The gender disparity in adult asthma hospitalizations dynamically relates to age

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.

Public interest in health data research: laying out the conceptual groundwork

The future of health research will be characterised by three continuing trends: rising demand for health data; increasing impracticability of obtaining specific consent for secondary research; and decreasing capacity to effectively anonymise data. In this context, governments, clinicians and the research community must demonstrate that they can be responsible stewards of health data. IRBs and RECs sit at heart of this process because in many jurisdictions they have the capacity to grant consent waivers when research is judged to be of particular value. However, several different terms are used to refer to this value (including public interest, public benefit, public good and social value), indicating a lack of conceptual clarity regarding the appropriate test for access to health data for research without consent. In this paper we do three things. First we describe the current confusion and instability in terminology relating to public interest in the context of consent waivers. Second we argue for harmonisation of terminology on the grounds of clarity, transparency and consistency. Third we argue that the term 'public interest' best reflects the normative work required to justify consent waivers because it is the broadest of the competing terms. 'Public interest' contains within its scope positive and negative implications of a study, as well as welfare, justice and rights considerations. In making this argument, we explain the normative basis for consent waivers, and provide a starting place for further discussion about the precise conditions in which a given study can be said to advance the public interest. Ipsos MORI study found that: … the public would be broadly happy with administrative data linking for research projects provided (1) Those projects have social value, broadly defined. (2) Data are de-identified. (3) Data are kept secure. (4) Businesses are not able to access the data for profit.

Validation of fitness tracker for sleep measures in women with asthma

OBJECTIVE

Nighttime wakening with asthma symptoms is a key to assessment and therapy decisions, with no gold standard objective measure. The study aims were to (1) determine the feasibility, (2) explore equivalence, and (3) test concordance of a consumer-based accelerometer with standard actigraphy for measurement of sleep patterns in women with asthma as an adjunct to self-report.

METHODS

Panel study design of women with poorly controlled asthma from a university-affiliated primary care clinic system was used. We assessed sensitivity and specificity, equivalence and concordance of sleep time, sleep efficiency, and wake counts between the consumer-based accelerometer Fitbit Charge™ and Actigraph wGT3X+. We linked data between devices for comparison both automatically by 24-hour period and manually by sleep segment.

RESULTS

Analysis included 424 938 minutes, 738 nights, and 833 unique sleep segments from 47 women. The fitness tracker demonstrated 97% sensitivity and 40% specificity to identify sleep. Between device equivalence for total sleep time (15 and 42-minute threshold) was demonstrated by sleep segment. Concordance improved for wake counts and sleep efficiency when adjusting for a linear trend.

CONCLUSIONS

There were important differences in total sleep time, efficiency, and wake count measures when comparing individual sleep segments versus 24-hour measures of sleep. Fitbit overestimates sleep efficiency and underestimates wake counts in this population compared to actigraphy. Low levels of systematic bias indicate the potential for raw measurements from the devices to achieve equivalence and concordance with additional processing, algorithm modification, and modeling. Fitness trackers offer an accessible and inexpensive method to quantify sleep patterns in the home environment as an adjunct to subjective reports, and require further informatics development.

Asthma-related health services and asthma control among women in Puerto Rico

Objectives:

This study evaluates social, behavioral, and environmental determinants to differentiate between active and inactive asthma and how predisposing, enabling, and need factors elucidate asthma-related health services and asthma control among women in Puerto Rico.

Methods:

This study analyzed secondary cross-sectional data from a subsample of 625 adult females who participated in the Asthma Call Back Survey in Puerto Rico. Logistic and multinomial regression analyses were conducted to examine associations between explanatory variables and asthma outcomes.

Results:

In total, 63% of women reported active asthma, from which 37.9% have not well controlled or very poorly controlled asthma. Women with active asthma were significantly more likely to be out of work, have middle income (US$25,000–<US$35,000), and be obese (≥30 kg/m²). Perceived need of health status is a good predictor to know the odds ratio of women to use emergency room. Women with poorly controlled asthma were significantly associated with increased units of physician urgent visits and emergency room visits.

Conclusion:

The findings confirmed significant determinants for active asthma and adds information on odds ratio for sensitive subgroups that utilize asthma-related health services in higher proportion than their counterparts. These associations suggest a development of asthma management plan targeting women to control the condition and reduce health-care utilization.

