Eva Lindberg

Risk factors for rehospitalisation in COPD: role of health status, anxiety and depression

The aim of the present study was to analyse the risk of rehospitalisation in patients with chronic obstructive pulmonary disease and associated risk factors. This prospective study included 416 patients from a university hospital in each of the five Nordic countries. Data included demographic information, spirometry, comorbidity and 12 month follow-up for 406 patients. The hospital anxiety and depression scale and St. Georges Respiratory Questionnaire (SGRQ) were applied to all patients. The number of patients that had a re-admission within 12 months was 246 (60.6%). Patients that had a re-admission had lower lung function and health status. A low forced expiratory volume in one second (FEV1) and health status were independent predictors for re-admission. Hazard ratio (HR; 95% CI) was 0.82 (0.74–0.90) per 10% increase of the predicted FEV1 and 1.06 (1.02–1.10) per 4 units increase in total SGRQ score. The risk of rehospitalisation was also increased in subjects with anxiety (HR 1.76 (1.16–2.68)) and in subjects with low health status (total SGRQ score >60 units). When comparing the different subscales in the SGRQ, the closest relation between the risk of rehospitalisation was seen with the activity scale (HR 1.07 (1.03–1.11) per 4 unit increase). In patients with low health status, anxiety is an important risk factor for rehospitalisation. This may be important for patient treatment and warrants further studies.

Sleep-disordered breathing and glucose metabolism in hypertensive men: a population-based study.

Abstract. Elmasry A, Lindberg E, Berne C, Janson C, Gislason T, Awad Tageldin M, Boman G (Uppsala University, Akademiska Sjukhuset, Uppsala, Sweden; Ain Shams University, Cairo, Egypt; and Vifilsstadir Hospital, Gardabaer, Iceland). Sleep‐disordered breathing and glucose metabolism in hypertensive men: a population‐based study. J Intern Med 2001; 249: 153–161.

The role of habitual snoring and obesity in the development of diabetes: a 10-year follow-up study in a male population.

Abstract. Elmasry A, Janson C, Lindberg E, Gislason T, Tageldin MA, Boman G (Uppsala University, Akademiska Sjukhuset, Uppsala, Sweden; Ain Shams University, Cairo, Egypt; and Viffilsstadir Hospital, Gardabær, Iceland). The role of habitual snoring and obesity in the development of diabetes: a 10‐year follow‐up study in a male population. J Intern Med 2000; 248: 13–20.

Increased mortality among sleepy snorers: a prospective population based study

BACKGROUND The long term health consequences of snoring and sleep apnoea syndrome are still uncertain. This study was conducted to assess the mortality risk associated with snoring and excessive daytime sleepiness (EDS), the two main symptoms of sleep apnoea syndrome, in men. METHODS In 1984 a sample of 3100 men aged 30–69 responded to a postal questionnaire including questions about snoring, EDS, and the prevalence of various diseases (response rate 77.1%). Mortality data for the period 1985–1995 were collected for the complete sample. RESULTS During the 10 year follow up period 213 men died, 88 of cardiovascular diseases. Compared with subjects with no snoring or EDS in 1984, men with isolated snoring or EDS displayed no significantly increased mortality. The combination of snoring and EDS was associated with a significant increase in mortality. However, the relative rates decreased with increasing age, and in men aged 60 and above no effect on mortality was found. Men below the age of 60 with both snoring and EDS had an age adjusted total death rate which was 2.7 times higher than men with no snoring or EDS (95% CI 1.6 to 4.5). The corresponding age adjusted hazard ratio for cardiovascular mortality was 2.9 (95% CI 1.3 to 6.7) for subjects with both snoring and EDS. Further adjustment for body mass index and reported hypertension, cardiac disease, and diabetes reduced the relative mortality risk associated with the combination of snoring and EDS to 2.2 (95% CI 1.3 to 3.8) and the relative risk of cardiovascular mortality to 2.0 (95% CI 0.8 to 4.7). CONCLUSION Snoring without EDS does not appear to carry an increased risk of mortality. The combination of snoring and EDS appears to be associated with an increased mortality rate, but the effects seems to be age dependent. The increased mortality is partly explained by an association between “snoring and EDS” and cardiovascular disease.

