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Qian Z, Lin HM, Chinchilli VM, Lehman EB, Duan Y, Craig TJ, Wilson WE, Liao D, Lazarus SC, Bascom R. Interaction of ambient air pollution with asthma medication on exhaled nitric oxide among asthmatics. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2009; 64:168-76. [PMID: 19864219 PMCID: PMC3713465 DOI: 10.1080/19338240903240616] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
The interaction between ambient air pollution and asthma medication remains unclear. The authors compared airway inflammation response to air pollution among asthmatics. Increases of 10 ppb of nitrogen dioxide (NO2) and of 10 microg/m3 of particulate matter < 10 micron in diameter (PM10) daily concentrations were associated with an increase in exhaled nitric oxide (eNO) of 0.13 ppb (95% confidence interval = 0.06, 0.19) and of 0.07 ppb (95% confidence interval = 0.02, 0.12), respectively, in models adjusted for important covariates. The results show that the medication could not counteract airway inflammation effects of air pollution. Specifically, the patients on triamcinolone decreased the sensitivity to PM10 but increased the sensitivity to NO2. The patients on salmeterol were more vulnerable to both NO2 and PM10. This study indicates that the current pollution levels may still enhance airway inflammation among patients with persistent asthma even when they are on asthma medications.
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Qian Z, Lin HM, Chinchilli VM, Lehman EB, Stewart WF, Shah N, Duan Y, Craig TJ, Wilson WE, Liao D, Lazarus SC, Bascom R. Associations between air pollution and peak expiratory flow among patients with persistent asthma. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2009; 72:39-46. [PMID: 18979353 PMCID: PMC2848818 DOI: 10.1080/15287390802445517] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Responses of patients with persistent asthma to ambient air pollution may be different from those of general populations. For example, asthma medications may modify the effects of ambient air pollutants on peak expiratory flow (PEF). Few studies examined the association between air pollution and PEF in patients with persistent asthma on well-defined medication regimens using asthma clinical trial data. Airway obstruction effects of ambient air pollutants, using 14,919 person-days of daily self-measured peak expiratory flow (PEF), were assessed from 154 patients with persistent asthma during the 16 wk of active treatment in the Salmeterol Off Corticosteroids Study trial. The three therapies were an inhaled corticosteroid, an inhaled long-acting beta-agonist, and placebo. The participants were nonsmokers aged 12 through 63 yr, recruited from 6 university-based ambulatory care centers from February 1997 to January 1999. Air pollution data were derived from the U.S. Environmental Protection Agency Aerometric Information Retrieval System. An increase of 10 ppb of ambient daily mean concentrations of NO2 was associated with a decrease in PEF of 1.53 L/min (95% confidence interval [CI] -2.93 to -0.14) in models adjusted for age, gender, race/ethnicity, asthma clinical center, season, week, daily average temperature, and daily average relative humidity. The strongest association between NO2 and PEF was observed among the patients treated with salmeterol. Negative associations were also found between PEF and SO2 and between PEF and PM(10), respectively. The results show that the two medication regimens protected against the effects of PM(10). However, salmeterol increased the sensitivity to NO2 and triamcinalone enhanced the sensitivity to SO2.
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Umstead TM, Freeman WM, Chinchilli VM, Phelps DS. Age-related changes in the expression and oxidation of bronchoalveolar lavage proteins in the rat. Am J Physiol Lung Cell Mol Physiol 2009; 296:L14-29. [DOI: 10.1152/ajplung.90366.2008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The incidence and severity of many lung diseases change with age. Some diseases, such as pneumonia, occur with increased frequency in children and the elderly. Proteins obtained by bronchoalveolar lavage (BAL) serve as the first line of defense against inhaled toxins and pathogens. Age-related changes in BAL protein expression and oxidative modification were examined in juvenile (1 mo), young adult (2 mo), and aged (18 mo) F344 rats using two-dimensional difference gel electrophoresis (2D-DIGE), matrix-assisted laser desorption ionization-time of flight/time of flight (MALDI-ToF/ToF) tandem mass spectrometry, and carbonyl immunoblotting. Using 2D-DIGE, we detected 563 protein spots, and MALDI-ToF/ToF identified 204 spots comprising 31 proteins; 21 changed significantly (17 increases) between juvenile and young adult or aged rats, but for 12 of these proteins, levels had a biphasic pattern, and levels in aged rats were less than in young adults. Relative carbonylation was determined by comparison of immunostaining with total protein staining on each oxidized protein blot. We found that aged rats had significantly increased oxidation in 13 proteins compared with juvenile rats. Many of the proteins altered in expression or oxidation level had functions in host defense, redox regulation, and protein metabolism. We speculate that low levels of expression of host defense proteins in juvenile rats and decreases in levels of these proteins between young adult and aged rats may predispose these groups to pneumonia. In addition, we have shown age-related increases in protein oxidation that may compromise host defense function in aged rats.