Air pollution and emergency department visits for respiratory diseases: A multi-city case crossover study

Increasing evidence suggests that ambient air pollution is a major risk factor for both acute and chronic respiratory disease exacerbations and emergencies. The objective of this study was to determine the association between ambient air pollutants and emergency department (ED) visits for respiratory conditions in nine districts across the province of Ontario in Canada. Health, air pollutant (PM_2.5, NO₂, O₃, and SO₂), and meteorological data were retrieved from April 2004 to December 2011. Respiratory diseases were categorized as: chronic obstructive pulmonary disease (COPD, including bronchiectasis) and acute upper respiratory diseases. A case-crossover design was used to test the associations between ED visits and ambient air pollutants, stratified by sex and season. For COPD among males, positive results were observed for NO₂ with lags of 3-6 days, for PM_2.5 with lags 1-8, and for SO₂ with lags of 4-8 days. For COPD among females, positive results were observed for O₃ with lags 2-4 days, and for SO₂ among lags of 3-6 days. For upper respiratory disease emergencies among males, positive results were observed for NO₂ (lags 5-8 days), for O₃, (lags 0-6 days), PM_2.5 (all lags), and SO₂ (lag 8), and among females, positive results were observed for NO₂ for lag 8 days, for O₃, PM_2.5 among all lags. Our study provides evidence of the associations between short-term exposure to air pollution and increased risk of ED visits for upper and lower respiratory diseases in an environment where air pollutant concentrations are relatively low.

Sex differences in outcomes after discharge from Alberta emergency departments for asthma: A large population-based study

OBJECTIVE

Asthma exacerbations frequently result in emergency department (ED) visits. While sex differences have been identified in some asthma studies, there is a paucity of literature on sex differences in the ED setting, especially population-based ones. This study examines sex differences in important outcomes of patients discharged from EDs for acute asthma in Alberta, Canada.

METHODS

Alberta residents aged from 2 to 55 years discharged from EDs with a primary diagnosis of asthma during 1999-2011 were identified from administrative databases from a single-payer health care system for the entire geographic region of Alberta. Multivariable Cox regression models analyzed time to first follow-up physician or specialist visit, and logistic regression models analyzed the binary outcome of ED return within 30 days for asthma.

RESULTS

There were 115,853 discharged patients analyzed (40.4% and 59.1% female in pediatric and adult groups, respectively). Approximately 26% of patients revisited the ED during 1999-2011 and 5.1% did so within 30 days. Women had higher odds of a 30-day ED return after ED discharge than men (unadjusted odds ratio [uOR] = 1.26; 95% confidence interval [CI] 1.17-1.36). Time to first non-ED physician follow-up was shorter for girls (unadjusted hazard ratio [uHR] = 1.05; 95%CI 1.03-1.07) and women (uHR = 1.62; 95%CI 1.59-1.64) than for boys and men, respectively. Significant interactions between sex and age, socio-economic status, area of residence, and comorbidities were identified and changed the effect of sex on outcomes.

CONCLUSIONS

In conclusion, women return to EDs within 30 days of discharge for acute asthma more often than men. Time to first non-ED physician follow-up for children and adults differed by sex. Multiple factors likely contribute to these differences; however, identifying these differences is critical to understand the influence of sex on health behaviors and outcomes.

Exercise-induced bronchoconstriction update-2016

The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.

Sexual maturation protects against development of lung inflammation through estrogen

Increasing levels of estrogen and progesterone are suggested to play a role in the gender switch in asthma prevalence during puberty. We investigated whether the process of sexual maturation in mice affects the development of lung inflammation in adulthood and the contributing roles of estrogen and progesterone during this process. By inducing ovalbumin-induced lung inflammation in sexually mature and immature (ovariectomized before sexual maturation) adult mice, we showed that sexually immature adult mice developed more eosinophilic lung inflammation. This protective effect of "puberty" appears to be dependent on estrogen, as estrogen supplementation at the time of ovariectomy protected against development of lung inflammation in adulthood whereas progesterone supplementation did not. Investigating the underlying mechanism of estrogen-mediated protection, we found that estrogen-treated mice had higher expression of the anti-inflammatory mediator secretory leukoprotease inhibitor (SLPI) and lower expression of the proasthmatic cytokine IL-33 in parenchymal lung tissue and that their expressions colocalized with type II alveolar epithelial cells (AECII). Treating AECII directly with SLPI significantly inhibited IL-33 production upon stimulation with ATP. Our data suggest that estrogen during puberty has a protective effect on asthma development, which is accompanied by induction of anti-inflammatory SLPI production and inhibition of proinflammatory IL-33 production by AECII.

