To Örebro University

Whether COPD should be diagnosed using the lower limit of normal (LLN) or a fixed FEV1/FVC ratio <0.70 (FR) is debated. We compared symptom and disease burden in COPD patients with FEV₁/FVC below both thresholds (FR + /LLN + ) versus those between them (FR + /LLN-). This cohort study included 572 COPD patients from primary and secondary care in the central Swedish regions of Dalarna, Gävleborg, and Uppsala. FR + /LLN + COPD patients with FEV1 ≥ 60% predicted (n = 194) was compared to FR + /LLN- COPD patients (n = 85) in order to have similar FEV1 levels in both groups. The symptom burden was assessed using the modified British Medical Research Council scale of dyspnoea (mMRC), the COPD Assessment Test (CAT), and the Clinical COPD Questionnaire (CCQ). The disease burden was assessed by exacerbations and hospital admissions over the subsequent three years. The 279 studied patients (57% females) had a mean age of 68.2 years and a mean FEV1% predicted of 73.0%. The FR + /LLN+ group had comparable clinical characteristics to the FR + /LLN- group regarding FEV1% predicted (72.5 vs 74.2%), use of inhaled medicines (76.3 vs 76.5%), and previous exacerbations (23.2 vs 18.8%), all p-values > 0.05. Moreover, comparable prevalence of exacerbations and hospital admissions were found during the subsequent three years (31.7 vs 37.7%, and 4.8 vs 2.6%, respectively, all p-values > 0.05). Symptom burden was comparable for mMRC and CCQ, but the FR + /LLN- group had a higher CAT score than the FR + /LLN+ group (10.6 vs 12.6, p = 0.038), a finding also confirmed in adjusted analyses. FR + /LLN+ and FR + /LLN- COPD patients had relatively comparable symptom and disease burden, suggesting that not meeting the LLN criteria does not indicate a milder disease in clinically diagnosed COPD with comparable FEV1.

Systemic inflammation is important in many medical conditions. Activation markers of inflammatory cells can be quantified, but are less studied. Therefore, we studied individual characteristics and diseases in relation to neutrophil gelatinase-associated lipocalin (NGAL) and myeloperoxidase (MPO), both for neutrophils, eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP), and mast cell tryptase. Spirometry and serum biomarkers were assessed in 498 participants (252 males) aged >= 40 years from the Uppsala center of the population-based Burden of Obstructive Lung Disease study. Higher MPO, NGAL and EDN levels related to heart disease. Higher ECP and EDN levels were both related to asthma while higher EDN related to male sex and atopy. Higher tryptase levels were found in subjects with obesity, chronic airflow limitation (CAL), or hypertension. In multivariate analyses, subjects with heart disease had 22.1% (95% confidence interval 4.1%, 43.3%) higher MPO, 19.3% (7.8%, 31.9%) higher NGAL, and 23.2% (3.0%, 47.3%) higher EDN than subjects without heart disease. The association between CAL and tryptase was not consistent after adjustment for age and BMI as continuous variables. The higher EDN levels in heart disease is a novel finding that require further studies to elucidate the clinical importance.

Background: In 2017, Burgel and colleagues developed an algorithm to identify clinical phenotypes that predict mortality in COPD. Our study aimed to 1) investigate whether the phenotypes can predict acute exacerbations of COPD (AECOPD) and 2) validate their ability to predict mortality.

Methods: The Tools Identifying Exacerbations (TIE) cohort study recruited participants with spirometry-verified COPD from primary and secondary care in three Swedish regions. Participants were allocated to phenotypes 1-5 using the previously developed algorithm containing comorbidities (heart failure, coronary artery disease, hypertension, and/or diabetes), dyspnoea, age, forced expiratory volume in 1 s (FEV1), and body mass index (BMI). Data on AECOPDs and deaths during the three-year follow-up were collected from medical records and analysed with Cox proportional hazards regressions. Harrel's C-index was used to assess the models' discriminative ability.

Results: Among the 566 participants, 59 % were female, and the mean +/- SD FEV1 was 57 +/- 18 % of predicted. The hazard ratios (HRs) [95 % CI] for time to AECOPD were 3.04 [1.93-4.79], 2.38 [1.54-3.66], and 3.52 [1.73-7.15] in phenotypes 1, 2, and 4 compared with 5 (C-index = 0.61). When AECOPD history was used to predict future AECOPD the C-index was 0.65. The HRs [95 % CI] for mortality were 8.24 [1.93-35.3], 6.26 [1.40-28.0], and 16.7 [3.25-86.3] in phenotypes 1, 3, and 4 compared to 5 (C-index = 0.68). For AECOPD history, the C-index was 0.55.