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Larsen GL, Morgan W, Heldt GP, Mauger DT, Boehmer SJ, Chinchilli VM, Lemanske RF, Martinez F, Strunk RC, Szefler SJ, Zeiger RS, Taussig LM, Bacharier LB, Guilbert TW, Radford S, Sorkness CA. Impulse oscillometry versus spirometry in a long-term study of controller therapy for pediatric asthma. J Allergy Clin Immunol 2008; 123:861-7.e1. [PMID: 19070356 DOI: 10.1016/j.jaci.2008.10.036] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 10/13/2008] [Accepted: 10/20/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Determination of the benefits and limitations of specific physiologic tests has not been well studied in long-term clinical pediatric trials. OBJECTIVE We sought to determine the utility of impulse oscillometry in a long-term comparison of 3 controller regimens in children with persistent asthma. METHODS Children 6 to 14 years of age with mild-to-moderate persistent asthma were characterized with oscillometry and spirometry before entry into a clinical trial and then serially during 48 weeks of therapy with either an inhaled corticosteroid, a combination inhaled corticosteroid with a long-acting beta-agonist, or a leukotriene receptor antagonist. RESULTS The FEV(1)/forced vital capacity ratio, as well as the forced expiratory flow from 25% to 75% of forced vital capacity in terms of spirometric parameters and the reactance area (XA) from impulse oscillometry, appeared to complement information provided by FEV(1) when comparing the tests and factors that appeared to predict a response to treatment. XA was unique in that it, as distinct from spirometric variables, reflected ongoing improvement during the latter part of the trial. In general, improvements in XA during the latter part of the study occurred independently of indices of atopy and the level of airway responsiveness. CONCLUSION Assessment of respiratory mechanics over time with oscillometry might offer additional insights into the response of asthmatic patients to therapy. In particular, the pattern of improvement seen in XA over the course of therapy suggests this test might detect alterations in airway mechanics not reflected by spirometry. The possibility that changes in XA reflect ongoing improvement in small airway function deserves additional study.
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Hillemeier MM, Downs DS, Feinberg ME, Weisman CS, Chuang CH, Parrott R, Velott D, Francis LA, Baker SA, Dyer AM, Chinchilli VM. Improving women's preconceptional health: findings from a randomized trial of the Strong Healthy Women intervention in the Central Pennsylvania women's health study. Womens Health Issues 2008; 18:S87-96. [PMID: 19059553 PMCID: PMC2744213 DOI: 10.1016/j.whi.2008.07.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 06/18/2008] [Accepted: 07/25/2008] [Indexed: 11/29/2022]
Abstract
PURPOSE Improving the health of women before pregnancy is an important strategy for reducing adverse pregnancy outcomes for mother and child. This paper reports the first pretest-posttest results from a randomized trial of a unique, multidimensional, small group format intervention, Strong Healthy Women, designed to improve the health behaviors and health status of preconceptional and interconceptional women. METHODS Nonpregnant pre- and interconceptional women ages 18-35 were recruited in 15 low-income rural communities in Central Pennsylvania (n = 692). Women were randomized in a ratio of 2-to-1 to intervention and control groups; participants received a baseline and follow-up health risk assessment at 14 weeks and completed questionnaires to assess behavioral variables. The analytic sample for this report consists of 362 women who completed both risk assessments. Outcomes include measures of attitudinal and health-related behavior change. MAIN FINDINGS Women in the intervention group were significantly more likely than controls to report higher self-efficacy for eating healthy food and to perceive higher preconceptional control of birth outcomes; greater intent to eat healthy foods and be more physically active; and greater frequency of reading food labels, physical activity consistent with recommended levels, and daily use of a multivitamin with folic acid. Significant dose effects were found: Each additional intervention session attended was associated with higher perceived internal preconceptional control of birth outcomes, reading food labels, engaging in relaxation exercise or meditation for stress management, and daily use of a multivitamin with folic acid. CONCLUSIONS The attitudinal and behavior changes attributable to the intervention were related primarily to nutrition and physical activity. These results show that these topics can be successfully addressed with pre- and interconceptional women outside the clinical setting in community-based interventions.