Recent advances in understanding and managing cystic fibrosis transmembrane conductance regulator dysfunction

Cystic fibrosis is the most common autosomal recessive genetic disease in Caucasians and has been extensively studied for many decades. The cystic fibrosis transmembrane conductance regulator gene was identified in 1989. It encodes a complex protein which has numerous cellular functions. Our understanding of cystic fibrosis pathophysiology and genetics is constantly expanding and being refined, leading to improved management of the disease and increased life expectancy in affected individuals.

Adult asthmatics increase the risk of acute coronary syndrome: A nationwide population-based cohort study

OBJECTIVES

Few studies have examined the risk of acute coronary syndrome (ACS) in asthmatics. We investigate the effects of asthma on the risk of ACS development in an Asian population.

METHODS

Asthma patients aged ≥ 18 years were identified, and asthma-free controls were randomly selected from the general population and frequency-matched according to age, sex, index year, and baseline comorbidity by using the National Health Insurance Research Database. Both cohorts were followed up until the end of 2011 to measure the incidence of ACS. The risk of ACS was analyzed using Cox proportional hazards regression models.

RESULTS

We observed the asthmatic patients for 97,506 person-years and followed the nonasthmatic people for 193,423 person-years. The incidence density rate of ACS increased in all groups of the asthmatic patients compared with those of the controls when the data were stratified according to sex, age, and comorbidities. The hazard ratio (HR) of ACS was 1.66-fold greater in the asthmatic cohort than in the nonasthmatic cohort, after adjusting for sex, age, and comorbidities (95% confidence interval [CI]: 1.31-2.11). The adjusted HR of developing ACS increased substantially as age and the frequency of asthmatic exacerbation and hospitalization increased.

CONCLUSIONS

Asthma is an independent risk factor of ACS, and poor control of asthma increases the risk of ACS development in a dose-dependent manner.

Increased stroke risk among adult asthmatic patients

BACKGROUND

We conducted a nationwide population-based cohort study to investigate the effects of asthma on the risk of stroke development in an Asian population.

MATERIALS AND METHODS

Newly diagnosed asthmatic patients aged ≥ 18 years were identified, and asthma-free controls were randomly selected from the general population and frequency matched according to age, sex and index year using records obtained from the National Health Insurance Research Database between 2000 and 2010. Both cohorts were followed up until the end of 2011 to measure the incidence of stroke. The risk of stroke was analysed using Cox proportional hazard regression models, including factors such as sex, age and comorbidities.

RESULTS

We followed the asthmatic patients for 104 697 person-years and followed the nonasthmatic people for 426 729 person-years. The incidence density rate of stroke increased in all of the groups of asthmatic patients compared with that of the controls when stratified according to sex, age and comorbidities. The hazard ratio (HR) of stroke was 1·37-fold greater for the asthmatic cohort, compared with that for the nonasthmatic cohort, after adjusting for sex, age and comorbidities. The adjusted HR of developing stroke substantially increased with older age and the increased frequency of asthmatic exacerbation and hospitalization. The patients receiving beta-2 agonists as a treatment exhibited a significantly greater risk of stroke compared with the patients receiving only inhaled corticosteroids, after adjusting for covariates.

CONCLUSION

Asthma may be an independent risk factor for stroke, and its severity exhibits a dose response of stroke development.

Age dependent sex disproportion in US asthma hospitalization rates, 2000-2010

BACKGROUND

Age-stratified sex differences in asthma hospitalizations rates have been reported to be most marked between the ages of 40 and 54 years in New York. It is not known whether age-dependent sex differences in asthma hospitalization rates also exist for the entire United States.

OBJECTIVES

To compare sex-specific hospitalization rates for asthma in adults in the United States and to describe the adjusted associations between female sex and age in the fifth to sixth decades of life.

METHODS

The National Inpatient Sample databases for 2000-2010 were queried for a principal diagnosis of asthma to calculate the ratio of female to male hospitalization rates for different decades of adult life. Logistic regression modeling was used to determine whether age in the fifth to sixth decades of life had associations with female sex that remained significant after adjusting for comorbidities and demographic features.