Obesity and nocturnal gastro-oesophageal reflux are related to onset of asthma and respiratory symptoms

Several studies have identified obesity as a risk factor for asthma in both children and adults. An increased prevalence of asthma in subjects with gastro-oesophageal reflux (GOR) and obstructive sleep apnoea syndrome has also been reported. The aim of this investigation was to study obesity, nocturnal GOR and snoring as independent risk factors for onset of asthma and respiratory symptoms in a Nordic population. In a 5–10 yr follow-up study of the European Community Respiratory Health Survey in Iceland, Norway, Denmark, Sweden and Estonia, a postal questionnaire was sent to previous respondents. A total of 16,191 participants responded to the questionnaire. Reported onset of asthma, wheeze and night-time symptoms as well as nocturnal GOR and habitual snoring increased in prevalence along with the increase in body mass index (BMI). After adjusting for nocturnal GOR, habitual snoring and other confounders, obesity (BMI >30) remained significantly related to the onset of asthma, wheeze and night-time symptoms. Nocturnal GOR was independently related to the onset of asthma and in addition, both nocturnal GOR and habitual snoring were independently related to onset of wheeze and night-time symptoms. This study adds evidence to an independent relationship between obesity, nocturnal gastro-oesophageal reflux and habitual snoring and the onset of asthma and respiratory symptoms in adults.

Snoring and Sleep Apnea A Study of Evolution and Consequences in a Male Population

Obstructive sleep apnea syndrome (OSAS) is characterized by snoring, repeated apneas during sleep and excessive daytime sleepiness (EDS). The available data suggest that there is a relationship between OSAS and cardiovascular morbidity and mortality, but the results diverge.In 1984, 3,201 men aged 30-69 answered a questionnaire on snoring, sleep disturbances and somatic diseases. A subsample of the men who reported symptoms related to OSAS were also investigated using whole-night polysomnography in 1985.Of the survivors in 1994, almost 90% participated in this 10-year follow-up and answered an identical questionnaire as well as questions about smoking, alcohol and physical activity. In both 1984 and 1994, the prevalence of snoring increased until age 50-60 and then decreased. At all ages, weight gain was an independent risk factor for developing habitual snoring. In men below age 50 at baseline, persistent smoking and a high BMI in 1984 were also significantly associated with the development of snoring.Among the men aged 30-59 in 1984, those who reported habitual snoring in both 1984 and 1994 ran a significantly increased risk of developing hypertension during the 10-year period (adjusted odds ratio 2.6, 95% CI 1.5-4.5). Among the subjects aged 50-69, no association was found between snoring and hypertension.Mortality data for the 10-year period were collected for the complete sample. Compared with subjects with no snoring or EDS, men with both snoring and EDS experienced a significant increase in overall mortality as well as cardiovascular mortality. However, the relative rates decreased with increasing age and, in men aged 60 and over, no effect on mortality was found. Isolated snoring or EDS did not influence mortality at any age.Of the men studied using polysomnography in 1985, 38 (70% of the survivors) were reinvestigated using polysomnography in 1995. In the group as a whole, a significant progression of the sleep disorder with time was found. Increasing EDS was strongly related to a deterioration in the sleep disorder.In conclusion, age strongly influences the prevalence of snoring in men, but the relationship is not linear. Risk factors for developing snoring differ with age and the cardiovascular health consequences appear to be most hazardous in the case of younger men. Sleepy male snorers are a high-risk group for developing OSAS, regardless of the results of the sleep recordings at baseline.

Obstructive sleep apnea is a common disorder in the population—a review on the epidemiology of sleep apnea

The prevalence of obstructive sleep apnea (OSA) defined at an apnea-hypopnea index (AHI) ≥5 was a mean of 22% (range, 9-37%) in men and 17% (range, 4-50%) in women in eleven published epidemiological studies published between 1993 and 2013. OSA with excessive daytime sleepiness occurred in 6% (range, 3-18%) of men and in 4% (range, 1-17%) of women. The prevalence increased with time and OSA was reported in 37% of men and in 50% of women in studies from 2008 and 2013 respectively. OSA is more prevalent in men than in women and increases with age and obesity. Smoking and alcohol consumption are also suggested as risk factors, but the results are conflicting. Excessive daytime sleepiness is suggested as the most important symptom of OSA, but only a fraction of subjects with AHI >5 report daytime sleepiness and one study did not find any relationship between daytime sleepiness and sleep apnea in women. Stroke and hypertension and coronary artery disease are associated with sleep apnea. Cross-sectional studies indicate an association between OSA and diabetes mellitus. Patients younger than 70 years run an increased risk of early death if they suffer from OSA. It is concluded that OSA is highly prevalent in the population. It is related to age and obesity. Only a part of subjects with OSA in the population have symptoms of daytime sleepiness. The prevalence of OSA has increased in epidemiological studies over time. Differences and the increase in prevalence of sleep apnea are probably due to different diagnostic equipment, definitions, study design and characteristics of included subjects including effects of the obesity epidemic. Cardiovascular disease, especially stroke is related to OSA, and subjects under the age of 70 run an increased risk of early death if they suffer from OSA.