Conclusion: Clinical COPD phenotypes based on comorbidities, dyspnoea, age, FEV1, and BMI predict AECOPDs but do not perform better than AECOPD history. However, they perform better than AECOPD history in predicting mortality.

Aim: Identifying patients at risk for acute exacerbations of COPD (AECOPDs) is crucial to improve outcomes. We aimed to evaluate the ability of three health status instruments to predict AECOPDs in subjects with and without previous AECOPDs.

Methods: A prospective cohort study of COPD patients from primary and outpatient care in three Swedish regions. AECOPDs were retrieved from medical records. The modified Medical Research Council Dyspnoea scale (mMRC), the COPD Assessment Test (CAT), and the Clinical COPD Questionnaire (CCQ) were evaluated. Thresholds for AECOPD prediction were estimated using receiver operator characteristic (ROC) curves. Predictive values were assessed using crude and multivariable Cox regression models.

Results: We included 572 patients (59% women, age 69 +/- 8 years, FEV1 57 +/- 18% of predicted) in 2014-2016. All three instruments independently predicted future AECOPDs within three years (adjusted hazard ratio [aHR] 1.5-1.8) using thresholds mMRC >= 2, CAT >= 13, and CCQ >= 1.6. Patients without prior-year AECOPDs but high scores on all instruments had a similar AECOPD risk as those with prior AECOPDs but scores below threshold (aHR 2.4-2.5). Among patients with >= 1 AECOPD the year before inclusion and at least one of the three health status instruments above threshold, the aHR for future AECOPD during the study period ranged from 4.6 to 5.7.

Conclusions: mMRC, CAT, and CCQ were independently associated with AECOPDs over the following three-year period. The health status instruments provided additional predictive value for future AECOPDS in patients both with and without previous AECOPDs.

Abbreviations: aHR: Adjusted Hazard Ratio; AECOPD: Acute Exacerbations of Chronic Obstructive Pulmonary Disease; AUC: Area Under Curve; BMI: Body Mass Index; CAT: COPD Assessment Test; CCQ: Clinical COPD Questionnaire; COPD: Chronic Obstructive Pulmonary Disease; DAG: Directed Acyclic Graphs; FEV1: Forced Expiratory Volume in 1 Second; FVC: Forced Vital Capacity; GOLD: Global Initiative for Obstructive Lung Disease; HR: Hazard Ratio; IHD: Ischaemic Heart Disease; ICS: Inhaled Corticosteroids; IQR: Interquartile Range; mMRC: Modified Medical Research Council Dyspnoea Scale; ROC: Receiver Operator Characteristic; SD: Standard Deviation; TIE: Tools for Identifying Exacerbations

PURPOSE: The study aims to improve the knowledge on the associations between comorbidities, symptom burden, inflammatory biomarkers and lung function deterioration in chronic obstructive pulmonary disease (COPD). MATERIALS AND

METHODS: Of the 572 COPD subjects initially included in the 2014-2016 Tools for Identifying Exacerbations in COPD study in Sweden, 228 had lung function data at the 7-year follow-up. Symptom burden was assessed by the modified British Medical Research Council scale of dyspnoea (mMRC), the COPD Assessment Test (CAT) and the Clinical COPD Questionnaire (CCQ). Relative lung function decline was assessed as decline in forced expiratory volume in one second (FEV1) from baseline/year.

RESULTS: Lower baseline symptom burden (mMRC, CAT and CCQ), higher FEV1 and FEV1% predicted, higher forced vital capacity (FVC) and having atrial fibrillation were associated with larger absolute FEV1 decline. Associations were found for having atrial fibrillation at baseline and larger relative FEV1 decline (Beta = -1.60, p = 0.005). Increased symptom burden (value at follow-up minus value at baseline), assessed by mMRC, CAT and CCQ, was positively associated with both larger absolute FEV1 decline (mMRC: Beta = 6.4, p = 0.009; CAT: Beta = 1.63, p = 0.002; CCQ: Beta = 10.6, p < 0.001) and larger relative FEV1 decline (mMRC: Beta = 0.44, p = 0.003; CAT: Beta = 0.13, p < 0.002; CCQ: Beta = 0.82, p < 0.001). Moreover, an increase in C-reactive protein (CRP) levels at follow-up was related to larger, both absolute and relative, FEV1 decline (Beta = 1.14, p = 0.031 and Beta = 0.07, p = 0.019, respectively).

