Urinary Volatile Organic Compound Metabolites Are Associated with Reduced Lung Function in U.S. Children and Adolescents

(1) Background: Volatile organic compounds (VOCs) are indoor pollutants absorbed by inhalation. The association of several VOCs with lung function in children and adolescents is unknown. (2) Methods: We analyzed 505 participants, 6-17-year-olds from the 2011-2012 National Health and Nutrition Examination Survey. Multiple linear regression models were fitted to estimate the associations of VOC metabolites with spirometry outcomes adjusting for covariates. (3) Results: Urinary metabolites of xylene, acrylamide, acrolein, 1,3-butadiene, cyanide, toluene, 1-bromopropane, acrylonitrile, propylene oxide, styrene, ethylbenzene, and crotonaldehyde were all detected in ≥64.5% of participants. Forced expiratory volume in 1 s (FEV1) % predicted was lower in participants with higher levels of metabolites of acrylamide (β: -7.95, 95% CI: -13.69, -2.21) and styrene (β: -6.33, 95% CI: -11.60, -1.07), whereas the FEV1 to forced vital capacity (FVC) ratio % was lower in children with higher propylene oxide metabolite levels (β: -2.05, 95% CI: -3.49, -0.61). FEV1 % predicted was lower with higher crotonaldehyde metabolite levels only in overweight/obese participants (β: -15.42, 95% CI: -26.76, -4.08) (Pinteraction < 0.001) and with higher 1-bromopropane metabolite levels only in those with serum cotinine > 1 ng/mL (β: -6.26, 95% CI: -9.69, -2.82) (Pinteraction < 0.001). (4) Conclusions: We found novel associations of metabolites for acrylamide, propylene oxide, styrene, 1-bromopropane and crotonaldehyde with lower lung function in children and adolescents.

Long-term cancer and overall mortality associated with drinking water nitrate in the United States

OBJECTIVES

Nitrate is a probable carcinogen regulated in drinking water by the US Environmental Protection Agency (EPA) to a maximum contaminant level (MCL) of 10 mg/L nitrate-nitrogen (NO3-N; equivalent to 44.3 mg/L NO3). We aimed to determine the association of US drinking water nitrate levels with overall as well as cardiovascular, cancer, and other cause mortality.

STUDY DESIGN

This study used a population-based retrospective cohort design.

METHODS

We analyzed data from 2029 participants of the 2005-2006 National Health and Nutrition Examination Survey followed for mortality until 2019 for a median of 13.9 years. We used Cox proportional hazards regression to estimate the hazard ratio (HR) and 95% confidence interval (CI) for mortality associated with drinking water nitrate, adjusting for covariates that included socio-economic factors and pack-years of cigarette smoking.

RESULTS

Drinking water nitrate was detected in 50.8 % of the samples, had a median concentration of 0.77 mg/L NO3, and was above US EPA MCL in 0.4 % of participants. In adjusted analysis, drinking water nitrate detection was associated with 73 % higher cancer mortality (HR: 1.73, 95% CI: 1.19-2.51), whereas a 10-fold increase in drinking water nitrate levels was associated with 69 % higher cancer mortality (HR: 1.69, 95% CI: 1.24-2.31) and 21 % higher overall mortality (HR: 1.21, 95% CI: 1.00-1.46). Drinking water nitrate below EPA MCL was still associated with higher cancer mortality (HR: 1.61, 95% CI: 1.07-2.43 per 10-fold increase and HR: 1.61, 95% CI: 1.08-2.42 for detection).

CONCLUSIONS

Levels of drinking water nitrate may be an overlooked contributor to cancer mortality in the United States.

Racial differences in length of stay and readmission for asthma in the all of us research program

BACKGROUND

This study addresses the limited research on racial disparities in asthma hospitalization outcomes, specifically length of stay (LOS) and readmission, across the U.S.

METHODS

We analyzed in-patient and emergency department visits from the All of Us Research Program, identifying various risk factors (demographic, comorbid, temporal, and place-based) associated with asthma LOS and 30-day readmission using Bayesian mixed-effects models.

RESULTS

Of 17,233 patients (48.0% White, 30.7% Black, 19.7% Hispanic/Latino, 1.3% Asian, and 0.3% Middle Eastern and North African) with 82,188 asthma visits, Black participants had 20% shorter LOS and 12% higher odds of readmission, compared to White participants in multivariate analyses. Public-insured patients had 14% longer LOS and 39% higher readmission odds than commercially insured patients. Weekend admissions resulted in a 12% shorter LOS but 10% higher readmission odds. Asthmatics with chronic diseases had a longer LOS (range: 6-39%) and higher readmission odds (range: 9-32%) except for those with allergic rhinitis, who had a 23% shorter LOS.

