The relationship of sex to asthma prevalence, health care utilization, and medications in a large managed care organization

Androgens have therapeutic potential in T2 asthma by mediating METTL3 in bronchial epithelial cells

Studies have shown that androgens can alleviate the symptoms of T2 asthma and are inversely correlated with the severity of allergic asthma. METTL3, a crucial component of m6A modification, mitigates the development of T2 asthma by inhibiting Th2 cell differentiation. However, the impact of androgens, such as dihydrotestosterone (DHT), on the progression of T2 asthma through METTL3 has yet to be investigated. At the clinical level, patients with T2 asthma exhibited reduced levels of DHT and METTL3 mRNA, along with increased levels of 17β-estradiol (E2). DHT and METTL3 were found to be negatively associated with the severity of T2 asthma, while E2 was positively associated with it. Administration of DHT and E2 in induced T2 asthma mouse models showed that DHT improved lung function, reduced airway inflammation, and inhibited Th2 cell differentiation. Interestingly, DHT reversed the damage to METTL3, whereas E2 had the opposite effect. In vitro studies of mouse bronchial epithelial cells (BECs) confirmed that METTL3-dependent m6A modification inhibited the T2 inflammatory response, and DHT inhibited Th2 cell differentiation in T2 asthma by promoting METTL3 expression in BECs. In conclusion, our study suggests that DHT has therapeutic potential for T2 asthma by regulating METTL3 in BECs.

The production, function, and clinical applications of IL-33 in type 2 inflammation-related respiratory diseases

Epithelial-derived IL-33 (Interleukin-33), as a member of alarm signals, is a chemical substance produced under harmful stimuli that can promote innate immunity and activate adaptive immune responses. Type 2 inflammation refers to inflammation primarily mediated by Type 2 helper T cells (Th2), Type 2 innate lymphoid cells (ILC2), and related cytokines. Type 2 inflammation manifests in various forms in the lungs, with diseases such as asthma and chronic obstructive pulmonary disease chronic obstructive pulmonary disease (COPD) closely associated with Type 2 inflammation. Recent research suggests that IL-33 has a promoting effect on Type 2 inflammation in the lungs and can be regarded as an alarm signal for Type 2 inflammation. This article provides an overview of the mechanisms and related targets of IL-33 in the development of lung diseases caused by Type 2 inflammation, and summarizes the associated treatment methods. Analyzing lung diseases from a new perspective through the alarm of Type 2 inflammation helps to gain a deeper understanding of the pathogenesis of these related lung diseases. This, in turn, facilitates a better understanding of the latest treatment methods and potential therapeutic targets for diseases, with the expectation that targeting lL-33 can propose new strategies for disease prevention.

Sex differences in asthma control, lung function and exacerbations: the ATLANTIS study

BACKGROUND

Asthma is a heterogeneous disease with a prevalence and severity that differs between male and female patients.

QUESTION

What are differences between male and female patients with asthma with regard to asthma control, lung function, inflammation and exacerbations?

METHODS

We performed a post hoc analysis in the ATLANTIS (Assessment of Small Airways Involvement in Asthma) study, an observational cohort study including patients with asthma from nine countries with a follow-up of 1 year during which patients were characterised with measures of large and small airway function, questionnaires, inflammation and imaging. We compared differences in baseline characteristics and longitudinal outcomes between male and female patients with asthma.

RESULTS

773 patients were enrolled; 450 (58%) of these were female. At baseline, female patients with asthma were in higher Global Initiative for Asthma (GINA) steps (p=0.042), had higher Asthma Control Questionnaire 6 (F: 0.83; M: 0.66, p<0.001) and higher airway resistance as reflected by uncorrected impulse oscillometry outcomes (ie, R5-R20: F: 0.06; M: 0.04 kPa/L/s, p=0.002). Male patients with asthma had more severe airway obstruction (forced expiratory volume in 1 s/forced vital capacity % predicted: F: 91.95; M: 88.33%, p<0.01) and more frequently had persistent airflow limitation (F: 27%; M: 39%, p<0.001). Blood neutrophils were significantly higher in female patients (p=0.014). With Cox regression analysis, female sex was an independent predictor for exacerbations.

INTERPRETATION

We demonstrate that female patients are in higher GINA steps, exhibit worse disease control, experience more exacerbations and demonstrate higher airway resistance compared with male patients. The higher exacerbation risk was independent of GINA step and blood eosinophil level. Male patients, in turn, have a higher prevalence of persistent airflow limitation and more severe airflow obstruction. These findings show sex can affect clinical phenotyping and outcomes in asthma.

TRIAL REGISTRATION NUMBER

NCT02123667.

Multivariate analysis and data mining help predict asthma exacerbations

BACKGROUND

Work-related asthma has become a highly prevalent occupational lung disorder.

OBJECTIVE

Our study aims to evaluate occupational exposure as a predictor for asthma exacerbation.

METHOD

We performed a retrospective evaluation of 584 consecutive patients diagnosed and treated for asthma between October 2017 and December 2019 in four clinics from Western Romania. We evaluated the enrolled patients for their asthma control level by employing the Asthma Control Test (ACT < 20 represents uncontrolled asthma), the medical record of asthma exacerbations, occupational exposure, and lung function (i.e. spirometry). Then, we used statistical and data mining methods to explore the most important predictors for asthma exacerbations.

RESULTS

We identified essential predictors by calculating the odds ratios (OR) for the exacerbation in a logistic regression model. The average age was 45.42 ± 11.74 years (19-85 years), and 422 (72.26%) participants were females. 42.97% of participants had exacerbations in the past year, and 31.16% had a history of occupational exposure. In a multivariate model analysis adjusted for age and gender, the most important predictors for exacerbation were uncontrolled asthma (OR 4.79, p < .001), occupational exposure (OR 4.65, p < .001), and lung function impairment (FEV1 < 80%) (OR 1.15, p = .011). The ensemble machine learning experiments on combined patient features harnessed by our data mining approach reveal that the best predictor is professional exposure, followed by ACT.

CONCLUSIONS

Machine learning ensemble methods and statistical analysis concordantly indicate that occupational exposure and ACT < 20 are strong predictors for asthma exacerbation.

Barriers to clinical remission in severe asthma

Severe asthma is associated with an increased risk for exacerbations, reduced lung function, fixed airflow obstruction, and substantial morbidity and mortality. The concept of remission in severe asthma as a new treatment goal has recently gained attention due to the growing use of monoclonal antibody therapies, which target specific pathologic pathways of inflammation. This review evaluates the current definitions of asthma remission and unveils some of the barriers for achieving this state in the severe asthma population. Although there is no unified definition, the concept of clinical remission in asthma should be based on a sustained period of symptom control, elimination of oral corticosteroid exposure and exacerbations, and stabilization of pulmonary function. The conjugation of these criteria seems a realistic treatment target in a minority of asthmatic patients. Some unmet needs in severe asthma may affect the achievement of clinical remission. Late intervention with targeted therapies in the severe asthma population may increase the risk of corticosteroid exposure and the development of irreversible structural airway changes. Moreover, airway infection is an important component in persistent exacerbations in patients on biologic therapies. Phenotyping exacerbations may be useful to guide therapy decisions and to avoid the liberal use of oral corticosteroids. Another challenge associated with the aim of clinical remission in severe asthma is the multifaceted interaction between the disease and its associated comorbidities. Behavioural factors should be evaluated in case of persistent symptoms despite optimised treatment, and assessing biomarkers and targeting treatable traits may allow for a more objective way of reaching remission. The concept of clinical remission will benefit from an international consensus to establish unifying criteria for its assessment, and it should be addressed in the future management guidelines.

Analysis of risk factors for depression and anxiety related to the degree of asthma control in children according to gender

OBJECTIVE

The purpose of the study was to investigate whether risk factors involved in the degree of asthma control were the same for children of both genders.

METHODS

This cross-sectional study collected relevant data from 320 children with asthma attending the respiratory asthma clinic at a local children's hospital. All the patients passed the Asthma Control Test (ACT) or the Childhood Asthma Control Test (cACT), lung-function-related tests, the Children's Depression Inventory (CDI), the Screening Scale for Anxiety-Related Mood Disorders (SCARED), and the Family Personal Information Questionnaire.

RESULTS

The study found that gender (p=0.034) was a risk factor for poor asthma control and that girls (odds ratio [OR]=1.669, p=0.042) were more likely to have poor asthma control than boys. Univariate logistic regression analysis found that severe wasting (OR=0.075, p=0.021), depression (OR=43. 550, p<0.001), anxiety (OR=4.769, p=0.036), FEV1% (OR=0.970, p=0.043), FEV1/FVC% (OR=0.921, p=0. 008), and PEF% (OR=0.961, p=0.012) were risk factors for poor asthma control in girls.

CONCLUSION

The risk factors for the degree of asthma control in children with asthma appeared to vary according to gender.

Allergic diseases aggravate the symptoms of SARS-CoV-2 infection in China

Background

The relationship between allergic diseases and the adverse outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been a subject of controversy. This study aimed to investigate the association between allergic diseases and the incidence and severity of symptoms in SARS-CoV-2 infection.