RESULTS

For all years of the study, there was a distinct peaking in female to male ratio most manifested in the fifth to sixth decades of life. This age grouping was significantly associated with female sex. Models revealed that female sex was significantly associated with this age grouping, even after adjustment for obesity, chronic obstructive pulmonary disease, race, insurance status, discharge year, and smoking. Excluding identifiable repeat admissions also did not abrogate the age grouping association.

CONCLUSION

There is a striking propensity of women in their fifth to sixth decades of life to be admitted for asthma, which appears to be independent of many known comorbidities.

Factors related with the higher percentage of hospitalizations due to asthma amongst women: the FRIAM study

INTRODUCTION

The reason why there is a higher hospitalization rate due to asthma exacerbations amongst women is unclear. The objective of this study is to explore the possible causes that may explain this fact.

METHODS

A multi-center, prospective study including asthma patients hospitalized in the pulmonary medicine departments during a two-year period. By means of a questionnaire, the following data were collected: demographic characteristics and treatment compliance, anxiety-depression, hyperventilation and asthma control, both prior to and during the hospitalization.

RESULTS

183 patients were included, 115 (62.84%) of whom were women. The women were older (52.4 ± 18.3/43.4 ± 18.7; P=.02), were more frequently prescribed inhaled corticosteroids (63.2%/47.1%; P=.03) and had a higher rate of hyperventilation syndrome (57.3/35.9; P=.02) and a longer mean hospital stay (7.3 ± 3.4/5.9 ± 3.6; P=.02). The percentage of smokers among the women was lower (21.2%/38.8%; p=0.01) and the FEV(1) was lower at admittance (58.2% ± 15.9/67.5% ± 17.4; P=.03). In the 40 to 60-year-old age range, an association was demonstrated between being female and the 'previous hospitalizations' variable (OR, 16.1; 95% CI, 1.6-156.7); sex and obesity were also independently associated (OR, 4.8; 95% CI, 1.06-22).

CONCLUSIONS

In this cohort, the rate of hospitalization for asthma was higher in women than in men. Being a woman between the ages of 40 and 60 is associated with previous hospitalizations and is a risk factor for asthma-related hospitalization. This situation could partially be explained by the hormonal changes during menopause, where polyposis and obesity are independent risk factors.

The impact of socioeconomic factors on asthma hospitalization rates by rural classification

Asthma hospitalization rates have increased in the past decade. Research has shown that there are multiple correlates for this increase but that driving causal factors may differ for asthma hospitalization rates in rural and non-rural settings. Here we examine the socioeconomic correlates to asthma hospitalization rates in Maine for both rural and non-rural populations to examine the similarity and differences in causal factors. Findings indicate a clear SES gradient relative to asthma hospitalization rates; as population measured SES decreased, asthma hospitalization rates increased. The associated causal factors were found to differ in rural and non-rural areas. In non-rural areas, the presence of insurance was associated with increases in the asthma hospitalization rates while in rural areas, income, occupation and the percentage of non-English language speaking persons were associated with lower asthma hospitalization rates. Public policy should focus on targeted prevention strategies at the community level, especially in rural areas where cultural competency and socioeconomic factors are increasingly important.

Overweight women and management of asthma

PURPOSE

We sought to describe clinical and psychosocial characteristics of overweight women with asthma.

METHODS

Telephone interview and medical record review involving 808 women with asthma participating in a randomized study to identify those who were overweight. We assessed the relationship of their weight to asthma symptoms, health care use, quality of life, self-esteem, need for social support, and demographic characteristics. Regression analyses were used to investigate relationships between overweight and asthma.

FINDINGS

Sixty-eight percent of the women in the study were overweight or obese. Demographic characteristics associated with overweight in women with asthma included being minority (p=.000), having a lower education level (p=.000), and a lower household income (p=.024). Overweight was associated with greater health care use, comorbidities (acid reflux, urinary incontinence), and persistent disease (p=.001). Overweight women exhibited lower self-esteem (p=.002) and lower perceived quality of life (p=.000).

CONCLUSION

Overweight females with asthma experience significant challenges because of their weight, more persistent and severe disease, specific comorbidities, and lower rates of obtaining psychosocial resources. Clinical consultations and interventions should account for the influence of overweight on asthma control and health status in female patients.