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Bacharier LB, Phillips BR, Zeiger RS, Szefler SJ, Martinez FD, Lemanske RF, Sorkness CA, Bloomberg GR, Morgan WJ, Paul IM, Guilbert T, Krawiec M, Covar R, Larsen G, Mellon M, Moss MH, Chinchilli VM, Taussig LM, Strunk RC. Episodic use of an inhaled corticosteroid or leukotriene receptor antagonist in preschool children with moderate-to-severe intermittent wheezing. J Allergy Clin Immunol 2008; 122:1127-1135.e8. [PMID: 18973936 DOI: 10.1016/j.jaci.2008.09.029] [Citation(s) in RCA: 196] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 09/15/2008] [Accepted: 09/18/2008] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute wheezing illnesses in preschoolers require better management strategies to reduce morbidity. OBJECTIVES We sought to examine the effectiveness of episodic use of an inhaled corticosteroid and a leukotriene receptor antagonist in preschoolers with intermittent wheezing. METHODS In a randomized, double-blind, placebo-controlled 12-month trial, 238 children aged 12 to 59 months with moderate-to-severe intermittent wheezing received 7 days of either budesonide inhalation suspension (1 mg twice daily), montelukast (4 mg daily), or placebo in addition to albuterol with each identified respiratory tract illness (RTI). Proportion of episode-free days (EFDs) during the 12-month trial was the primary outcome. RESULTS The 3 treatment groups did not differ in proportions of EFDs, with adjusted mean EFDs of 76% (95% CI, 70% to 81%) for budesonide, 73% (95% CI, 66% to 79%) for montelukast, and 74% (95% CI, 65% to 81%) for conventional therapy (P = .66). The 3 groups did not differ in oral corticosteroid use, health care use, quality of life, or linear growth. However, during RTIs, budesonide and montelukast therapy led to modest reductions in trouble breathing (38% [P = .003] and 37% [P = .003], respectively) and interference with activity scores (32% [P = .01] and 40% [P = .001], respectively) that were most evident in those with positive asthma predictive indices. CONCLUSIONS In preschool children with moderate-to-severe intermittent wheezing, episodic use of either budesonide or montelukast early in RTIs, when added to albuterol, did not increase the proportion of EFDs or decrease oral corticosteroid use over a 12-month period. However, indicators of severity of acute illnesses were reduced, particularly in children with positive asthma predictive indices.
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Walter MJ, Castro M, Kunselman SJ, Chinchilli VM, Reno M, Ramkumar TP, Avila PC, Boushey HA, Ameredes BT, Bleecker ER, Calhoun WJ, Cherniack RM, Craig TJ, Denlinger LC, Israel E, Fahy JV, Jarjour NN, Kraft M, Lazarus SC, Lemanske RF, Martin RJ, Peters SP, Ramsdell JW, Sorkness CA, Sutherland ER, Szefler SJ, Wasserman SI, Wechsler ME. Predicting worsening asthma control following the common cold. Eur Respir J 2008; 32:1548-54. [PMID: 18768579 DOI: 10.1183/09031936.00026808] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The asthmatic response to the common cold is highly variable, and early characteristics that predict worsening of asthma control following a cold have not been identified. In this prospective multicentric cohort study of 413 adult subjects with asthma, the mini-Asthma Control Questionnaire (mini-ACQ) was used to quantify changes in asthma control and the Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21) to measure cold severity. Univariate and multivariable models were used to examine demographic, physiological, serological and cold-related characteristics for their relationship to changes in asthma control following a cold. Clinically significant worsening of asthma control was observed following a cold (mean+/-SD increase in mini-ACQ score of 0.69+/-0.93). Univariate analysis demonstrated that season, centre location, cold duration and cold severity measurements were all associated with a change in asthma control. Multivariable analysis of the covariates available within the first 2 days of cold onset revealed that the day 2 and cumulative sum of day 1 and 2 WURSS-21 scores were significant predictors of the subsequent changes in asthma control. In asthmatic subjects, cold severity within the first 2 days can be used to predict subsequent changes in asthma control. This information may help clinicians prevent deterioration in asthma control following a cold.
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Rizk EB, Cockroft KM, Chinchilli VM, Stetter C. Assessment of Early versus Late Tracheostomy in Severly Head Injured Patients. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000333497.58227.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Mikerov AN, Gan X, Umstead TM, Miller L, Chinchilli VM, Phelps DS, Floros J. Sex differences in the impact of ozone on survival and alveolar macrophage function of mice after Klebsiella pneumoniae infection. Respir Res 2008; 9:24. [PMID: 18307797 PMCID: PMC2268931 DOI: 10.1186/1465-9921-9-24] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Accepted: 02/28/2008] [Indexed: 11/10/2022] Open
Abstract
Background Sex differences have been described in a number of pulmonary diseases. However, the impact of ozone exposure followed by pneumonia infection on sex-related survival and macrophage function have not been reported. The purpose of this study was to determine whether ozone exposure differentially affects: 1) survival of male and female mice infected with Klebsiella pneumoniae, and 2) the phagocytic ability of macrophages from these mice. Methods Male and female C57BL/6 mice were exposed to O3 or to filtered air (FA) (control) and then infected intratracheally with K. pneumoniae bacteria. Survival was monitored over a 14-day period, and the ability of alveolar macrophages to phagocytize the pathogen in vivo was investigated after 1 h. Results 1) Both male and female mice exposed to O3 are significantly more susceptible to K. pneumoniae infection than mice treated with FA; 2) although females appeared to be more resistant to K. pneumoniae than males, O3 exposure significantly increased the susceptibility of females to K. pneumoniae infection to a greater degree than males; 3) alveolar macrophages from O3-exposed male and female mice have impaired phagocytic ability compared to macrophages from FA-exposed mice; and 4) the O3-dependent reduction in phagocytic ability is greater in female mice. Conclusion O3 exposure reduces the ability of mice to survive K. pneumoniae infection and the reduced phagocytic ability of alveolar macrophages may be one of the contributing factors. Both events are significantly more pronounced in female mice following exposure to the environmental pollutant, ozone.