Methods

Clinical data of individuals, including children and their parents, infected with SARS-CoV-2 from December 2022 to January 2023 in China were retrospectively analyzed. The data were collected through questionnaires. Statistical analysis, including chi-squared tests, nonparametric analysis, one-way ANOVA, and logistic regression analysis, was used to examine the relationship between allergic diseases, prior medication, and the symptoms of SARS-CoV-2 infection.

Results

There were 3,517 adults and 3,372 children with SARS-CoV-2 infection included in the study. Fever was found to occur at similar rates in children (86.5%) and adults (86.8%). However, other symptoms related to respiratory issues (such as cough and sore throat), neurological symptoms (headache, loss of smell, and loss of taste), and systemic symptoms (muscle soreness and weakness) were observed more frequently in adults (P < 0.001). Additionally, adults exhibited higher overall symptom scores, indicating greater severity. Allergic diseases were found to be associated with the incidence of certain SARS-CoV-2 infection symptoms in both children and adults. Specifically, children with allergic rhinitis (AR) were observed to be more susceptible to upper respiratory symptoms (OR: 1.320, 95% CI: 1.081-1.611, P = 0.006), while asthma patients were found to be more susceptible to severe respiratory symptoms (OR: 1.736, 95% CI: 1.250-2.411, P = 0.001). Similar patterns were identified in adults. Furthermore, AR was also suggested to be a risk factor for symptom severity in both children (OR: 1.704, 95% CI: 1.314-2.209, P < 0.001) and adults (OR: 1.736, 95% CI: 1.250-2.411, P = 0.001). However, prior medication for allergic diseases did not exhibit a preventive effect on SARS-CoV-2 infection symptoms.

Conclusions

Both children and adults with allergic diseases were found to be more prone to experiencing symptoms of SARS-CoV-2 infection, and these symptoms tended to be more severe.

Evaluation of mucosal immune profile associated with Zileuton nanocrystal-formulated BCS-II drug upon oral administration in Sprague Dawley rats

Nanocrystal drug formulation involves several critical manufacturing procedures that result in complex structures to improve drug solubility, dissolution, bioavailability, and consequently the efficacy of poorly soluble Biopharmaceutics Classification System (BCS) II and IV drugs. Nanocrystal formulation of an already approved oral drug may need additional immunotoxic assessment due to changes in the physical properties of the active pharmaceutical ingredient (API). In this study, we selected Zileuton, an FDA-approved drug that belongs to BCS-II for nanocrystal formulation. To evaluate the efficacy and mucosal immune profile of the nanocrystal drug, 10-week-old rats were dosed using capsules containing either API alone or nanocrystal formulated Zileuton (NDZ), or with a physical mixture (PM) using flexible oral gavage syringes. Control groups consisted of untreated, or placebo treated animals. Test formulations were administrated to rats at a dose of 30 mg/kg body weight (bw) once a day for 15 days. The rats treated with NDZ or PM had approximately 4.0 times lower (7.5 mg/kg bw) API when compared to the micron sized API treated rats. At the end of treatment, mucosal (intestinal tissue) and circulating cytokines were measured. The immunological response revealed that NDZ decreased several proinflammatory cytokines in the ileal mucosa (Interleukin-18, Tumor necrosis Factor-α and RANTES [regulated upon activation, normal T cell expressed and secreted]). A similar pattern in the cytokine profile was also observed for the micron sized API and PM treated rats. The cytokine production revealed that there was a significant increase in the production of IL-1β and IL-10 in the females in all experimental groups. Additionally, NDZ showed an immunosuppressive effect on proinflammatory cytokines both locally and systemically, which was similar to the response in micron sized API treated rats. These findings indicate that NDZ significantly decreased several proinflammatory cytokines and it displays less immunotoxicity, probably due to the nanocrystal formulation. Thus, the nanocrystal formulation is more suitable for oral drug delivery, as it exhibited better efficacy, safety, and reduced toxicity.

Impact of gold nanoparticles (AuNPs) on eosinophils isolated from male and female individuals

It is well established that some differences exist between the male and female immune systems. Despites this, a sex-based analysis is not frequently performed in most scientific published reports. Knowing that inflammation is a common undesired effect observed resulting from nanoparticle (NP) exposure, we investigate here how in vitro treatment of gold NPs with a primary size of 20 and 70 nm (AuNP20 and AuNP70, respectively) will alter the biology of human eosinophils isolated from men and women blood. We found that treatment of AuNP70, but not AuNP20, significantly delay apoptosis only in eosinophils isolated from women. AuNPs were found to decrease eosinophil phagocytosis, however, significance was only observed in AuNP20-induced eosinophils isolated from women. The production of IL-8 was significantly increased in response to both AuNPs but only in eosinophils isolated from men and the production of IL-1β was increased in AuNPs-induced eosinophils, although significance was observed only in AuNP70-induced eosinophils isolated from women. We conclude that future studies investigating the toxicity of AuNPs (or other NPs) should include a sex-based analysis, especially if the tested NPs have potential medical applications knowing the increased interest in the development of personalized precision medicine.

Sex steroid hormones and allergic diseases in children: a pilot birth cohort study in the Japan Environment and Children's Study cohort

BACKGROUND

Numerous studies suggest that sex steroids might play a role in sex disparity observed in allergic diseases in adults. However, whether sex hormones influence allergic diseases in children remains unclear. The aim of the present study was to examine the association of sex steroid hormones with allergic disease in Japanese children.

METHODS

The present cross-sectional study included 145 6-year-old children participating in a pilot birth cohort study in the Japan Environment and Children's Study. Data on allergic diseases were obtained from questionnaires, and serum levels of sex steroid hormones and allergen-specific IgE were measured. Logistic regression was performed to evaluate the association of sex hormones with allergic diseases.

RESULTS

After adjusted sex, amount of body fat at 6 years, parental history of allergic disease, and exposure to tobacco smoke, serum dehydroepiandrosterone sulfate level was significantly associated with reduced odds of any allergic disease (adjusted odds ratio, 0.58; 95% confidence interval, 0.36-0.93; P = 0.024) and serum follicle-stimulating hormone level was significantly associated with increased odds of any allergic disease (adjusted odds ratio, 2.04; 95% confidence interval, 1.01-4.11, P = 0.046). Dehydroepiandrosterone sulfate level showed a significant association with number of allergic diseases.

CONCLUSIONS

The current study findings suggest that sex hormones may play an important role in the development of allergic diseases in prepubertal children.

Dual activation of estrogen receptor alpha and glucocorticoid receptor upregulate CRTh2-mediated type 2 inflammation; mechanism driving asthma severity in women?

BACKGROUND

Type 2-high asthma is characterized by elevated levels of circulating Th2 cells and eosinophils, cells that express chemoattractant-homologous receptor expressed on Th2 cells (CRTh2). Severe asthma is more common in women than men; however, the underlying mechanism(s) remain elusive. Here we examined whether the relationship between severe asthma and type 2 inflammation differs by sex and if estrogen influences Th2 cell response to glucocorticoid (GC).

METHODS

Type 2 inflammation and the proportion of blood Th2 cells (CD4⁺ CRTh2⁺ ) were assessed in whole blood from subjects with asthma (n = 66). The effects of GC and estrogen receptor alpha (ERα) agonist on in vitro differentiated Th2 cells were examined. Expression of CRTh2, type 2 cytokines and degree of apoptosis (Annexin V⁺ , 7-AAD) were determined by flow cytometry, qRT-PCR, western blot and ELISA.

RESULTS

In severe asthma, the proportion of circulating Th2 cells and hospitalizations were higher in women than men. Women with severe asthma also had more Th2 cells and serum IL-13 than women with mild/moderate asthma. Th2 cells, eosinophils and CRTh2 mRNA correlated with clinical characteristics associated with asthma control in women but not men. In vitro, GC and ERα agonist treated Th2 cells exhibited less apoptosis, more CRTh2 as well as IL-5 and IL-13 following CRTh2 activation than Th2 cells treated with GC alone.

CONCLUSION

Women with severe asthma had higher levels of circulating Th2 cells than men, which may be due to estrogen modifying the effects of GC, enhancing Th2 cell survival and type 2 cytokine production.

Obstructive sleep apnea screening in children with asthma

RATIONALE

Obstructive sleep apnea is highly prevalent in children with asthma, particularly in obese children. The sleep-related breathing disorder screening questionnaire has low screening accuracy for obstructive sleep apnea in children with asthma. Our goal was to identify the questions on the sleep-related breathing disorder survey associated with obstructive sleep apnea in children with asthma.

METHODS

Participants completed the survey, underwent polysomnography and their body mass index z-score was measured. Participants with survey scores above 0.33 were considered high risk for obstructive sleep apnea and those with an apnea-hypopnea index ≥ 2 events/h classified as having obstructive sleep apnea. Logistic regression was used to examine the association of each survey question and obstructive sleep apnea. Positive and negative predictive values were calculated to estimate screening accuracy.