Mortality in COPD patients discharged from hospital: the role of treatment and co-morbidity

BackgroundThe aim of this study was to analyse mortality and associated risk factors, with special emphasis on health status, medications and co-morbidity, in patients with chronic obstructive pulmonary disease (COPD) that had been hospitalized for acute exacerbation.MethodsThis prospective study included 416 patients from each of the five Nordic countries that were followed for 24 months. The St. Georges Respiratory Questionnaire (SGRQ) was administered. Information on treatment and co-morbidity was obtained.ResultsDuring the follow-up 122 (29.3%) of the 416 patients died. Patients with diabetes had an increased mortality rate [HR = 2.25 (1.28–3.95)]. Other risk factors were advanced age, low FEV1 and lower health status. Patients treated with inhaled corticosteroids and/or long-acting beta-2-agonists had a lower risk of death than patients using neither of these types of treatment.ConclusionMortality was high after COPD admission, with older age, decreased lung function, lower health status and diabetes the most important risk factors. Treatment with inhaled corticosteroids and long-acting bronchodilators may be associated with lower mortality in patients with COPD.

Snoring and hypertension - a 10-year follow-up

In many cross-sectional studies an association has been found between snoring and hypertension. However, differing results have been obtained when confounding factors have been taken into account. To establish whether snoring is a risk factor for developing hypertension, a population-based, prospective survey was performed. In 1984 and 1994, 2,668 males, aged 30-69 yrs at baseline, answered questionnaires concerning sleep disturbances and somatic disease. Of the habitual snorers in 1984, 12.5% reported that they had developed hypertension during the period, compared with 7.4% of the remaining subjects (p<0.001). In a multiple logistic regression model persistent snoring, i.e., reported habitual snoring in both 1984 and 1994, was found to be an independent predictor for the development of hypertension among males aged 30-49 yrs (odds ratio 2.6, 95% confidence interval 1.5-4.5) after adjustments for age, body mass index (BMI), weight gain, smoking, alcohol dependence, and physical inactivity. Among the subjects aged 50-69 yrs in 1984, no association between snoring and development of hypertension was found. Although based only on reported data, the results indicate that persistent snoring is an independent risk factor for the development of hypertension among males aged <50 yrs. Prospective surveys, including whole-night sleep recordings, are needed to establish whether this is due to a higher prevalence of obstructive sleep apnoea syndrome among snorers or whether nonapnoeic snorers with increased upper airway resistance also have an increased risk of developing hypertension.

Sleep Apnea and Glucose Metabolism: A Long-term Follow-up in a Community-Based Sample

BACKGROUND It has been suggested that sleep-disordered breathing (SDB) is a risk factor for diabetes, but long-term follow-up studies are lacking. The aim of this community-based study was to analyze the influence of SDB on glucose metabolism after > 10 years. METHODS Men without diabetes (N = 141; mean age, 57.5 years) were investigated at baseline, including whole-night respiratory monitoring. After a mean period of 11 years and 4 months, they were followed up with an interview, anthropometric measurements, and blood sampling. Insulin resistance was quantified using the homeostasis model assessment of insulin resistance (HOMA-IR). ΔHOMA-IR was calculated as (HOMA-IR at follow-up − HOMA-IR at baseline). An oral glucose tolerance test was performed on 113 men to calculate the insulin sensitivity index. RESULTS The mean apnea-hypopnea index (AHI) and oxygen desaturation index (ODI) at baseline were 4.7 and 3.3, respectively. At follow-up, 23 men had diabetes. An ODI > 5 was a predictor of developing diabetes (OR, 4.4; 95% CI, 1.1-18.1, after adjusting for age, BMI, and hypertension at baseline and ΔBMI and years with CPAP during follow-up). The ODI was inversely related to the insulin sensitivity index at follow-up (r = −0.27, P = .003). A deterioration in HOMA-IR was significantly related to all variables of SDB (AHI, AHI > 5; ODI, ODI > 5; minimum arterial oxygen saturation), even when adjusting for confounders. When excluding the variable years with CPAP from the multivariate model, all associations weakened. CONCLUSIONS SDB is independently related to the development of insulin resistance and, thereby, the risk of manifest diabetes mellitus.