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King TS, Chinchilli VM, Wang KL, Carrasco JL. A class of repeated measures concordance correlation coefficients. J Biopharm Stat 2007; 17:653-72. [PMID: 17613646 DOI: 10.1080/10543400701329455] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The repeated measures concordance correlation coefficient was proposed for measuring agreement between two raters or two methods of measuring a response in the presence of repeated measurements (King et al., 2007). This paper proposes a class of repeated measures concordance correlation coefficients that are appropriate for both continuous and categorical data. We illustrate the methodology with examples comparing (1) 1-hour vs. 2-hour blood draws for measuring cortisol in an asthma clinical trial, (2) two measurements of percentage body fat, from skinfold calipers and dual energy x-ray absorptiometry, and (3) two binary measures of quality of health from an asthma clinical trial.
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King TS, Chinchilli VM, Carrasco JL. A repeated measures concordance correlation coefficient. Stat Med 2007; 26:3095-113. [PMID: 17216594 DOI: 10.1002/sim.2778] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The concordance correlation coefficient is commonly used to assess agreement between two raters or two methods of measuring a response when the data are measured on a continuous scale. However, the situation may arise in which repeated measurements are taken for each rater or method, e.g. longitudinal studies in clinical trials or bioassay data with subsamples. This paper proposes a coefficient for measuring agreement between two raters or two methods of measuring a response in the presence of repeated measurements. We illustrate the methodology with examples comparing (1) 1-hr versus 2-hr blood draws for measuring cortisol in an asthma clinical trial and (2) two measurements of percentage body fat, from skinfold calipers and dual energy X-ray absorptiometry.
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Carrasco JL, Jover L, King TS, Chinchilli VM. Comparison of Concordance Correlation Coefficient Estimating Approaches with Skewed Data. J Biopharm Stat 2007; 17:673-84. [PMID: 17613647 DOI: 10.1080/10543400701329463] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The concordance correlation coefficient (CCC) is an index that assesses the agreement between continuous measures made by different observers. At least four methods are used to estimate the CCC: two (Lin's method, Variance Components) which are defined on the basis that data are normally distributed, and the two others (U-statistics, GEE) which do not assume any particular distribution of the data. Here the four methods are compared with skewed data from a model in which the subject means follow a log-normal distribution while the within-subject variability is assumed to be normally distributed. An example of alcohol consumption is considered and a simulation study is performed.
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Bowman G, Bonneau RH, Chinchilli VM, Tracey KJ, Cockroft KM. A novel inhibitor of inflammatory cytokine production (CNI-1493) reduces rodent post-hemorrhagic vasospasm. Neurocrit Care 2007; 5:222-9. [PMID: 17290094 DOI: 10.1385/ncc:5:3:222] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a devastating complication, yet despite multiple lines of investigation an effective treatment remains lacking. Cytokine-mediated inflammation has been implicated as a causative factor in the development of posthemorrhagic vasospasm. In previous experiments using the rat femoral artery model of vasospasm, we demonstrated that elevated levels of the proinflammatory cytokine interleukin (IL)-6 are present after hemorrhage and that a polyclonal antibody against IL-6 is capable of attenuating experimental vasospasm. METHODS In the present study, we tested the ability of a novel selective proinflammatory cytokine inhibitor (CNI-1493) to protect against the occurrence of experimental vasospasm in the same rat femoral artery model. CNI-1493 was administered by injection directly into the blood-filled femoral pouches of animals at the time of their initial surgery (hemorrhage). Control animals received an equal volume of vehicle alone. Animals were killed at 8 days posthemorrhage and degree of vasospasm was assessed by image analysis of artery cross-sectional area. In a separate series of experiments, enzyme-linked immunosorbent assay (ELISA) was used to assess levels of the proinflammatory cytokine IL-6 and the prototypical antiinflammatory cytokine transforming growth factor (TGF)-beta1 after treatment with CNI-1493. RESULTS Pretreatment with CNI-1493 provided dose-dependent attenuation of posthemorrhagic vasospasm, with the highest dose (200 microg in 8 microL dH2O) causing complete reversal of vasospasm (vessel cross-sectional area ratio 1.06 +/- 0.04 versus 0.87 +/- 0.06, p < 0.05, one-way analysis of variance). Assessment of cytokine levels by ELISA confirmed the selectivity of CNI-1493 by demonstrating significant reductions in IL-6 levels, but no suppression of TGF-beta1 levels. CONCLUSIONS These findings support the conclusion that inflammatory cytokines, in particular IL-6, play an important role in development of vasospasm in the rat femoral artery model. Furthermore, these results suggest that the inhibition of inflammatory cytokines may be an appropriate strategy for the treatment of vasospasm after SAH.