CONCLUSIONS

A comprehensive understanding of the factors influencing asthma hospitalization, in conjunction with diverse datasets and clinical-community partnerships, can help physicians and policymakers to systematically address racial disparities, healthcare utilization and equitable outcomes in asthma care.

Prenatal exposure to replacement flame retardants and organophosphate esters and childhood adverse respiratory outcomes

BACKGROUND

The association of prenatal exposure to organophosphate esters (OPEs) and replacement brominated flame retardants (RBFRs) with respiratory outcomes has not been previously investigated in humans, despite reports that these chemicals can cross the placenta and alter lung development as well as immune functions.

METHODS

In a cohort of 342 pregnant women recruited between 2003 and 2006 in the greater Cincinnati, Ohio Metropolitan area, we measured indoor dust OPEs and RBFRs at 20 weeks of gestation and urinary OPEs at 16 and 26 weeks of gestation and at delivery. We performed generalized estimating equations and linear mixed models adjusting for covariates to determine the associations of prenatal OPEs and RBFRs exposures with adverse respiratory outcomes in childhood, reported every six months until age 5 years and with lung function at age 5 years. We used multiple informant modeling to examine time-specific associations between maternal urinary OPEs and the outcomes.

RESULTS

Dust concentrations of triphenyl phosphate (TPHP) (RR: 1.40, 95% CI: 1.18-1.66), 2-ethylhexyl-2,3,4,5-tetrabromobenzoate (RR: 1.51, 95% CI: 1.23-1.85), and bis(2-ethylhexyl) tetrabromophthalate (RR: 1.57, 95% CI: 1.28-1.94) were associated with higher risk of wheezing during childhood. Dust TPHP concentrations were associated with higher risk of respiratory infections (RR: 1.43, 95% CI: 1.08-1.94), and dust tris-(2-chloroethyl) phosphate concentrations were associated with hay fever/allergies (RR: 1.11, 95% CI: 1.01-1.21). We also found that dust tris-(2-chloroethyl) phosphate loadings were associated with lower lung function. Urinary OPEs mainly at week 16 of gestation tended to be associated with adverse respiratory outcome, while bis(1-chloro-2-propyl) phosphate and diphenyl phosphate at delivery were associated with lower risk of hay fever/allergies.

CONCLUSIONS

In-utero exposure to OPEs and RBFRs may be a risk factor for adverse respiratory outcomes in childhood, depending on the timing of exposure.

Exposure to dust organophosphate and replacement brominated flame retardants during infancy and risk of subsequent adverse respiratory outcomes

BACKGROUND

Children are highly exposed to flame retardants in indoor environments, partly through inhalation. However, the associations of early life exposure to novel organophosphate (OPFRs) and replacement brominated flame retardants (RBFRs) with adverse respiratory outcomes during childhood are unclear.

METHODS

We used a prospective birth cohort of 234 children recruited from the greater Cincinnati, Ohio metropolitan area between 2003 and 2006. OPFRs and RBFRs were analyzed in dust sampled from the homes' main activity room and the children's bedroom floor at child age 1 year. Caregivers reported subsequent respiratory symptoms every six months until child age 5 years and we measured forced expiratory volume in 1 s as well as peak expiratory flow (PEF) at child age 5 years. We performed generalized estimating equations and linear regression modeling adjusted for covariates to examine the exposure-outcome associations.

RESULTS

Geometric means (GMs) (standard error [SE]) for dust concentrations were 10.27 (0.63) μg/g for total OPFRs (ΣOPFRs) and 0.48 (0.04) μg/g for total RBFRs (ΣRBFRs); GMs (SE) for dust loadings were 2.82 (0.26) μg/m2 for ΣOPFRs and 0.13 (0.01) μg/m2 for ΣRBFRs. Dust ∑OPFRs concentrations at age 1 year were associated with higher subsequent risks of wheezing (relative risk [RR]: 1.68, 95% confidence interval [CI]: 1.20-2.34), respiratory infections (RR: 4.01, 95% CI: 1.95-8.24), and hay fever/allergies (RR: 1.33, 95% CI: 1.10-1.60), whereas ∑OPFRs dust loadings at age 1 year were associated with higher risks of subsequent respiratory infections (RR: 1.87, 95% CI: 1.05-3.34) and hay fever/allergies (RR: 1.34, 95% CI: 1.19-1.51). PEF (mL/min) was lower with higher ∑OPFRs dust loadings (β: -12.10, 95% CI: -21.10, -3.10) and with the RBFR bis(2-ethylhexyl) tetrabromophthalate (β: -9.05, 95% CI: -17.67, -0.43).