RESULTS

The prevalence of obstructive sleep apnea was 40% in our sample (n = 136). Loud snoring, morning dry mouth, and being overweight were the survey questions associated with obstructive sleep apnea. The composite survey score obtained from all 22 questions had positive and negative predictive values of 51.0% and 65.5%, while the combined model of loud snoring, morning dry mouth, and being overweight had positive and negative predictive values of 60.3% and 77.6%. On the other hand, the body mass index z-score alone had positive and negative predictive values of 76.3% and 72.2%.

CONCLUSIONS

The body mass index z-score is useful for obstructive sleep apnea screening in children with asthma and should be applied routinely given its simplicity and concerns that obstructive sleep apnea may contribute to asthma morbidity.

Physiological estrogen levels are dispensable for the sex difference in immune responses during allergen-induced airway inflammation

Women show an increased prevalence of adult-onset asthma compared to men and previous studies have shown that testosterone inhibits while estrogen worsens allergen-induced airway inflammation. However, detailed knowledge about the aggravating effects of estrogen on immune responses remain unclear. Defining the effects of physiological levels of estrogen on immune responses in asthma would aid in the development of improved treatment strategies. In this study, the importance of estrogen for the sex difference in asthma was determined using a murine model of house dust mite (HDM)-induced airway inflammation on intact female and male mice, as well as on ovariectomized (OVX) female mice treated with a physiological dose of 17β-estradiol (E2). Innate and adaptive immune responses were defined in bronchoalveolar lavage fluid, mediastinal lymph node (mLN) and lung tissue. The results reveal increased numbers of lung eosinophils, macrophages, and dendritic cells in female but not in male mice after HDM challenge. Females also exhibit higher numbers of Th17 cells in both mLN and lung in response to HDM. However, treatment of OVX mice with physiological levels of E2 does not influence any of the analyzed cell populations. Together, this study confirms the previously reported sex difference in allergen-induced airway inflammation and show that female mice mount stronger innate and adaptive immune responses to HDM challenge, but these effects are not mediated by physiological levels of E2.

Sex differences of small airway function and fractional exhaled nitric oxide in patients with mild asthma

BACKGROUND

Sex differences of small airway function (SAF) and fractional exhaled nitric oxide (FeNO) in patients with mild asthma remain unclear.

OBJECTIVE

To evaluate sex differences of SAF and FeNO in patients with mild asthma confirmed by positive methacholine challenge test (MCT) result.

METHODS

This cross-sectional, double-centered, observational study enrolled 1609 adult patients with forced expiratory volume in 1 second greater than or equal to 80% and suspected asthma symptoms. Data of spirometry, FeNO, impulse oscillometry measurements, and peripheral blood test result were compared between males and females. The receiver-operating characteristic curves of SAF parameters and FeNO in predicting positive MCT result were also calculated.

RESULTS

In patients with mild asthma matched by age, males had better SAF but higher FeNO levels than females (60 [29.27%] vs 187 [46.75%] for small airway dysfunction, 78.6% vs 72.0% for forced expiratory flow [FEF]_50%, 67.5% vs 60.1% for FEF_75%, 73.7% vs 67.4% for FEF_25%-75%, and 42.0 ppb vs 29.0 ppb for FeNO, respectively, all P ≤ .001). The FeNO levels in male current smokers were considerably lower than those of nonsmokers. SAF and FeNO values declined more rapidly with age among female than male patients with asthma. The optimal cutoff values of FEF_25%-75%, FEF_50%, and FeNO for predicting a positive MCT result were 81.5%, 86.4%, and 41.0 ppb in males vs 73.7%, 76.9%, and 35.0 ppb in females.

CONCLUSION

In patients with mild asthma, the female patients have worse SAF, lower FeNO levels, and a more prominent decline trend of those parameters with age than males. Sex-specific cutoff values should be considered when SAF parameters (FEF_25%-75%, FEF_50%), alone or combined with FeNO, are used to predict positive MCT result in asthma diagnosis.

Characterization of sex-related differences in allergen house dust mite-challenged airway inflammation, in two different strains of mice

Biological sex impacts disease prevalence, severity and response to therapy in asthma, however preclinical studies often use only one sex in murine models. Here, we detail sex-related differences in immune responses using a house dust mite (HDM)-challenge model of acute airway inflammation, in adult mice of two different strains (BALB/c and C57BL/6NJ). Female and male mice were challenged (intranasally) with HDM extract (~ 25 μg) for 2 weeks (N = 10 per group). Increase in serum HDM-specific IgE showed a female bias, which was statistically significant in BALB/c mice. We compared naïve and HDM-challenged mice to define immune responses in the lungs by assessing leukocyte accumulation in the bronchoalveolar lavage fluid (BALF), and profiling the abundance of 29 different cytokines in BALF and lung tissue lysates. Our results demonstrate specific sex-related and strain-dependent differences in airway inflammation. For example, HDM-driven accumulation of neutrophils, eosinophils and macrophages were significantly higher in females compared to males, in BALB/c mice. In contrast, HDM-mediated eosinophil accumulation was higher in males compared to females, in C57BL/6NJ mice. Differences in lung cytokine profiles indicated that HDM drives a T-helper (Th)17-biased response with higher IL-17 levels in female BALB/c mice compared to males, whereas female C57BL/6NJ mice elicit a mixed Th1/Th2-skewed response. Male mice of both strains showed higher levels of specific Th2-skewed cytokines, such as IL-21, IL-25 and IL-9, in response to HDM. Overall, this study details sex dimorphism in HDM-mediated airway inflammation in mice, which will be a valuable resource for preclinical studies in allergic airway inflammation and asthma.

Hormonal Effects on Asthma, Rhinitis, and Eczema

Hormones significantly influence the pathogenesis of asthma, rhinitis, and eczema. This review aims to summarize relevant clinical considerations for practicing allergists and immunologists. The first section reviews the effects of sex hormones: estrogen, progesterone, and testosterone. The second concerns insulin production in the context of type 1 and type 2 diabetes. The third concludes with a discussion of thyroid and adrenal pathology in relationship to asthma, rhinitis, and eczema.

Impact of COVID-19 pandemic on asthma exacerbations: Retrospective cohort study of over 500,000 patients in a national English primary care database

Background

Several countries reported a substantial reduction in asthma exacerbations associated with COVID-19 pandemic-related restrictions. However, it is not known if these early reported declines were short-term and if these have rebounded to pre-pandemic levels following easing of lockdown restrictions.

Methods

We undertook a retrospective, cohort study of all asthma patients in a national primary care database of almost 10 million patients, Optimum Patient Care Database (OPCRD), identified from January 1, 2010, to December 31, 2015, using a previously validated algorithm. We subsequently followed the identified cohort of asthma patients from January 1, 2016, to October 3, 2021, and identified every asthma exacerbation episode with a validated algorithm. To quantify any pandemic-related change in exacerbations, we created a control time-series (mean of 2016-2019) and then compared the change in exacerbation rate in 2020-2021 over quarterly periods when compared with the control period (the pre-pandemic period). We undertook overall and stratified analyses by age group, sex, and English region.

Findings

We identified 100,362 asthma patients (502,669 patient-years) from across England who experienced at least one exacerbation episode (298,390 exacerbation episodes during the entire follow-up). Except for the first quarter of 2020, the exacerbation rates were substantially lower (>25%) during all quarters in 2020-2021 when compared with the rates during 2016-2019 (39.7% (95% Confidence Interval (CI): 34.6, 44.9) in quarter-2, 2020; 46.5% (95%CI: 36.7, 56.4) in quarter-3, 2020; 56.3% (95%CI: 48.7, 63.9) in quarter-4, 2020; 63.2% (95%CI: 53.9, 72.5) in quarter-1, 2021; 57.7% (95%CI: 52.9, 62.4) in quarter-2, 2021; 53.3% (95%CI: 43.8, 62.8) in quarter-3, 2021).

Interpretation

There was a substantial and persistent reduction in asthma exacerbations across England over the first 18 months after the first lockdown. This is unlikely to be adequately explained by changes in health-seeking behaviour, pandemic-related healthcare service disruption, or any air-quality improvements.

Funding

Asthma UK, Health Data Research UK (HDR UK), Medical Research Council (MRC), National Institute for Health Research (NIHR).

Clinical response to biologics for severe asthma: any relevance for sex in different age ranges?

Background

Whether sex can influence the clinical response to biological treatment in patients with severe asthma has not been fully addressed.

Aims and methods

The aim of this study was to investigate in patients with severe asthma undergoing biological treatment the individual evolution of lung function measurements and patient-reported asthma control scores over a 12-month follow-up period, in relation to patients’ sex, in different age ranges. Second, the change in the administered dose of oral corticosteroids (OCS) before and after 12 months of treatment was investigated.

Results

64 patients (58% female and 42% male) with a median age of 52 years were enrolled in the study. There were no relevant differences between sexes in terms of lung function, patient-reported asthma control, exacerbation rate and daily OCS dose within the study timeframe. A separate sub-analysis by biological treatment confirmed the same finding. Stratifying individuals by age, we showed that older men had lower lung function parameter values (forced expiratory volume in 1 s (FEV₁) % predicted and FEV₁/forced vital capacity index) than older women, whereas an opposite trend was observed in terms of Asthma Control Test score. No other relevant differences were detected after age stratification.