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Buyantseva LV, Tulchinsky M, Kapalka GM, Chinchilli VM, Qian Z, Gillio R, Roberts A, Bascom R. Evolution of lower respiratory symptoms in New York police officers after 9/11: a prospective longitudinal study. J Occup Environ Med 2007; 49:310-7. [PMID: 17351517 DOI: 10.1097/jom.0b013e318032256e] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We studied the evolution of lower respiratory symptoms at 1 month (initial) and 19 months (follow-up) after the collapse of the World Trade Center on September 11, 2001 (9/11). METHODS A total of 1588 New York police officers completed initial self-administered questionnaires. The level of 9/11 exposure and pre-9/11 health was available in 1373. Of those, 471 (426 with no pre-9/11 chronic respiratory disease) completed a follow-up telephone survey. RESULTS Prevalence of cough was 43.5% at both initial and follow-up assessments, but increased were the prevalence of phlegm (14.4% to 30.7%, P<0.001), shortness of breath (18.9% to 43.6%, P<0.001), and wheeze (13.1% to 25.9%, P<0.001). Rates of delayed-onset (present on follow-up assessment only) cough, phlegm, shortness of breath, and wheeze were 21%, 21.9%, 31.7%, and 17.3%, respectively. CONCLUSIONS Most of the lower respiratory symptoms increased between 1 month and 19 months after 9/11.
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Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, Adinoff AD, Bachert C, Borish L, Chinchilli VM, Danzig MR, Ferguson BJ, Fokkens WJ, Jenkins SG, Lund VJ, Mafee MF, Naclerio RM, Pawankar R, Ponikau JU, Schubert MS, Slavin RG, Stewart MG, Togias A, Wald ER, Winther B. Rhinosinusitis: Developing guidance for clinical trials. Otolaryngol Head Neck Surg 2007; 135:S31-80. [PMID: 17081855 DOI: 10.1016/j.otohns.2006.09.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication, "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.
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Pesola GR, Magari RT, Dartey-Hayford S, Coelho-D'Costa V, Chinchilli VM. Total lung capacity: single breath methane dilution versus plethysmography in normals. Respirology 2007; 12:291-4. [PMID: 17298466 DOI: 10.1111/j.1440-1843.2006.01040.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE AND BACKGROUND Methane is an inert tracer gas used to obtain TLC estimates during single breath diffusion capacity (DL(CO)) measurements. The aim of this study was to assess the accuracy of methane dilution TLC in normal subjects undergoing single breath diffusion capacity measurements using plethysmography as the gold standard comparison method. METHODS Fifty non-smoking adults underwent lung function testing. Total lung volume was obtained by both plethysmography and methane dilution during a single breath DL(CO) measurement. Deming regression and the concordance correlation coefficient, r(ccc), were used to determine agreement between methods for TLC. Bias was the mean difference between methods and limits of agreement were the mean difference between methods +/- 1.96 (SD). All values are mean +/- SD unless otherwise stated. RESULTS Plethysmography and methane dilution TLC values were not significantly different. The r(ccc) was 0.87 (95% confidence interval (CI) 0.78-0.92). Deming regression revealed a slope of 0.93 (P = 0.17, H(o): beta = 1.0; 95% CI 0.84-1.03) and a y-intercept of 0.20 (P = 0.39, H(o): alpha = 0; 95% CI -0.27-0.70). The bias was 0.11 L favouring plethysmography. Limits of agreement varied as 0.11 +/- 0.92 L. CONCLUSIONS There is statistical agreement between methods suggesting the average TLC by methane could substitute for plethysmography in normals at the population level. At the individual level, a normal methane dilution value indicates a normal TLC whereas values below the normal range should be validated using plethysmography.
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Bacharier LB, Phillips BR, Bloomberg GR, Zeiger RS, Paul IM, Krawiec M, Guilbert T, Chinchilli VM, Strunk RC. Severe intermittent wheezing in preschool children: a distinct phenotype. J Allergy Clin Immunol 2007; 119:604-10. [PMID: 17336610 DOI: 10.1016/j.jaci.2006.12.607] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 12/02/2006] [Accepted: 12/04/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND Young children with wheezing predominantly with respiratory tract illnesses experience severe exacerbations separated by extended periods of wellness and may be described as having "severe intermittent wheezing," a diagnostic category not currently recognized in national guidelines. OBJECTIVE We sought to characterize a cohort of children with recurrent severe wheezing. METHODS A total of 238 children 12 to 59 months enrolled in the Acute Intervention Management Strategies trial were characterized through comprehensive allergy, asthma, environmental, and quality of life assessments. RESULTS Asthma symptoms over the period of the preceding year occurred at frequencies consistent with intermittent asthma, as 94.5% of children experienced activity limitation < or = 2 times per month. However, frequent severe exacerbations were common, because 71% experienced > or = 4 wheezing episodes over the period of the preceding year, 95% made at least 1 primary care visit, 52% missed school or daycare, 40% made an emergency department visit, and 8% were hospitalized for wheezing illnesses. Atopic features were common, including eczema (37%), aeroallergen sensitization (46.8%), and positive asthma predictive index (59.7%). Oral corticosteroid use in the previous year (59.7% of the cohort) identified a subgroup with more severe disease documented by a higher incidence of urgent care visits (P = .0048), hospitalizations (P = .0061), aeroallergen sensitization (P = .047), and positive asthma predictive indices (P = .007). CONCLUSION Among preschool children enrolled in the Acute Intervention Management Strategies trial, a subgroup was identified with severe intermittent wheezing characterized by atopic features and substantial illness-related symptom burden despite prolonged periods of wellness. CLINICAL IMPLICATIONS Preschool children with recurrent severe wheezing episodes experience significant illness-related morbidity and exhibit features of atopic predisposition.