CONCLUSIONS: Changes in systemic inflammation and symptom burden between two visits were positively associated with a 7-year lung function decline.

Aims: The objective was to compare anxiety, depression, and quality of life (QoL) in individuals living with type 1 (T1D) and type 2 (T2D) diabetes with matched controls during the second wave of the COVID-19 pandemic.

Methods: Via randomization, individuals living with diabetes T1D (n = 203) and T2D (n = 413), were identified during February-July 2021 through health-care registers. Population controls (n = 282) were matched for age, gender, and residential area. Questionnaires included self-assessment of anxiety, depression, QoL, and demographics in relation to SARS-CoV-2 exposure. Blood was collected through home-capillary sampling, and SARS-CoV-2 Nucleocapsid (NCP) and Spike antibodies (SC2_S1) were determined by multiplex Antibody Detection by Agglutination-PCR (ADAP) assays.

Results: Younger age and health issues were related to anxiety, depression, and QoL, with no differences between the study groups. Female gender was associated with anxiety, while obesity was associated with lower QoL. The SARS-CoV-2 NCP seroprevalence was higher in T1D (8.9 %) compared to T2D (3.9 %) and controls (4.0 %), while the SARS-CoV-2 SC2_S1 seroprevalence was higher for controls (25.5 %) compared to T1D (16.8 %) and T2D (14.0 %).

Conclusions: A higher SARS-CoV-2 infection rate in T1D may be explained by younger age and higher employment rate, and the associated increased risk for viral exposure.

Purpose: At the outbreak of the COVID-19 pandemic, health care was at the centre of the crisis. New demands made existing organizational practices and services obsolete. Primary health care had a great deal of responsibility for COVID-19-related care. The pandemic demanded effective leadership to manage the new difficulties. This paper aims to explore experiences and perceptions of managers in primary health care in relation to their efforts to manage the COVID-19 crisis in their everyday work.

Design/methodology/approach: The authors used a qualitative approach based on 14 semi-structured interviews with managers in primary health care from four regions in Sweden. The interviews were conducted during September to December 2020. Data were analysed using conventional qualitative content analysis.

Findings: Data analysis yielded three categories: lonely in decision-making; stretched to the limit; and proud to have coped. The participants felt lonely in their decision-making, and they were stretched to the limit of their own and the organization's capacity. The psychosocial working conditions in primary care worsened considerably during the pandemic because demands on leaders increased while their ability to control the work situation decreased. However, they also expressed pride that they and their employees had managed the situation by being flexible and having a common focus.

Originality/value: Looking ahead and using lessons learnt, and apart from making wise decisions under pressure, an important implication for primary health-care leaders is to not underestimate the power of acknowledging the virtues of humanity and justice during a crisis. Continuing professional education for leaders focusing on crisis leadership could help prepare leaders for future crises.

BACKGROUND: Swimming-induced pulmonary edema (SIPE) has been reported to subside within 24-48 hours, but comprehensive follow-up studies on symptom duration and long-term effects are missing.

RESEARCH QUESTION: What is the symptom duration, recurrence, and long-term effects of SIPE?

STUDY DESIGN AND METHODS: A follow-up study was conducted based on 165 cases of SIPE from Sweden's largest open water swimming event with 26,125 individuals participating during 2017-2019. Data on patient characteristics, clinical findings and symptoms were collected upon admission. Telephone interviews at 10 days and 30 months were performed to explore symptom duration, recurrence of SIPE symptoms, need of medical evaluation and long-term effects of self-assessed general health and physical activity level.

RESULTS: Follow-up at 10 days was performed for 132 cases and at 30 months for 152 cases. Most of the cases were women and mean age was 48 years. At the 10-day follow-up, symptom duration >2 days after the swimming race were reported by 38%. The most common symptoms were dyspnea and cough. In patients followed for 30 months, recurrence of respiratory symptoms during open water swimming was reported by 28%. In multivariable logistic regression, asthma was independently associated with both symptom duration >2 days and recurrence of SIPE symptoms (p =0.045 and p =0.022 respectively). Most participants reported equal or improved general health (93%) and physical activity level (85%) after experiencing SIPE, but 58% had not swum in open water since the event.

INTERPRETATION: The present large cohort study challenges the established hallmark of SIPE symptom duration of <48 hours, while SIPE recurrence was in the previously reported range. At 30 months, most patients reported unchanged self-assessed general health and physical activity level. These findings add to our understanding of the course of SIPE and can provide evidence-based information to swimmers and health care professionals.