Conclusion

According to our findings, sex does not act as a determinant of treatment response to biologicals in people with severe asthma. Although to be confirmed in larger studies, our data suggest that neither sex nor age should limit biological treatment prescription, once the eligibility criteria for that therapy are satisfied.

Sex does not seem to act as a determinant of treatment response to biologicals in severe asthma. Neither sex nor age should limit biological treatment prescription, once the eligibility criteria for that therapy are satisfied.https://bit.ly/370frEP

Lung function in young adulthood: differences between males and females with asthma

Background

There are phenotypic differences in asthma in males and females. Differences in lung function between the sexes at the peak lung function level in young adulthood are so far not directly addressed. The aim of the present study was to assess lung function in early adulthood in males and females depending on asthma onset and remission.

Methods

Participants were included from the population-based birth cohort BAMSE and classified as having: never asthma, childhood asthma in remission, adolescent onset asthma or persistent asthma. Pre- and post-bronchodilator lung function (in Z-score) and lung clearance index (LCI) were measured at age 24 years. Lung function was compared stratified for sex between the never asthma and asthma groups univariately and in multiple linear regression analyses adjusted for maternal and paternal asthma, maternal smoking during pregnancy, secondary smoking, daily smoking, early respiratory syncytial virus infection, traffic pollution, childhood allergic sensitisation, and body mass index at age 24 years.

Results

All asthma phenotypes were associated with a lower forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) post-bronchodilation at 24 years. This was most pronounced in males with persistent asthma compared to males with never asthma (regression coefficient: −0.503; 95% CI: −0.708– −0.298). Childhood asthma (in remission or persistent) was associated with a lower FEV₁. After adjustment, the associations remained significant for males. For females, the significant associations with lower FEV₁ and FEV₁/FVC remained only for subjects with asthma in remission. Persistent asthma was associated with higher LCI in females.

Conclusions

In females, in contrast to males, the association between asthma and lower lung function was attenuated after adjustment for known risk factors.

Current or previous asthma is associated with lower lung function in early adulthood. In females, in contrast to males, the association between asthma and lower lung function is attenuated after adjustment for known risk factors.https://bit.ly/37vDzzu

Sex Disparities in Asthma Development and Clinical Outcomes: Implications for Treatment Strategies

A gender-related disparity exists in asthma morbidity and mortality, which shifts at around puberty from a male predominance to a female predominance. This is clinically reflected in the fact that asthma that occurs in childhood (childhood-onset asthma) mainly affects boys, and that asthma that occurs in adulthood (adult-onset asthma) mainly affects women. Adult-onset asthma is often non-atopic, more severe, and associated with a poorer prognosis, thus posing a marked burden to women’s health and healthcare system. Many factors have been indicated to explain this gender-related disparity, including sociocultural and environmental factors as well as biological sex differences (genetic, pulmonary and immunological factors). It has long been suggested that sex hormones may be implicated in at least these biological sex differences. Overall, the evidence remains equivocal for the role of most sex hormones in asthma pathogenesis and clinical outcomes. Well-designed randomized clinical trials are required assessing the potential preventive or therapeutic effects of hormonal contraceptives on asthma in women, thereby helping to advance the evidence to inform future practice guidelines. The mechanisms underlying the role of sex hormones in asthma are complex, and our understanding is not yet complete. Additional mechanistic studies elucidating sex hormone signaling pathways and their interactions involved in the pathogenesis and clinical manifestations of asthma will help to identify potential sex hormone-driven asthma endotypes and novel therapeutic targets, providing the basis for a more personalized asthma management strategy.

Severe asthma exacerbation rates are increased among female, Black, Hispanic, and younger adult patients: results from the US CHRONICLE study

OBJECTIVE

To describe clinical outcomes in patients with severe asthma (SA) by common sociodemographic determinants of health: sex, race, ethnicity, and age.

METHODS

CHRONICLE is an observational study of subspecialist-treated, United States adults with SA receiving biologic therapy, maintenance systemic corticosteroids, or uncontrolled by high-dosage inhaled corticosteroids with additional controllers. For patients enrolled between February 2018 and February 2020, clinical characteristics and asthma outcomes were assessed by sex, race, ethnicity, age at enrollment, and age at diagnosis. Treating subspecialists reported exacerbations, exacerbation-related emergency department visits, and asthma hospitalizations from 12 months before enrollment through the latest data collection. Patients completed the St. George's Respiratory Questionnaire and the Asthma Control Test at enrollment.

RESULTS

Among 1884 enrolled patients, the majority were female (69%), reported White race (75%), non-Hispanic ethnicity (69%), and were diagnosed with asthma as adults (60%). Female, Black, Hispanic, and younger patients experienced higher annualized rates of exacerbations that were statistically significant compared with male, White, non-Hispanic, and older patients, respectively. Black, Hispanic, and younger patients also experienced higher rates of asthma hospitalizations. Female and Black patients exhibited poorer symptom control and poorer health-related quality of life.

CONCLUSIONS

In this contemporary, real-world cohort of subspecialist-treated adults with SA, female sex, Black race, Hispanic ethnicity, and younger age were important determinants of health, potentially attributable to physiologic and social factors. Knowledge of these disparities in SA disease burden among subspecialist-treated patients may help optimize care for all patients.

Supplemental data for this article is available online at at www.tandfonline.com/ijas .

Sex and gender in asthma

Asthma is a heterogenous disease, and its prevalence and severity are different in males versus females through various ages. As children, boys have an increased prevalence of asthma. As adults, women have an increased prevalence and severity of asthma. Sex hormones, genetic and epigenetic variations, social and environmental factors, and responses to asthma therapeutics are important factors in the sex differences observed in asthma incidence, prevalence and severity. For women, fluctuations in sex hormone levels during puberty, the menstrual cycle and pregnancy are associated with asthma pathogenesis. Further, sex differences in gene expression and epigenetic modifications and responses to environmental factors, including SARS-CoV-2 infections, are associated with differences in asthma incidence, prevalence and symptoms. We review the role of sex hormones, genetics and epigenetics, and their interactions with the environment in the clinical manifestations and therapeutic response of asthma.

Role of Sex Hormones at Different Physiobiological Conditions and Therapeutic Potential in MBD2 Mediated Severe Asthma

Sex hormone has become a “hot topic” to evaluate the hormonal therapeutic potential in severe asthma. Th17 cell is one of the main influencing factors involved in the pathogenesis of severe asthma, hence also called as kernel of severe asthma, and Th17 subtype of non-T2 asthma is less responsive (resistance) to inhaled corticosteroid (ICS), so severe in nature. Methyl-CpG binding domain protein 2 (MBD2) is overexpressed and regulates the Th17 differentiation, showing the possibility of therapeutic target in treating Th17 mediated severe asthma. Sex hormone fluctuates at the different physiobiological conditions of the human body and affects the asthma pathobiology showing its role in asthma prevalence, severity, remission, and therapy. This review briefly overviews the sex hormones, their influence in asthma at the different physiobiological conditions of human body, and MBD2 severe asthma connection with the possible therapeutic potential of sex steroids in MBD2 mediated Th17 predominant severe asthma. Male sex hormone tends to show a beneficial effect and possibly downregulates the expression of Th17 cells via regulating MBD2 through a mechanism distinct from corticosteroid treatment and guides us towards discovery of new therapeutic agent, reduces the asthma-related complications, and promotes long-term survival by lowering the risk of therapy-resistant issues of old age severe asthma.

Sex, Cells, and Asthma

There are marked sex differences in asthma prevalence and severity. Sex hormones play a central role in these sex biases and directly interact with multiple key cells involved in the pathogenesis of asthma. Here we review the known effects of estrogen, progesterone, and testosterone on airway epithelial cells, airway smooth muscle cells, the mononuclear phagocyte system, innate lymphoid cells, eosinophils, mast cells, T cells, and B cells, all in the context of asthma. Furthermore, we explore unresolved clinical questions, such as the role of sex hormones in the link between asthma and obesity.

Fetal Growth Restriction and Asthma: Is the Damage Done?

Trajectories of airway remodeling and functional impairment in asthma are consistent with the notion that airway pathology precedes or coincides with the onset of asthma symptoms and may be present at birth. An association between intrauterine growth restriction (IUGR) and asthma development has also been established, and there is value in understanding the underlying mechanism. This review considers airway pathophysiology as a consequence of IUGR that increases susceptibility to asthma.