CONCLUSIONS

Exposure to OPFRs and RBFRs during infancy may be a risk factor for adverse respiratory outcomes during childhood.

Outliers in nutrient intake data for U.S. adults: national health and nutrition examination survey 2017-2018

Objectives

An important step in preparing data for statistical analysis is outlier detection and removal, yet no gold standard exists in current literature. The objective of this study is to identify the ideal decision test using the National Health and Nutrition Examination Survey (NHANES) 2017-2018 dietary data.

Methods

We conducted a secondary analysis of NHANES 24-h dietary recalls, considering the survey's multi-stage cluster design. Six outlier detection and removal strategies were assessed by evaluating the decision tests' impact on the Pearson's correlation coefficient among macronutrients. Furthermore, we assessed changes in the effect size estimates based on pre-defined sample sizes. The data were collected as part of the 2017-2018 24-h dietary recall among adult participants (N=4,893).

Results

Effect estimate changes for macronutrients varied from 6.5 % for protein to 39.3 % for alcohol across all decision tests. The largest proportion of outliers removed was 4.0 % in the large sample size, for the decision test, >2 standard deviations from the mean. The smallest sample size, particularly for alcohol analysis, was most affected by the six decision tests when compared to no decision test.

Conclusions

This study, the first to use 2017-2018 NHANES dietary data for outlier evaluation, emphasizes the importance of selecting an appropriate decision test considering factors such as statistical power, sample size, normality assumptions, the proportion of data removed, effect estimate changes, and the consistency of estimates across sample sizes. We recommend the use of non-parametric tests for non-normally distributed variables of interest.

Urinary volatile organic compound metabolites and reduced lung function in U.S. adults

BACKGROUND

Volatile organic compounds (VOCs) are associated with adverse respiratory outcomes at high occupational exposures. However, whether exposure levels found in the general population have similar effects is unknown.

METHODS

We analyzed data on 1342 adult participants in the 2011-2012 National Health and Nutrition Examination Survey aged ≥18 years old who had urinary VOC metabolites and spirometry measurements available. Linear regression models adjusting for covariates were fitted to estimate the associations of VOC exposures levels and spirometry outcomes, while accounting for survey design and sampling weights to generate nationally representative estimates.

RESULTS

The urinary metabolites for xylene, acrylamide, acrolein, 1,3-butadiene, cyanide, toluene, 1-bromopropane, acrylonitrile, propylene oxide, styrene, ethylbenzene, and crotonaldehyde in our analysis were all detected in >75% of participants. Forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) ratio % was lower with urinary metabolites of acrylamide (β: -2.65, 95% CI: -4.32, -0.98), acrylonitrile (β: -1.02, 95% CI: -2.01, -0.03), and styrene (β: -3.13, 95% CI: -5.35, -0.90). FEV1% predicted was lower with the urinary metabolites of acrolein (β: -7.77, 95% CI: -13.29, -2.25), acrylonitrile (β: -2.05, 95% CI: -3.77, -0.34), propylene oxide (β: -2.90, 95% CI: -5.50, -0.32), and styrene (β: -4.41, 95% CI: -6.97, -1.85).

CONCLUSIONS

This is the first study of a representative sample of the U.S. adult population to reveal associations of acrylonitrile, propylene oxide, and styrene urinary metabolites with reduced lung function at non-occupational exposures. Results also support previous evidence of acrylamide and acrolein's association with adverse respiratory outcomes.

Comorbidities in childhood-onset and adult-onset asthma

BACKGROUND

Age of asthma onset has emerged as an important determinant of asthma phenotypes; however, the comorbidities that predominate in either childhood- or adult-onset asthma are not known.

OBJECTIVE

To identify comorbidities associated with adult-onset asthma vs childhood-onset asthma and with age of asthma diagnosis.

METHODS

We analyzed data on 27,437 adult participants in the National Health and Nutrition Examination Surveys conducted from 2001 to 2018. Logistic regression adjusted for covariates was used to identify comorbidities associated with the asthma phenotypes and age of asthma diagnosis.

