory symptoms are valuable predictors of airflow limitation and should be emphasized when selecting patients for spirometry. [ABSTRACT FROM AUTHOR]

C-reactive protein (CRP) value is usually elevated in patients with group A streptococcal (GAS) pharyngitis. The aim of this study was to describe the daily changes in CRP value after start of antibiotic treatment and to compare these changes with commonly used outcome measures in GAS pharyngitis. Eleven adult patients with sore throat and confirmed GAS infection were examined daily by specially trained medical students who registered symptoms and signs, performed a CRP test (NycoCard) and measured body temperature. At baseline, the mean CRP value was 100.3 mg/L (SD 80.9). The mean reduction after one day was 34.1% (SD 15.3), after two days 60.1% (SD 14.1) and after three days 75.3% (SD 12.5). Corresponding reductions were found for sign and symptom scores and temperature, but the standard deviations for these measures were much larger. The CRP value was significantly associated with both the symptom score and the number of days after start of treatment (p < 0.01), but not with the sign score and body temperature, as shown by multiple regression analysis for repeated measurements. The CRP test seems to be a valid test for monitoring the clinical course in GAS pharyngitis. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To study the effect of an educational intervention on general practitioners' (GPs') ability to diagnose bronchial obstruction after clinical examination. DESIGN: Based on physical chest examination 11 GPs assessed the degree of bronchial obstruction by estimating the patient's predicted forced expiratory volume in one second (FEV1%). Half way in the study the GPs were taught new knowledge on associations between lung sounds and bronchial airflow. The agreements between estimated and measured FEV1% predicted before and after this educational intervention were compared. SETTING: 11 GPs in five health centres in northern Norway took part. PATIENTS: 351 adult patients were included in phase 1, and 341 in phase 2. MAIN OUTCOME MEASURES: Estimated and measured FEV1% predicted were compared in subgroups of patients according to clinical findings in phase 1 and 2. The effect of the intervention on the doctors' weighting of various chest signs could thus be evaluated. Kappa agreement and correlation between estimated and measured FEV1% predicted in both phases were determined. RESULTS: The agreement between estimated and measured FEV1% predicted increased from Kw (weighted Kappa) = 0.33 in phase 1 to Kw = 0.43 in phase 2 (95% confidence interval 0.35-0.52). The GPs laid more relevant emphasis on rhonchi in their estimates after the educational intervention, while too much weight was laid on uncertain chest findings in phase 2. CONCLUSION: The study shows a potential for better use of physical chest examination in the diagnosis of bronchial obstruction. [ABSTRACT FROM AUTHOR]

Objectives - 1. To find out whether a stay in local general practitioner hospitals (GP hospitals) prior to an emergency admission to higher level hospitals aggravated or prolonged the course of the disease, or contributed to permanent health loss for some patients. 2. To detect cases where a transitory stay in a GP hospital might have been favourable. Design - A retrospective expert panel study based on records from GP hospitals and general hospitals. The included patients had participated in a previous prospective study of consecutive admissions to GP hospitals during 8 weeks. Setting - Fifteen out of 16 GP hospitals in Finnmark county, Norway. Subjects - Seventy-three patients transferred to higher level hospitals from a total of 395 admitted to GP hospitals. Main outcome measures - Three outcome categories were considered for each patient: 'possible permanent health loss', 'possible significantly prolonged or aggravated disease course', and 'possible favourable effect on the disease course'. Results - There was agreement about the possibility of negative effects in two patients (2.7%), while a possible favourable influence was ascribed to six cases (8.2%). Conclusion - Negative health effects due to transitory stays in GP hospitals are uncommon and moderate, and balanced by benefits, particularly with regard to early access to life saving treatment for critically ill patients. [ABSTRACT FROM AUTHOR]

Abstract Background Respiratory tract infections (RTIs) may be more severe in those with asthma or COPD and these patients are more frequently in need of health care. The aim of the study was to describe the frequency of RTI symptoms in a general adult population and how care-seeking is associated with the presence of obstructive lung disease. Methods Cross-sectional data including spirometry and self-reported chronic diseases were collected among middle-aged and elderly subjects in the Tromsø population survey (Tromsø 6). Self- reported RTI symptoms, consultations and antibiotic use were the main outcome variables. Possible predictors of RTI symptoms were evaluated by multivariable logistic regression. Results Of the 6414 subjects included, 798 (12.4%) reported RTI symptoms in the previous week. RTI symptoms were reported less frequently by subjects aged 75 years or above, than by those younger than 55 years (OR 0.5). Winter season (OR 1.28), current smoking (OR 1.60), low self-rated health (OR 1.26) and moderate to severe bronchial obstruction (OR 1.51), were also statistically significant independent predictors of RTI symptoms, but these variables did not predict RTI symptoms that had started within the previous seven days. Among subjects with RTI symptoms, 5.1% also reported a consultation with a doctor. In those with bronchial obstruction by spirometry, who did not report asthma or COPD, this frequency was 2.4%. Antibiotic treatment was reported by 7.4% of the participants, among whom one third had consulted a doctor. Antibiotics were taken more frequently when asthma or COPD was reported (13.7%), but not in subjects with bronchial obstruction who did not report these diseases (7.2%). Conclusions RTI symptoms seldom led to consultation with a doctor and not even in subjects with obstructive lung disease. This was in particular the case in subjects who did not know about their obstructive lung disease. Strategies for early diagnosis of COPD and providing health care to subjects with such disease cannot rely on their doctor visits due to respiratory symptoms.