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Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, Adinoff AD, Bachert C, Borish L, Chinchilli VM, Danzig MR, Ferguson BJ, Fokkens WJ, Jenkins SG, Lund VJ, Mafee MF, Naclerio RM, Pawankar R, Ponikau JU, Schubert MS, Slavin RG, Stewart MG, Togias A, Wald ER, Winther B. Rhinosinusitis: developing guidance for clinical trials. J Allergy Clin Immunol 2007; 118:S17-61. [PMID: 17084217 DOI: 10.1016/j.jaci.2006.09.005] [Citation(s) in RCA: 205] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Revised: 08/25/2006] [Accepted: 09/01/2006] [Indexed: 01/21/2023]
Abstract
The Rhinosinusitis Initiative was developed by 5 national societies. The current guidance document is an expansion of the 2004 publication "Rhinosinusitis: Establishing definitions for clinical research and patient care" and provides templates for clinical trials in antimicrobial, anti-inflammatory, and symptom-relieving therapies for the following: (1) acute presumed bacterial rhinosinusitis, (2) chronic rhinosinusitis (CRS) without nasal polyps, (3) CRS with nasal polyps, and (4) classic allergic fungal rhinosinusitis. In addition to the templates for clinical trials and proposed study designs, the Rhinosinusitis Initiative has developed 6 appendices, which address (1) health outcomes, (2) nasal endoscopy and staging of CRS, (3) radiologic imaging, (4) microbiology, (5) laboratory measures, and (6) biostatistical methods.
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270
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Martin RJ, Szefler SJ, King TS, Kraft M, Boushey HA, Chinchilli VM, Craig TJ, Dimango EA, Deykin A, Fahy JV, Israel E, Lazarus SC, Lemanske RF, Leone FT, Pesola GR, Peters SP, Sorkness CA, Szwejbka LA, Wechsler ME. The Predicting Response to Inhaled Corticosteroid Efficacy (PRICE) trial. J Allergy Clin Immunol 2007; 119:73-80. [PMID: 17208587 PMCID: PMC2872157 DOI: 10.1016/j.jaci.2006.10.035] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Revised: 10/25/2006] [Accepted: 10/30/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although guidelines recommend anti-inflammatory therapy for persistent asthma, recent studies suggest that 25% to 35% of patients with asthma may not improve lung function with inhaled corticosteroids. OBJECTIVE To evaluate potential biomarkers of predicting short-term (6-week) response to inhaled corticosteroid with subsequent evaluation of responders and nonresponders to asthma control over a longer interval (16 additional weeks). METHODS Eighty-three subjects with asthma off steroid were enrolled in this multicenter study. Biomarkers and asthma characteristics were evaluated as predictors of inhaled corticosteroid response over a 6-week trial for changes in FEV(1) and methacholine PC(20). After this, an additional 4-month trial evaluated asthma control. RESULTS Although multiple baseline predictors had significant correlations with improvements for short-term inhaled steroid success, the only strong correlations (r >or= +/- 0.6) were albuterol reversibility (r = 0.83; P < .001), FEV(1)/forced vital capacity (r = -0.75; P < .001), and FEV(1) % predicted (r = -0.71; P < .001). Dividing the subjects in the short-term inhaled steroid trial into responders (>5% FEV(1) improvement) and nonresponders (<or=5%) determined the longer-term need for steroids. For the nonresponders, asthma control remained unchanged whether inhaled corticosteroids were continued or were substituted with a placebo (P = .99). The good short-term responders maintained asthma control longer-term only if maintained on inhaled steroids (P = .007). CONCLUSION The short-term response to inhaled corticosteroids with regard to FEV(1) improvement predicts long-term asthma control. CLINICAL IMPLICATIONS The decision to use long-term inhaled steroids could be based on a short-term trial. Different therapeutic strategies would need to be established for nonresponders.
