ILSA 2017 in Tromsø : proceedings from the 42nd annual conference of the International Lung Sound Association

Edited by Hasse Medbye, med bidrag fra flere.<brThe usefulness of lung auscultation is changing. It depends on how well practitioners understand the generation of sounds. It also depends on their knowledge on how lung sounds are associated with lung and heart diseases, as well as with other factors such as ageing and smoking habits. In clinical practice, practitioners need to give sufficient attention to lung auscultation, and they should use the same terminology, or at least understand each other’s use of terms. Technological innovations lead to an extended use of lung auscultation. Continuous monitoring of lung sounds is now possible, and computers can extract more information from the complex lung sounds than human hearing is capable of. Learning how to carry out lung auscultation and to interpret the sounds are essential skills in the education of doctors and other health professionals. Thus, new computer based learning tools for the study of recorded sounds will be helpful. In this conference there will be focus on all these determinants for efficient lung auscultation. In addition to free oral presentations, we have three symposia: on computerized analysis based on machine learning, on diagnostics, and on learning lung sounds, including the psychology of hearing. The symposia include extended presentations from invited speakers. The 42nd conference is the first in history arranged by a research unit for general practice. Primary care doctors are probably the group of health professionals that put the greatest emphasis on lung auscultation in their clinical work. Many patients with chest symptoms consult without a known diagnosis, and several studies have shown that general practitioners pay attention to crackles and wheezes when making decisions, for instance when antibiotics are prescribed to coughing patients. In hospital, the diagnosis of lung diseases is more strongly influenced by technologies such as radiography and blood gas analysis. Since lung auscultation holds a strong position in the work of primary care doctors, I think it is just timely, that the 42nd ILSA conference is hosted by General Practice Research Unit in Tromsø. I hope all participants will find presentations of importance, and that the stay in Tromsø will be enjoyable

GP utilisation by education level among adults with COPD or asthma: A cross-sectional register-based study

Published version. Source at http://doi.org/10.1038/npjpcrm.2016.27. License CC BY 4.0.There is a marked socioeconomic gradient in the prevalence of chronic obstructive pulmonary disease (COPD) and asthma, but a large proportion of patients remain undiagnosed. It is a challenge for general practitioners (GPs) to both identify patients and contribute to equity and high quality in services delivered. The aim of this study was to identify patients with COPD and asthma diagnoses recorded by GPs and explore their utilisation of GP services by education level. This was a cross-sectional, national, register-based study from Norwegian general practice in the period 2009–2011. Based on claims from GPs, the number of patients aged ⩾40 years with a diagnosis of COPD or asthma and their GP services utilisation were estimated and linked to the national education database. Multivariate Poisson and logistic regression models were used to explore the variations in GP utilisation. In the population aged ⩾40 years, 2.8% had COPD and 3.8% had asthma according to GPs’ diagnoses. COPD was four times more prevalent in patients with basic education than higher education; this increase was ⩽80% for asthma. Consultation rates were 12% higher (P<0.001) for COPD and 25% higher (P<0.001) for asthma in patients with low versus high education in the age group of 40–59 years after adjusting for comorbidity, and patient and GP characteristics. Approximately 25% of COPD patients and 20% of asthma patients had ⩾1 spirometry test in general practice in 2011, with no significant education differences in adjusted models. The higher consultation rate in lower-education groups indicates that GPs contribute to fair distribution of healthcare

Predictors of ICS/LABA prescribing in COPD patients: A study from general practice

BACKGROUND: A combination of inhaled corticosteroid and long-acting beta(2) agonist (ICS/LABA) is used frequently to treat chronic obstructive pulmonary disease (COPD) patients. The aim of the study was to determine whether prescribing ICS/LABA to COPD patients in primary care in 2009/10 was within the GOLD guidelines and whether and to what degree patient characteristics were associated with prescription of these drugs by GPs. METHODS: This was a cross-sectional study in seven Norwegian GP practices. Patients registered with a diagnosis of asthma or COPD in the previous five years were included. RESULTS: Among the 376 patients included in the analysis, 149 patients had COPD, defined as a post-bronchodilator FEV(1)/FVC <0.7 and 55.6% of these patients were treated with ICS/LABA. The rate of prescribing was significantly higher in the COPD patients also diagnosed with asthma than in those with COPD as the only diagnosis, 66.7%, and 39.0%, respectively (P = 0.001). The prescribing rate in the latter subgroup would have been 18.6% if the 2007 GOLD guidelines had been followed. One or more exacerbations in the previous year was the strongest predictor of ICS/LABA prescribing in the COPD patients who were not registered with a concomitant diagnosis of asthma (OR 3.2, 95% CI 1.0–10.0) but this association was limited to the patients with severe disease (FEV(1)% predicted <50) (OR 13.5, 95% CI 1.8–101.1). Cardiovascular disease was associated with decreased ICS/LABA prescribing (OR 0.4, 95% CI 0.2–0.8) in the COPD group. A Kappa coefficient of 0.32 was found between the actual prescribing rate and that recommended in the 2007 GOLD guidelines. CONCLUSIONS: Overprescribing of ICS/LABA for the COPD patients was shown. Previous exacerbation was a strong predictor of ICS/LABA prescribing only in patients with severe COPD. Because of the low emphasis on previous exacerbation when prescribing for COPD patients with mild to moderate disease, the actual prescribing rate agreed more closely with the GOLD guidelines from 2007 than with those published in 2011. Cardiovascular disease was associated with decreased prescribing, indicating that GPs adjust the treatment in cases with multimorbidity