Sex Differences in Pulmonary Eicosanoids and Specialized Pro-Resolving Mediators in Response to Ozone Exposure

Ozone (O3) is a criteria air pollutant known to increase the morbidity and mortality of cardiopulmonary diseases. This occurs through a pulmonary inflammatory response characterized by increased recruitment of immune cells into the airspace, pro-inflammatory cytokines, and pro-inflammatory lipid mediators. Recent evidence has demonstrated sex-dependent differences in the O3-induced pulmonary inflammatory response. However, it is unknown if this dimorphic response is evident in pulmonary lipid mediator metabolism. We hypothesized that there are sex-dependent differences in lipid mediator production following acute O3 exposure. Male and female C57BL/6J mice were exposed to 1 part per million O3 for 3 hours and were necropsied at 6 or 24 hours following exposure. Lung lavage was collected for cell differential and total protein analysis, and lung tissue was collected for mRNA analysis, metabololipidomics, and immunohistochemistry. Compared to males, O3-exposed female mice had increases in airspace neutrophilia, neutrophil chemokine mRNA, pro-inflammatory eicosanoids such as prostaglandin E2, and specialized pro-resolving mediators (SPMs) such as resolvin D5 in lung tissue. Likewise, precursor fatty acids (arachidonic and docosahexaenoic acid; DHA) were increased in female lung tissue following O3 exposure compared to males. Experiments with ovariectomized females revealed that loss of ovarian hormones exacerbates pulmonary inflammation and injury. However, eicosanoid and SPM production were not altered by ovariectomy despite depleted pulmonary DHA concentrations. Taken together, these data indicate that O3 drives an increased pulmonary inflammatory and bioactive lipid mediator response in females. Furthermore, ovariectomy increases susceptibility to O3-induced pulmonary inflammation and injury, as well as decreases pulmonary DHA concentrations.

Intrauterine growth restriction predisposes to airway inflammation without disruption of epithelial integrity in postnatal male mice

Evidence from animal models demonstrate that intrauterine growth restriction (IUGR) alters airway structure and function which may affect susceptibility to disease. Airway inflammation and dysregulated epithelial barrier properties are features of asthma which have not been examined in the context of IUGR. This study used a maternal hypoxia-induced IUGR mouse model to assess lung-specific and systemic inflammation and airway epithelial tight junctions (TJs) protein expression. Pregnant BALB/c mice were housed under hypoxic conditions (10.5% O2) from gestational day (GD) 11 to 17.5 (IUGR group; term, GD 21). Following hypoxic exposure, mice were returned to a normoxic environment (21% O2). A Control group was housed under normoxic conditions throughout pregnancy. Offspring weights were recorded at 2 and 8 weeks of age and euthanized for bronchoalveolar lavage (BAL) and peritoneal cavity fluid collection for inflammatory cells counts. From a separate group of mice, right lungs were collected for Western blotting of TJs proteins. IUGR offspring had greater inflammatory cells in the BAL fluid but not in peritoneal fluid compared with Controls. At 8 weeks of age, interleukin (IL)-2, IL-13, and eotaxin concentrations were higher in male IUGR compared with male Control offspring but not in females. IUGR had no effect on TJs protein expression. Maternal hypoxia-induced IUGR increases inflammatory cells in the BAL fluid of IUGR offspring with no difference in TJs protein expression. Increased cytokine release, specific to the lungs of IUGR male offspring, indicates that both IUGR and sex can influence susceptibility to airway disease.

Bronchodilator response and lung function decline: Associations with exhaled nitric oxide with regard to sex and smoking status

Background

Fractional exhaled nitric oxide (FeNO) is a marker of type-2 inflammation used both to support diagnosis of asthma and follow up asthma patients. The associations of FeNO with lung function decline and bronchodilator (BD) response have been studied only scarcely in large populations.

Objectives

To study the association between FeNO and a) retrospective lung function decline over 20 years, and b) lung function response to BD among asthmatic subjects compared with non-asthmatic subjects and with regards to current smoking and sex.

Methods

Longitudinal analyses of previous lung function decline and FeNO level at follow-up and cross-sectional analyses of BD response and FeNO levels in 4257 participants (651 asthmatics) from the European Community Respiratory Health Survey.

Results

Among asthmatic subjects, higher percentage declines of FEV₁ and FEV₁/FVC were associated with higher FeNO levels (p = 0.001 for both) at follow-up. These correlations were found mainly among non-smoking individuals (p = 0.001) and females (p = 0.001) in stratified analyses.

Percentage increase in FEV₁ after BD was positively associated with FeNO levels in non-asthmatic subjects. Further, after stratified for sex and smoking separately, a positive association was seen between FEV₁ and FeNO levels in non-smokers and women, regardless of asthma status.

Conclusions

We found a relationship between elevated FeNO and larger FEV₁ decline over 20 years among subjects with asthma who were non-smokers or women. The association between elevated FeNO levels and larger BD response was found in both non-asthmatic and asthmatic subjects, mainly in women and non-smoking subjects.

The Human Microbiome, an Emerging Key-Player in the Sex Gap in Respiratory Diseases

The sex gap is well-documented in respiratory diseases such as cystic fibrosis and chronic obstructive pulmonary disease. While the differences between males and females in prevalence, severity and prognosis are well-established, the pathophysiology of the sex difference has been poorly characterized to date. Over the past 10 years, metagenomics-based studies have revealed the presence of a resident microbiome in the respiratory tract and its central role in respiratory disease. The lung microbiome is associated with host immune response and health outcomes in both animal models and patient cohorts. The study of the lung microbiome is therefore an interesting new avenue to explore in order to understand the sex gap observed in respiratory diseases. Another important parameter to consider is the gut-lung axis, since the gut microbiome plays a crucial role in distant immune modulation in respiratory diseases, and an intestinal “microgenderome” has been reported: i.e., sexual dimorphism in the gut microbiome. The microgenderome provides new pathophysiological clues, as it defines the interactions between microbiome, sex hormones, immunity and disease susceptibility. As research on the microbiome is increasing in volume and scope, the objective of this review was to describe the state-of-the-art on the sex gap in respiratory medicine (acute pulmonary infection and chronic lung disease) in the light of the microbiome, including evidence of local (lung) or distant (gut) contributions to the pathophysiology of these diseases.

Roles of Genetic Predisposition in the Sex Bias of Pulmonary Pathophysiology, as a Function of Estrogens : Sex Matters in the Prevalence of Lung Diseases

In addition to studies focused on estrogen mediation of sex-different regulation of systemic circulations, there is now increasing clinical relevance and research interests in the pulmonary circulation, in terms of sex differences in the morbidity and mortality of lung diseases such as inherent-, allergic- and inflammatory-based events. Thus, female predisposition to pulmonary artery hypertension (PAH) is an inevitable topic. To better understand the nature of sexual differentiation in the pulmonary circulation, and how heritable factors, in vivo- and/or in vitro-altered estrogen circumstances and changes in the live environment work in concert to discern the sex bias, this chapter reviews pulmonary events characterized by sex-different features, concomitant with exploration of how alterations of genetic expression and estrogen metabolisms trigger the female-predominant pathological signaling. We address the following: PAH (Sect.7.2) is characterized as an estrogenic promotion of its incidence (Sect. 7.2.2), as a function of specific germline mutations, and as an estrogen-elicited protection of its prognosis (Sect.7.2.1). More detail is provided to introduce a less recognized gene of Ephx2 that encodes soluble epoxide hydrolase (sEH) to degrade epoxyeicosatrienic acids (EETs). As a susceptible target of estrogen, Ephx2/sEH expression is downregulated by an estrogen-dependent epigenetic mechanism. Increases in pulmonary EETs then evoke a potentiation of PAH generation, but mitigation of its progression, a phenomenon similar to the estrogen-paradox regulation of PAH. Additionally, the female susceptibility to chronic obstructive pulmonary diseases (Sect. 7.3) and asthma (Sect.7.4), but less preference to COVID-19 (Sect. 7.5), and roles of estrogen in their pathogeneses are briefly discussed.

Asthma, atopy, and exercise: Sex differences in exercise-induced bronchoconstriction

Asthma is a chronic inflammatory lung disease affecting approximately 7.7% of the US population. Sex differences in the prevalence, incidence, and severity of asthma have been widely described throughout the lifespan, showing higher rates in boys than girls before puberty, but a reversed pattern in adults. Asthma is often associated with atopy, i.e. the tendency to develop allergic diseases, and can be worsened by environmental stimuli and/or exercise. While not exclusive to patients with asthma, exercise-induced bronchoconstriction (EIB) is a common complication of athletes and individuals who exercise regularly. Currently, there is limited research on sex differences in EIB and its relationship with atopy and asthma in men and women. In this minireview, we summarize the available literature on this topic. Overall, the collective knowledge supports the notion that physiological changes triggered during exercise affect males and females differently, suggesting an interaction among sex, exercise, sex hormones, and atopic status in the course of EIB pathophysiology. Understanding these differences is important to provide personalized management plans to men and women who exercise regularly and suffer from underlying asthma and/or atopy.

Household mold, pesticide use, and childhood asthma: A nationwide study in the U.S

OBJECTIVES

To investigate the associations of household mold and pesticide use with risk of childhood asthma and examine the potential effect modification by child's sex at a national level in the U.S.