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271
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Simon LJ, Chinchilli VM. A matched crossover design for clinical trials. Contemp Clin Trials 2007; 28:638-46. [PMID: 17383239 PMCID: PMC2001189 DOI: 10.1016/j.cct.2007.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Revised: 01/28/2007] [Accepted: 02/20/2007] [Indexed: 11/25/2022]
Abstract
Two design principles are used frequently in clinical trials: 1) A subject is "matched" or "paired" with a similar subject to reduce the chance that other variables obscure the primary comparison of interest. 2) A subject serves as his/her own control by "crossing over" from one treatment to another during the course of an experiment. There are situations in which it may be advantageous to use the two design principles - crossing over and matching - simultaneously. That is, it may be advantageous to conduct a "paired crossover design," in which each subject, while paired with a similar subject, crosses over and receives each experimental treatment. In this paper, we describe two clinical trials conducted by the National Heart, Lung and Blood Institute's Asthma Clinical Research Network that used a paired 2x2 crossover design. The Beta Adrenergic Response by GEnotype (BARGE) Study compared the effects of regular use of inhaled albuterol on mildly asthmatic patients with different genotypes at the 16th position of the beta-agonist receptor gene. The Smoking Modulates Outcomes of Glucocorticoid (SMOG) Therapy in Asthma Study evaluated the hypothesis that smoking reduces the response to inhaled corticosteroids. For such paired crossover designs, the primary parameter of interest is typically the treatment-by-pairing interaction term. In evaluating the relative efficiency of the paired 2x2 crossover design to two independent crossover designs with respect to this interaction term, we show that the paired 2x2 crossover design is more efficient if the correlations between the paired members on the same treatments are greater than their correlations on different treatments. This condition should hold in most circumstances, and therefore the paired crossover design deserves serious consideration for any clinical trial in which the crossing over and matching of subjects is deemed simultaneously beneficial.
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272
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Deykin A, Wechsler ME, Boushey HA, Chinchilli VM, Kunselman SJ, Craig TJ, DiMango E, Fahy JV, Kraft M, Leone F, Lazarus SC, Lemanske RF, Martin RJ, Pesola GR, Peters SP, Sorkness CA, Szefler SJ, Israel E. Combination therapy with a long-acting beta-agonist and a leukotriene antagonist in moderate asthma. Am J Respir Crit Care Med 2007; 175:228-34. [PMID: 16973987 PMCID: PMC1899264 DOI: 10.1164/rccm.200601-112oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 09/08/2006] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Long-acting beta-agonists (LABAs) and inhaled corticosteroids administered together appear to be complementary in terms of effects on asthma control. The elements of asthma control achieved by LABAs (improved lung function) and leukotriene receptor antagonists (LTRAs; protection against exacerbations) may be complementary as well. OBJECTIVE We sought to determine whether the combination of the LTRA montelukast and the LABA salmeterol could provide an effective therapeutic strategy for asthma. METHODS AND MEASUREMENTS In a randomized, placebo-controlled, crossover study of 192 subjects with moderate asthma, we compared the clinical efficacy of regular treatment over 14 weeks with the combination of montelukast and salmeterol to that with the combination of beclomethasone and salmeterol in moderate asthma. The primary efficacy outcome was time to treatment failure. MAIN RESULTS Three months after the randomization of the last subject, the Data and Safety Monitoring Board determined that the primary research question had been answered and terminated the trial. The combination of montelukast and salmeterol was inferior to the combination of beclomethasone and salmeterol as judged by protection against asthma treatment failures (p = 0.0008), lung function (26 L/min difference in a.m. peak expiratory flow rate, p = 0.011), asthma control score (0.22 difference in Asthma Control Questionnaire score, p = 0.038), and markers of inflammation and airway reactivity. CONCLUSIONS Patients with moderate asthma similar to those we studied should not substitute the combination of an LTRA and an LABA for the combination of inhaled corticosteroid and an LABA.
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273
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Lazarus SC, Chinchilli VM, Rollings NJ, Boushey HA, Cherniack R, Craig TJ, Deykin A, DiMango E, Fish JE, Ford JG, Israel E, Kiley J, Kraft M, Lemanske RF, Leone FT, Martin RJ, Pesola GR, Peters SP, Sorkness CA, Szefler SJ, Wechsler ME, Fahy JV. Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. Am J Respir Crit Care Med 2007; 175:783-90. [PMID: 17204725 PMCID: PMC1899291 DOI: 10.1164/rccm.200511-1746oc] [Citation(s) in RCA: 308] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE One-quarter to one-third of individuals with asthma smoke, which may affect response to therapy and contribute to poor asthma control. OBJECTIVES To determine if the response to an inhaled corticosteroid or a leukotriene receptor antagonist is attenuated in individuals with asthma who smoke. METHODS In a multicenter, placebo-controlled, double-blind, double-dummy, crossover trial, 44 nonsmokers and 39 light smokers with mild asthma were assigned randomly to treatment twice daily with inhaled beclomethasone and once daily with oral montelukast. MEASUREMENTS AND MAIN RESULTS Primary outcome was change in prebronchodilator FEV(1) in smokers versus nonsmokers. Secondary outcomes included peak flow, PC(20) methacholine, symptoms, quality of life, and markers of airway inflammation. Despite similar FEV(1), bronchodilator response, and sensitivity to methacholine at baseline, subjects with asthma who smoked had significantly more symptoms, worse quality of life, and lower daily peak flow than nonsmokers. Adherence to therapy did not differ significantly between smokers and nonsmokers, or between treatment arms. Beclomethasone significantly reduced sputum eosinophils and eosinophil cationic protein (ECP) in both smokers and nonsmokers, but increased FEV(1) (170 ml, p = 0.0003) only in nonsmokers. Montelukast significantly increased a.m. peak flow in smokers (12.6 L/min, p = 0.002), but not in nonsmokers. CONCLUSIONS In subjects with mild asthma who smoke, the response to inhaled corticosteroids is attenuated, suggesting that adjustments to standard therapy may be required to attain asthma control. The greater improvement seen in some outcomes in smokers treated with montelukast suggests that leukotrienes may be important in this setting. Larger prospective studies are required to determine whether leukotriene modifiers can be recommended for managing asthma in patients who smoke.