Self-treatment of acute exacerbations of chronic obstructive pulmonary disease requires more than symptom recognition – a qualitative study of COPD patients’ perspectives on self-treatment

Source at http://dx.doi.org/10.1186/s12875-017-0582-8 Background: Self-treatment of acute exacerbations of COPD with antibiotics and/or oral corticosteroids has emerged as a promising strategy to reduce hospitalization rates, mortality and health costs. However, for reasons little understood, the effect of self-treatment, particularly when not part of comprehensive self-management programs, remains unclear. Therefore, this study aims to get insight into the patients’ perspective on self-treatment of acute exacerbations of COPD, focusing specifically on how patients decide for the right moment to start treatment with antibiotics and/or oral corticosteroids, what they consider important when making this decision and aspects which might interfere with successful implementation. Methods: We interviewed 19 patients with chronic obstructive pulmonary disease using qualitative semi-structured interviews, and applied thematic analysis for data analysis. Results: Patients were well equipped with experiential knowledge to recognize and promptly respond to worsening COPD symptoms. Worries regarding potential adverse effects of antibiotics and oral corticosteroids played an important role in the decision to start treatment and could result in hesitation to start treatment. Although selftreatment represented a practical and appreciated option for some patients with predictable symptom patterns and treatment effect, all patients favoured assistance from a medical professional when their perceived competence reached its limits. However, a feeling of obligation to succeed with self-treatment or distrust in their doctors or the health care system could keep patients from timely help seeking. Conclusion: COPD patients regard self-treatment of exacerbations with antibiotics and/or oral corticosteroids as a valuable alternative. How they engage in self-treatment depends on their concerns regarding the medications’ adverse effects as well as on their understanding of and preferences for self-treatment as a means of health care. Caregivers should address these perspectives in a collaborative approach when offering COPD patients the opportunity for self-treatment of exacerbations

Convolutional neural network for breathing phase detection in lung sounds

We applied deep learning to create an algorithm for breathing phase detection in lung sound recordings, and we compared the breathing phases detected by the algorithm and manually annotated by two experienced lung sound researchers. Our algorithm uses a convolutional neural network with spectrograms as the features, removing the need to specify features explicitly. We trained and evaluated the algorithm using three subsets that are larger than previously seen in the literature. We evaluated the performance of the method using two methods. First, discrete count of agreed breathing phases (using 50% overlap between a pair of boxes), shows a mean agreement with lung sound experts of 97% for inspiration and 87% for expiration. Second, the fraction of time of agreement (in seconds) gives higher pseudo-kappa values for inspiration (0.73-0.88) than expiration (0.63-0.84), showing an average sensitivity of 97% and an average specificity of 84%. With both evaluation methods, the agreement between the annotators and the algorithm shows human level performance for the algorithm. The developed algorithm is valid for detecting breathing phases in lung sound recordings

Symptoms of respiratory tract infection and associated care-seeking in subjects with and without obstructive lung disease; The Tromso Study: Tromso 6.