METHODS

Nationally representative data were drawn from the cross-sectional 2017 and 2018 National Surveys of Children's Health. Household mold and pesticide exposures during the past 12 months and physician-diagnosed childhood asthma were assessed by standard questionnaires administered to primary caregivers. Multivariable logistic regression models were used to calculate adjusted odds ratios (aOR) for current asthma, adjusting for child, caregiver, and household covariates. We also examined potential effect modification by child's sex. Sampling weights accounted for the complex survey design.

RESULTS

Among 41,423 U.S. children in 2017-2018, the weighted prevalence of current asthma was 10.8% in household mold-exposed children, compared with 7.2% in non-exposed children (P < 0.001). After adjusting for covariates including child's obesity, children with household mold exposure compared to those with no household mold exposure had a 1.41-fold (95% CI: 1.07, 1.87) higher odds of current asthma. Associations between household mold and current asthma were pronounced among boys (aOR 1.57; 95% CI: 1.03-2.38) but not girls (aOR 1.28; 0.90-1.83; P for interaction <0.001). No significant associations were observed between household pesticide use and current asthma, after adjusting for covariates.

CONCLUSIONS

Our findings suggest that household mold is associated with current asthma among children, independent of other major risk factors including child's obesity status. Our findings may inform strategies targeting mitigation of household mold as an important indoor environment factor to address childhood asthma.

Association of socioeconomic deprivation with asthma care, outcomes, and deaths in Wales: A 5-year national linked primary and secondary care cohort study

BACKGROUND

Socioeconomic deprivation is known to be associated with worse outcomes in asthma, but there is a lack of population-based evidence of its impact across all stages of patient care. We investigated the association of socioeconomic deprivation with asthma-related care and outcomes across primary and secondary care and with asthma-related death in Wales.

METHODS AND FINDINGS

We constructed a national cohort, identified from 76% (2.4 million) of the Welsh population, of continuously treated asthma patients between 2013 and 2017 using anonymised, person-level, linked, routinely collected primary and secondary care data in the Secure Anonymised Information Linkage (SAIL) Databank. We investigated the association between asthma-related health service utilisation, prescribing, and deaths with the 2011 Welsh Index of Multiple Deprivation (WIMD) and its domains. We studied 106,926 patients (534,630 person-years), 56.3% were female, with mean age of 47.5 years (SD = 20.3). Compared to the least deprived patients, the most deprived patients had slightly fewer total asthma-related primary care consultations per patient (incidence rate ratio [IRR] = 0.98, 95% CI 0.97-0.99, p-value < 0.001), slightly fewer routine asthma reviews (IRR = 0.98, 0.97-0.99, p-value < 0.001), lower controller-to-total asthma medication ratios (AMRs; 0.50 versus 0.56, p-value < 0.001), more asthma-related accident and emergency (A&E) attendances (IRR = 1.27, 1.10-1.46, p-value = 0.001), more asthma emergency admissions (IRR = 1.56, 1.39-1.76, p-value < 0.001), longer asthma-related hospital stay (IRR = 1.64, 1.39-1.94, p-value < 0.001), and were at higher risk of asthma-related death (risk ratio of deaths with any mention of asthma 1.56, 1.18-2.07, p-value = 0.002). Study limitations include the deprivation index being area based and the potential for residual confounders and mediators.

CONCLUSIONS

In this study, we observed that the most deprived asthma patients in Wales had different prescribing patterns, more A&E attendances, more emergency hospital admissions, and substantially higher risk of death. Interventions specifically designed to improve treatment and outcomes for these disadvantaged groups are urgently needed.

Significant Clinical Associations Between Exposure Type Factors and Recurrent Wheezing and Asthma in Children

The study aimed to identify certain factors related to family history, pathological conditions, or exposure-type that are significantly correlated with recurrent wheezing and/or asthma in children. One hundred nine children with recurrent wheezing and 44 children with asthma were studied in order to identify the degree of correlation of these conditions with familial history of asthma or atopy, child’s age group, gender, premature birth, perinatal asphyxia, neonatal infection, and antibiotic treatment during the neonatal period, history of atopy and obesity and histamine intolerance, nasopharyngeal bacterial colonization, pneumonia with bronchospasm. The clinical picture of these two diseases was also compared regarding the severity of exacerbations and their response to controller therapy. The medium age of children diagnosed with recurrent wheezing was significantly lower than those diagnosed with asthma (5.64 vs. 9.01 years; p<0.001). Inside the recurrent wheezing group, age distribution differed significantly from the asthma group (p-value <0.001). Atopy was the only pathological condition significantly associated with asthma (56.0%) when compared with the recurrent wheezing group (30.2%) with a relative risk value of 1.34 (p<0.004). For patients colonized with Staphylococcus aureus, the medium number of wheezing exacerbations was significantly higher (p<0.049). Approximately 91% of patients in the recurrent wheezing group and 71% from the asthma group responded to appropriate controller treatment. Our study showed a significant association between asthma and atopy, justifying the need to monitor asthma risk in a child with wheezing and atopy. Nasal carriage of Staphylococcus aureus proved to be significantly associated with the recurrence of wheezing in children.

Sex Differences in Severe Asthma: Results From Severe Asthma Network in Italy-SANI

Purpose

After adolescence, asthma is more frequent in females than in males due to different hormonal, immunologic, and occupational/environmental factors. The higher prevalence and severity of the disease in females have already been reported in international registries. The aim of this study was to explore the difference in terms of clinical, functional, and biological characteristics between male and female patients with severe asthma in a real-life, registry-based setting.

Methods

Baseline data from the Severe Asthma Network in Italy registry were analyzed in 1,123 patients with severe asthma, according to sex.

Results

Almost 2/3 of severe asthmatics were female. Late-onset asthma, obesity and gastro-esophageal reflux were more frequent in females than in males, while previous smoking habits and nasal polyposis were more frequent in males. Females had poor asthma control and a higher number of severe exacerbations leading to hospitalization, in comparison to males. Biomarkers of type 2 inflammation (blood eosinophil, exhaled nitric oxide, and serum immunoglobulin E levels) were significantly higher in males than in females. The type 2 profile (defined by a combination of these 3 biomarkers) was significantly more frequent in males than in females. In multivariate analysis, late-onset asthma and a normal body mass index were only independent variables associated with the type 2 profile, while male sex and age showed only a trend toward the association with the type 2 profile.

Conclusions

Significant differences may be observed between male and female patients with severe asthma, influencing the asthma pheno-endotyping in both sexes.

Characteristics and outcomes of asthmatic patients with COVID-19 pneumonia who require hospitalisation

Background

Viral respiratory infections are the main causes of asthma exacerbation. The susceptibility of patients with asthma to develop an exacerbation when they present with severe pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is unknown. The objective of this study was to investigate the characteristics and outcomes of asthmatic patients with coronavirus disease 2019 (COVID-19) pneumonia who required hospitalisation during the spring 2020 outbreak in Paris, France.

Methods

A prospective cohort follow-up was carried out from 15 March to 15 April 2020 in Bicêtre Hospital, University Paris-Saclay, France. All hospitalised patients with a SARS-CoV-2 infection who reported a history of asthma were included.

Results

Among 768 hospitalised patients, 37 (4.8%) reported a history of asthma, which had been previously confirmed by a pulmonologist in 85% of cases. These asthmatic patients were mainly female (70%) and nonsmokers (85%), with a median age of 54 years (interquartile range (IQR) 42–67 years). None of them presented with an asthma exacerbation. 22 (59%) had major comorbidities and 31 (84%) had a body mass index ≥25 kg·m⁻². The most common comorbidities were obesity (36%), hypertension (27%) and diabetes (19%). All patients had a confirmed diagnosis of COVID-19 pneumonia on computed tomography of the chest. Eosinopenia was a typical biological feature with a median count of 0 cells·mm⁻³ (IQR 0–0 cells·mm⁻³). 11 patients (30%) were admitted into the intensive care unit, with three deaths (8.1%) occurring in the context of comorbidities.

Conclusion

Asthma patients were not overrepresented among those with severe pneumonia due to SARS-CoV-2 infection who required hospitalisation. The worst outcomes were observed mainly in patients with major comorbidities.

Asthmatic patients were not overrepresented among those with severe pneumonia due to SARS-CoV-2 infection who required hospitalisation. None presented with an asthma exacerbation. Worst outcomes were observed mainly in patients with major comorbidities.https://bit.ly/303djG6

Different baseline characteristics are associated with incident wheeze in female and male adolescents

AIM

To investigate the independent relationships between baseline characteristics and incident wheeze in adolescents, with particular regard to gender.

METHODS

Adolescents (N = 959), aged 12-15 years, answered a standardised respiratory questionnaire and underwent height and weight measurements at baseline. Four years later, 96% of the subjects completed a similar questionnaire. The present study included the adolescents without self-reported wheeze at baseline (n = 795; 394 girls).

RESULTS

The proportion of adolescents with obesity was higher among subjects with incident wheeze than among subjects who never reported wheeze: 19.1% vs 8.3%. When stratifying for gender, this difference was only found in girls. In stepwise logistic regression models (odds ratios [95% confidence interval]), obesity (2.84 [1.17-6.86]) and rhinitis (3.04 [1.53-6.03]) at baseline and current smoking (2.60 [1.16-5.82]) at follow-up were associated with incident wheeze in girls. For boys, FEV₁ <-1.65 standard deviation (3.20 [1.04-9.79]), family asthma (3.16 [1.46-6.86]) and seasonal allergic symptoms (5.61 [2.56-12.27]) at baseline were independently associated with incident wheeze.