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Denlinger LC, Sorkness CA, Chinchilli VM, Lemanske RF. Guideline-defining asthma clinical trials of the National Heart, Lung, and Blood Institute's Asthma Clinical Research Network and Childhood Asthma Research and Education Network. J Allergy Clin Immunol 2006; 119:3-11; quiz 12-3. [PMID: 17141853 PMCID: PMC2742212 DOI: 10.1016/j.jaci.2006.10.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 10/02/2006] [Accepted: 10/06/2006] [Indexed: 11/25/2022]
Abstract
Because of an increasing prevalence, morbidity, and mortality associated with asthma, the National Heart, Lung, and Blood Institute created the Asthma Clinical Research Network and the Childhood Asthma Research and Education Network to improve public health. The objectives of these clinical research networks are to conduct multiple, well-designed clinical trials for rapid evaluation of new and existing therapeutic approaches to asthma and to disseminate laboratory and clinical findings to the health care community. These trials comprise a large proportion of the data driving the treatment guidelines established and reviewed by the National Asthma Education and Prevention Program. This article will review the basic design and major findings of selected Asthma Clinical Research Network and Childhood Asthma Research and Education Network trials involving both adults and children with asthma. Collectively, these studies have helped refine the therapeutic role of existing controller medications, establish standard models for side-effect evaluation and risk-benefit models, validate symptom-based assessments for asthma control, and identify baseline characteristics that might predict individual patient responses. Remaining challenges include shaping the role of novel therapeutics in future guidelines, incorporating pharmacogenomic data in treatment decisions, and establishing better implementation strategies for translation to community settings, all with the goal of reducing the asthma burden on society.
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Sorkness CA, Lemanske RF, Mauger DT, Boehmer SJ, Chinchilli VM, Martinez FD, Strunk RC, Szefler SJ, Zeiger RS, Bacharier LB, Bloomberg GR, Covar RA, Guilbert TW, Heldt G, Larsen G, Mellon MH, Morgan WJ, Moss MH, Spahn JD, Taussig LM. Long-term comparison of 3 controller regimens for mild-moderate persistent childhood asthma: the Pediatric Asthma Controller Trial. J Allergy Clin Immunol 2006; 119:64-72. [PMID: 17140647 DOI: 10.1016/j.jaci.2006.09.042] [Citation(s) in RCA: 201] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 08/30/2006] [Accepted: 09/05/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND More evidence is needed on which to base recommendations for treatment of mild-moderate persistent asthma in school-aged children. OBJECTIVE The Pediatric Asthma Controller Trial (PACT) compared the effectiveness of 3 regimens in achieving asthma control. METHODS A total of 285 children (ages 6-14 years) with mild-moderate persistent asthma on the basis of symptoms, and with FEV(1) >or= 80% predicted and methacholine FEV(1) PC(20) <or= 12.5 mg/mL, were randomized to 1 of 3 double-blind 48-week treatments: fluticasone 100 microg twice daily (fluticasone monotherapy), fluticasone 100 microg/salmeterol 50 microg in the morning and salmeterol 50 mug in the evening (PACT combination), and montelukast 5 mg in the evening. Outcomes included asthma control days (primary outcome), exacerbations, humanistic measurements, and pulmonary function measurements. RESULTS Fluticasone monotherapy and PACT combination were comparable in many patient-measured outcomes, including percent of asthma control days, but fluticasone monotherapy was superior for clinic-measured FEV(1)/forced vital capacity (P = .015), maximum bronchodilator response (P = .009), exhaled nitric oxide (P < .001), and PC(20) (P < .001). Fluticasone monotherapy was superior to montelukast for asthma control days (64.2% vs 52.5%; P = .004) and for all other control outcomes. Growth over 48 weeks was not statistically different (fluticasone, 5.3 cm; PACT combination, 5.3 cm; montelukast, 5.7 cm). CONCLUSION Both fluticasone monotherapy and PACT combination achieved greater improvements in asthma control days than montelukast. However, fluticasone monotherapy was superior to PACT combination in achieving other dimensions of asthma control. Growth was similar in all groups. CLINICAL IMPLICATIONS Therefore, of the regimens tested, the PACT study findings favor fluticasone monotherapy in treating children with mild-moderate persistent asthma with FEV(1) >or= 80% predicted, confirming current guideline recommendations.
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