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. Cross-sectional data including spirometry and self-reported chronic diseases were collected among middle-aged and elderly subjects in the Tromso population survey (Tromso 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. 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 %). 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 subject 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

Predictors of exacerbations of asthma and COPD during one year in primary care

Aims. To investigate the incidence of asthma and chronic obstructive pulmonary disease (COPD) exacerbations in primary care during one year and to identify risk factors for such events. Methods. The study was carried out at seven general practice offices in Norway. Patients aged 40 years or more registered with a diagnosis of asthma and/or COPD the previous 5 years were included. After a baseline examination, the participants consulted their GP during exacerbations for the following 12 months. A questionnaire on exacerbations during the follow-up year was distributed to all. Univariable and multivariable logistic regression was performed to determine predictors of future exacerbations. Results. Three hundred and eighty patients attended the baseline examination and complete follow-up data were retrieved from 340 patients. COPD as defined by forced expiratory volume in the first second of expiration/forced vital capacity (FEV1 /FVC) < 0.7, was found in 132 (38.8%) patients. One hundred and fifty-nine patients (46.8%) experienced one exacerbation or more and 101 (29.7%) two exacerbations or more. Patients who had an exacerbation treated with antibiotics or systemic corticosteroids or leading to hospitalization the year before baseline (N = 88) had the highest risk of getting an exacerbation during the subsequent year (odds ratio 9.2), whether the FEV1 /FVC was below 0.7 or not. Increased risk of future exacerbations was also related to age ≥ 65 years and limitations in social activities, but not to the FEV1 . Conclusions. The study confirms that previous exacerbations strongly predict future exacerbations in patients with COPD or asthma. Identification and a closer follow-up of patients at risk of such events could promote earlier treatment when necessary and prevent a rapid deterioration of their condition

Innleggelser ved forverring av astma og kols

Bakgrunn. Behandling av astma- og kolsforverringer bør ofte igangsettes raskt. Akuttinnleggelse i sykehus kan være nødvendig. Vi ønsket å kartlegge hva slags legekontakter pasientene hadde hatt og hva slags behandling de fikk før de ble innlagt med en slik forverring. Materiale og metode. Et spørreskjema ble delt ut til pasienter over 18 år som var innlagt for astma- eller kolsforverring ved Helgelandssykehuset og ved Universitetssykehuset Nord-Norge i Tromsø fra januar 2010 til januar 2011. Pasientene svarte blant annet på spørsmål om varighet av forverringen, om legekontakter og om medisinsk behandling før innleggelsen. Resultater. Svar fra 100 av 122 forespurte pasienter ble analysert. Median sykdomsvarighet ved første legekontakt var fire dager. 52 av pasientene hadde kontaktet fastlegen først, 40 kontaktet først legevakt og åtte tok direkte kontakt med sykehuset. Første kontakt med lege førte til innleggelse hos 56 pasienter, 21 (40 %) av dem som kontaktet fastlegen og 26 (70 %) av dem som kontaktet legevaktlege. 41 pasienter ble innlagt uten å være blitt klinisk undersøkt av innleggende lege samme dag, 32 etter telefonkonsultasjon med fastlege eller legevaktlege. Innleggelse uten klinisk undersøkelse forekom hyppigere hos dem som var over 70 år og hos dem som hadde vært innlagt tidligere. Fortolkning. Pasienter med astmaeller kolsforverring blir ofte direkte innlagt etter telefonkonsultasjon med fastlege eller legevaktlege

Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review

Objective The objective of this study was to determine the diagnostic accuracy in detecting valvular heart disease (VHD) by heart auscultation, performed by medical doctors. Design/methods A systematic literature search for diagnostic studies comparing heart auscultation to echocardiography or angiography, to evaluate VHD in adults, was performed in MEDLINE (1947–November 2021) and EMBASE (1947–November 2021). Two reviewers screened all references by title and abstract, to select studies to be included. Disagreements were resolved by consensus meetings. Reference lists of included studies were also screened. The results are presented as a narrative synthesis, and risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. Main outcome measures Sensitivity, specificity and likelihood ratios (LRs). Results We found 23 articles meeting the inclusion criteria. Auscultation was compared with full echocardiography in 15 of the articles; pulsed Doppler was used as reference standard in 2 articles, while aortography and ventriculography was used in 5 articles. One article used point-of-care ultrasound. The articles were published from year 1967 to 2021. Sensitivity of auscultation ranged from 30% to 100%, and specificity ranged from 28% to 100%. LRs ranged from 1.35 to 26. Most of the included studies used cardiologists or internal medicine residents or specialists as auscultators, whereas two used general practitioners and two studied several different auscultators. Conclusion Sensitivity, specificity and LRs of auscultation varied considerably across the different studies. There is a sparsity of data from general practice, where auscultation of the heart is usually one of the main methods for detecting VHD. Based on this review, the diagnostic utility of auscultation is unclear and medical doctors should not rely too much on auscultation alone. More research is needed on how auscultation, together with other clinical findings and history, can be used to distinguish patients with VHD