CONCLUSION

Data stratified by gender showed that obesity in girls and an atopic constitution in boys were independently associated with increased risk of developing wheeze within four years.

Assessment of Asthma Control Among Asthmatic Patients at Primary Healthcare Centers in Makkah, Saudi Arabia

Introduction

Asthma is the most common respiratory disease worldwide. In Saudi Arabia, asthma is considered as a major public health concern and has a negative impact in the life of patients, their families, and the community, including lost days of work, absence from school, and poor quality of life, which can eventually lead to frequent emergency department visits, hospitalizations, and sometimes, to death. Thus, the objectives of this study were to evaluate asthma control status among asthmatic patients in primary health care centers (PHCCs) in Makkah, Saudi Arabia and to identify factors associated with poor asthma control.

Methods

This was a cross-sectional study conducted from March to May 2016 in selected PHCCs in Makkah, Saudi Arabia. Data was collected from five PHCCs which were selected using a stratified random sample technique from a total of 47 PHCCs to represent the different geographic regions of the city. The 167 asthmatic patients, aged four years and above, presented during the study period were included. Each respondent completed two tools: the first is a self-administrated questionnaire and the second is the asthma control test. Statistical analyses were performed with SPSS version 21 software (IBM Corp, Armonk, USA). Qualitative variables were analyzed with the Chi-square test or Fisher's exact test as appropriate.

Results

Around one-third (34.1%) of all asthmatic patients were categorized as having uncontrolled asthma and about one-quarter (24.6%) were partially controlled asthma. Dust (91.6%), exposure to incense, detergent and essence (86.8%), common cold (82%) and cold weather (79.6%) were the factors that trigger or exacerbate asthma attacks. Physical activity/exercise and cold weather were the commonest factors that significantly exacerbate asthma attacks particularly among children and were mostly uncontrolled. More than one-third (36.5%) of the asthmatic patients in the PHCCs were cared for by general practitioners.

Conclusion

Poor asthma control was observed in a high proportion of asthmatic children, adolescents and adults in the Makkah region and they were mostly from non-specialized PHCCs. The poor asthma control among the respondents affects their quality of sleep ( i.e., frequent awakening at night), recurrent absences from work and school, increased hospitalizations, emergency and unscheduled visits to the hospital. 

Pharmacotherapeutic management of asthma in pregnancy and the effect of sex hormones

INTRODUCTION

Asthma is a common medical condition that can frequently affect pregnancy, and thus optimal management of asthma in pregnancy is important for both mother and baby. This article reviews recent developments of asthma pharmacotherapy and provides emerging data on the safety of asthma controller medications and biological therapies in pregnancy. The authors highlight the clinical outcomes of asthma during pregnancy, and summarize emerging new data related to the influence of sex hormones and fetal sex on asthma severity.

AREAS COVERED

This review of asthma pharmacotherapy during pregnancy examines the recent guidelines and reports the most pertinent publications on safety data and asthma management.

EXPERT OPINION

Asthma management during pregnancy follows the same principles as that of non-pregnant asthma. The available data for most asthma medications are reassuring, however there is a lack of adequate safety data available because pregnant women are generally excluded from clinical trials. More clarity is needed in guidelines regarding the management of asthma in pregnancy, and high-quality randomized control trials are required to strengthen the evidence base and inform future guidelines. In particular, safety studies examining biological therapies in pregnant women with severe asthma are needed.

Emergency department visits and hospitalisations for emergent asthmatic symptoms from 2014 to 2016: cross-sectional study in Korea

OBJECTIVE

To evaluate the characteristics of emergent patients with asthma who visited emergency departments (EDs) in Korea, and the consequences of these visits.

DESIGN

Retrospective cross-sectional study.

SETTING

We used data from the National Emergency Department Information System database from 2014 to 2016. The data included reports collected from 408 EDs in Korea.

PARTICIPANTS

We analysed the ED cases for asthma-related emergent symptoms that met the following inclusion criteria: (1) had a main diagnosis code of asthma (International Classification of Diseases 10th Revision code: J45/J46), and (2) recorded as an emergent symptom in the EDs.

RESULTS

During 2014-2016, there were 58 713 ED visits related to an asthma diagnosis with emergent symptoms. Following an ED visit, 31.69% were hospitalised, of which 89.88% were admitted to the general wards, and 10.12% to the intensive care units (ICUs). More than 50% of the hospitalised cases included in the group ≥70 years of age. The incidence of death during hospitalisation generally increased with age and the proportion of death in ICU exceeded 10% among the group ≥70 years. The ratio of ICU/general ward admission at the arrival time of 0-03:00, in the ≥60 years age group was the highest compared with other times of the day and age groups.

CONCLUSIONS

We found that among all age groups, ED visits by older patients resulted in more ICU admissions. Our results can help in providing a better understanding of medical resource utilisation by emergent patients with asthma.

The course of asthma: A population-based 10-year study examining asthma remission in children diagnosed with asthma in preschool

BACKGROUND

The natural course of asthma may differ depending on the age of onset.

OBJECTIVE

To investigate predictors of asthma remission with a focus on the age of asthma onset.

METHODS

The study was a retrospective birth cohort of children with asthma in Saskatchewan, Canada. Using the Saskatchewan Ministry of Health databases, we identified children with a diagnosis of asthma in the first 6 years of life and who had at least 10 years of follow-up after diagnosis (n = 22 563). Of these, we included 6393 children either with persistent asthma (≥1 physician visit or hospitalization for asthma [PVHA] during each year of follow-up) and those who had remission (had PVHA in the first year after diagnosis but at some point during the follow-up no longer received PVHA until end of the study). We used survival analysis to examine associations between remission and age of asthma onset.

RESULTS

Of the study participants, 87.2% had early-onset (≤3 years) and 12.8% had late-onset (4-6 years) asthma. Over the 10-years of follow-up, the rate of asthma remission was 37 per 100 person-years. Early-onset asthma (hazard ratio [HR] = 1.10; 95%confidence interval [CI]: 1.01-1.20), being female (HR = 1.12; 95%CI: 1.07-1.18), living in a rural (HR = 1.20; 95%CI: 1.14-1.27) and medium urban (HR = 1.16; 95%CI: 1.08-1.26) location were positively associated with remission while history of atopy decreased likelihood of remission (HR = 0.73; 95%CI: 0.54-0.97).

CONCLUSION

Most children with asthma experienced remission, especially those with the onset of symptoms within the first 3 years of life.

Associations between prenatal exposure to DDT and DDE and allergy symptoms and diagnoses in the Venda Health Examination of Mothers, Babies and their Environment (VHEMBE), South Africa

Dichlorodiphenyl trichloroethane (DDT) is an organochlorine insecticide that is banned internationally except for use as part of Indoor Residual Spraying (IRS) programs to control malaria. Although animal studies show that DDT and its breakdown product dichlorodiphenyl dichloroethylene (DDE) affect the immune system and may cause allergies, no studies have examined this question in populations where IRS is conducted. The aim of our study was to investigate whether prenatal exposure to DDT and DDE is associated with allergy symptoms and diagnose among South African children living in an area where IRS is conducted. To accomplish this aim, we used data from the Venda Health Examination of Mothers, Babies and their Environment (VHEMBE), an ongoing birth cohort study of 752 children born between 2012 and 2013 in the rural Vhembe district of Limpopo, South Africa. We measured maternal peripartum serum concentrations of DDT and DDE, and administered a questionnaire to the caregivers of 658 children aged 3.5 years to collect information on allergy symptoms and diagnoses as well as potential confounders using validated instruments. Using multiple logistic regression models, we found positive associations between DDT and DDE serum concentrations and most of the allergy symptoms and diagnoses. Maternal DDT (Odds Ratio [OR] = 1.5 per 10-fold increase, 95% Confidence interval, CI = 1.0, 2.3) and DDE (OR = 1.4, 95% CI = 0.8, 2.4) serum concentrations were most strongly associated with caregiver report of wheezing or whistling in the chest. Concentrations of DDT and/or DDE were also associated with increased odds of children's chests sounding wheezy during or after exercise, itchy rashes coming and going for at least six months, diagnosis of food allergy, and diagnosis of dust or dust mites allergy but confidence intervals crossed the null. Results suggest that prenatal exposure to DDT, and possibly DDE, is associated with elevated odds of wheezing among children from an IRS area.

Elevated Testosterone Is Associated with Decreased Likelihood of Current Asthma Regardless of Sex

BACKGROUND

Asthma prevalence decreases postpuberty in males. Testosterone inhibits airway smooth muscle contraction and attenuates type 2 inflammation.

OBJECTIVE

To investigate the relationship between serum testosterone and current asthma prevalence and lung function in a nationally representative data set.

METHODS

Serum testosterone and self-reported physician-diagnosed current asthma data were obtained from 7584 participants aged 6 to 80 years from the cross-sectional 2011-2012 National Health and Nutrition Examination Survey. We used logistic regression to test associations between testosterone and current asthma, adjusting for demographic characteristics and stratifying by sex and age; linear regression to evaluate correlations between testosterone and lung function among patients with asthma; and interaction terms to test for effect modification by blood eosinophils and fractional exhaled nitric oxide.

RESULTS

Serum testosterone inversely associated with odds of current asthma in both men and women, but this association was nonlinear. Similar protective effect sizes were observed for both sexes after log₂-transformation of serum testosterone. For every 1-unit increase in log₂ testosterone, the odds of current asthma decreased by 11% in men and 10% in women, although the association was statistically significant in women only among those 12 years or older after multiple imputation. Serum testosterone did not associate with current asthma prevalence among those younger than 12 years. Testosterone associated with increases in FEV₁ in participants with asthma of both sexes. Neither blood eosinophils nor fractional exhaled nitric oxide modified the association between testosterone and current asthma.

CONCLUSIONS

Serum testosterone inversely associates with current asthma prevalence regardless of sex and correlates with better lung function in a nationally representative database. Androgen therapy for asthma should be further investigated.

5α-dihydrotestosterone abrogates sex bias in asthma like features in the mouse

Androgen levels inversely correlate with the incidence, susceptibility and severity of asthma. However, whether male sex hormones such as 5α-dihydrotestosterone (DHT) have beneficial effects on asthma symptoms and/or could affect asthma susceptibility have not been investigated. DHT administration to female mice, during the sensitization phase, abrogates the sex bias in bronchial hyperreactivity. This effect correlates with inhibition of leukotriene biosynthesis in the lung. DHT significantly inhibits also other asthma-like features such as airway hyperplasia and mucus production in sensitized female mice. Conversely, DHT does not affect plasma IgE levels as well as CD3⁺CD4⁺ IL-4⁺ cell and IgE⁺c-Kit⁺ cell infiltration within the lung but prevents pulmonary mast cell activation. The in vitro study on RBL-2H3 cells confirms that DHT inhibits mast cell degranulation. In conclusion, our data demonstrate that immunomodulatory effects of DHT on mast cell activation prevent the translation of allergen sensitization into clinical manifestation of asthma.

Sex Modifies Acute Ozone-Mediated Airway Physiologic Responses

Sex differences clearly exist in incidence, susceptibility, and severity of airway disease and in pulmonary responses to air pollutants such as ozone (O3). Prior rodent O3 exposure studies demonstrate sex-related differences in the expression of lung inflammatory mediators and signaling. However, whether or not sex modifies O3-induced airway physiologic responses remains less explored. To address this, we exposed 8- to 10-week-old male and female C57BL/6 mice to either 1 or 2 ppm O3 or filtered air (FA) for 3 h. At 12, 24, 48, and 72 h following exposure, we assessed airway hyperresponsiveness to methacholine (MCh), bronchoalveolar lavage fluid cellularity, cytokines and total protein/albumin, serum progesterone, and whole lung immune cells by flow cytometry. Male mice generated consistent airway hyperresponsiveness to MCh at all time points following exposure. Alternatively, females had less consistent airway physiologic responses to MCh, which were more variable between individual experiments and did not correlate with serum progesterone levels. Bronchoalveolar lavage fluid total cells peaked at 12 h and were persistently elevated through 72 h. At 48 h, bronchoalveolar lavage cells were greater in females versus males. Bronchoalveolar lavage fluid cytokines and total protein/albumin increased following O3 exposure without sex differences. Flow cytometry of whole lung tissue identified dynamic O3-induced immune cell changes also independent of sex. Our results indicate sex differences in acute O3-induced airway physiology responses and airspace influx without significant difference in other injury and inflammation measures. This study highlights the importance of considering sex as a biological variable in acute O3-induced airway physiology responses.

Sex Steroid Hormones and Asthma in a Nationwide Study of U.S. Adults

Rationale: Women have a higher burden of asthma than men. Although sex hormones may explain sex differences in asthma, their role is unclear.Objectives: To examine sex hormone levels and asthma in adults.Methods: Cross-sectional study of serum levels of free testosterone and estradiol and current asthma in 7,615 adults (3,953 men and 3,662 women) aged 18-79 years who participated in the 2013-2014 and 2015-2016 U.S. National Health and Nutrition Examination Survey. Logistic regression was used for the multivariable analysis of sex hormones and current asthma, which was conducted separately in women and men.Measurements and Main Results: Free testosterone levels in the fourth quartile were associated with lower odds of current asthma in women (odds ratio [OR] for the fourth quartile [Q4] vs. Q1, 0.56; 95% confidence interval [CI], 0.39-0.80). Given an interaction between obesity and sex hormones on current asthma, we stratified the analysis by obesity. In this analysis, elevated free testosterone (OR for Q4 vs. Q1, 0.59; 95% CI, 0.37-0.91) and estradiol (OR for Q4 vs. Q1, 0.43; 95% CI, 0.23-0.78) levels were associated with reduced odds of current asthma in obese women, and an elevated serum estradiol was associated with lower odds of current asthma in nonobese men (OR for Q4 vs. Q1, 0.44; 95% CI, 0.21-0.90).Conclusions: Our findings suggest that sex hormones play a role in known sex differences in asthma in adults. Moreover, our results suggest that obesity modifies the effects of sex hormones on asthma in adults.

Sex differences in the association between asthma incidence and modifiable risk factors in Korean middle-aged and older adults: NHIS-HEALS 10-year cohort

Background

This study investigated the sex-specific incidence of asthma and the effects of modifiable risk factors, particularly obesity, on asthma incidence among middle-aged and older individuals in Korea.

Methods

We used data from the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS), which includes health examinees aged 40–79 years in 2002–2003. In total, 459,529 participants with baseline anthropometric measurements were followed-up for 10 years and the development of asthma was evaluated (2004–2013). For subgroup analysis, 246,019 participants who had body mass index (BMI) and waist circumference (WC) measurements taken in 2008–2009 were included in the analysis of the asthma incidence for 2010–2013. Factors associated with asthma were analysed using Cox proportional hazard models.

Results

The cohort comprised 4,248,813 (men, 2,358,541; women, 1,890,272) person-years of follow-up for 2004–2013. The asthma incidence was 10.58 and 15.03 per 1000 person-years for men and women, respectively. Asthma incidence increased with age, notably so in men. Obesity based on the baseline BMI was significantly associated with asthma development in both sexes (men, HR = 1.23, 95% confidence interval (CI) = 1.13–1.34; women, HR = 1.40 95% CI = 1.32–1.48). High WC was also related to asthma incidence in both sexes with statistical significance (men, HR = 1.34, 95% CI = 1.16–1.57; women, HR = 1.19 95% CI = 1.03–1.37). Analysis of the combined effects of BMI and WC showed that men had a higher asthma risk in the group with both general obesity and abdominal obesity than in the group with non-abdominal obesity and normal BMI. However, obese women had a higher risk of asthma regardless of abdominal obesity. Similarly, smoking was associated with asthma in both sexes but drinking and physical activity showed different associations between the sexes.

Conclusions

Our results revealed that asthma incidence was substantially high at old age and lifestyle factors were associated with asthma development. Practical strategies including weight control and healthy lifestyle modification are required to prevent asthma in older people.

Sex differences in health services and medication use among older adults with asthma

Sex differences are well documented in chronic disease populations with cardiovascular disease and diabetes. Although recent research has suggested that asthma is more severe in older women compared to men, the extent of this difference remains poorly understood. The objective of this study was to compare rates of asthma-specific health services use (HSU) and medication use, between older women and men with asthma.

This population-based cohort study included 209 054 individuals aged ≥66 years with asthma from health administrative data in Ontario, Canada. The primary exposure was sex. Outcomes included asthma-specific HSU (spirometry, emergency department (ED), hospitalisation, physician office and specialist visits) and medication use (asthma controller and reliever prescriptions). Negative binomial regression models adjusted for age, socioeconomic status and comorbidities were used to ascertain outcomes by sex from 2010 to 2016.

Compared to men, women had lower rates of spirometry (adjusted relative rate (ARR) 0.87, 95% CI 0.85–0.89) and specialist visits for asthma (ARR 0.93, 95% CI 0.90–0.96), but higher rates of asthma-specific ED (ARR 1.43, 95% CI 1.33–1.53) and physician office visits (ARR 1.03, 95% CI 1.01–1.05). Women also had lower asthma controller (ARR 0.98, 95% CI 0.97–0.99) but higher asthma reliever (ARR 1.03, 95% CI 1.02–1.05) prescription fill rates, compared to men.

These findings may indicate poorer disease control, greater asthma severity and poorer access to specialist asthma care in women.

Older women with asthma have lower rates of spirometry, asthma specialist visits and asthma controller fill rates, and higher rates of ED visits for asthma, physician office visits for asthma and asthma reliever fill rates, compared to menhttp://bit.ly/33PfMD6