RESULTS

Approximately 12.6% of participants were ever diagnosed with asthma; the prevalence of childhood-onset (before 18 years old) and adult-onset (≥ 18 years old) current asthma was 2.7% and 5.5%, respectively. After adjustment for covariates including age, adult-onset asthma was associated with higher odds of obesity (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.09-1.96), hypercholesterolemia (OR, 1.67; 95% CI, 1.08-2.56), borderline high serum triglycerides (OR, 1.78; 95% CI, 1.17-2.71), and osteoarthritis (OR, 1.52; 95% CI, 1.04-2.20) than was childhood-onset asthma. Older age of asthma diagnosis (per 5-year increase) was also associated with higher odds of diabetes (OR, 1.04; 95% CI, 1.00-1.07) and hypertension (OR, 1.05; 95% CI, 1.02-1.07), whereas younger age of asthma diagnosis was associated with higher odds of chronic obstructive pulmonary disease (OR, 1.12; 95% CI, 1.04-1.19).

CONCLUSION

Age- and covariates-adjusted prevalence of obesity, dyslipidemia, arthritis, diabetes, and hypertension is higher in adult-onset asthma than in childhood-onset asthma, and with older age of asthma diagnosis. Conversely, the prevalence of chronic obstructive pulmonary disease increases with younger age of asthma diagnosis.

Serum antioxidant vitamins and respiratory morbidity and mortality: a pooled analysis

Background

Oxidative stress plays a key role in the pathogenesis of respiratory diseases; however, studies on antioxidant vitamins and respiratory outcomes have been conflicting. We evaluated whether lower serum levels of vitamins A, C, D, and E are associated with respiratory morbidity and mortality in the U.S. adult population.

Methods

We conducted a pooled analysis of data from the 1988–1994 and 1999–2006 National Health and Nutrition Examination Survey (participants aged ≥ 20 years). We estimated covariate-adjusted odds ratios (aOR) per interquartile decrease in each serum vitamin level to quantify associations with respiratory morbidity, and covariate-adjusted hazard ratios (aHR) to quantify associations with respiratory mortality assessed prospectively through 2015. Vitamin supplementation and smoking were evaluated as potential effect modifiers.

Results

Lower serum vitamin C increased the odds of wheeze among all participants (overall aOR: 1.08, 95% CI: 1.01–1.16). Among smokers, lower serum α-tocopherol vitamin E increased the odds of wheeze (aOR: 1.11, 95% CI: 1.04–1.19) and chronic bronchitis/emphysema (aOR: 1.13, 95% CI: 1.03–1.24). Conversely, lower serum γ-tocopherol vitamin E was associated with lower odds of wheeze and chronic bronchitis/emphysema (overall aORs: 0.85, 95% CI: 0.79–0.92 and 0.85, 95% CI: 0.76–0.95, respectively). Lower serum vitamin C was associated with increased chronic lower respiratory disease (CLRD) mortality in all participants (overall aHR: 1.27, 95% CI: 1.07–1.51), whereas lower serum 25-hydroxyvitamin D (25-OHD) tended to increase mortality from CLRD and influenza/pneumonia among smokers (aHR range: 1.33–1.75). Mortality from influenza/ pneumonia increased with decreasing serum vitamin A levels in all participants (overall aHR: 1.21, 95% CI: 0.99–1.48). In pooled analysis, vitamin C deficiency and 25-OHD insufficiency were associated with mortality from influenza/pneumonia, increasing mortality risk up to twofold.

Conclusions

Our analysis of nationally representative data on over 34,000 participants showed that lower serum levels of vitamins A, C, D, and α-tocopherol vitamin E are associated with increased respiratory morbidity and/or mortality in U.S. adults. The results underscore the importance of antioxidant vitamins in respiratory health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02059-w.

Exposure to neonicotinoids and serum testosterone in men, women, and children

Neonicotinoids are the most used pesticides in the world and, despite being harmful to honeybees, they are considered safe for mammals. However, they have been associated with decreasing testosterone levels in several experimental animal models. In the present study, we aimed to determine the association of urinary neonicotinoids with serum testosterone in humans. We analyzed data on 2014 male and female participants to the National Health and Nutrition Examination Survey conducted between 2015 and 2016 aged 6 or older. In linear regression adjusted for age and potential confounders, serum total testosterone was 37.78% lower with 10-fold increase in urinary total neonicotinoids (95% CI: -58.82, -6.00), 20.81% lower with 10-fold increase in urinary 5-hydroxy-imidacloprid (95% CI: -34.94, -3.62) and 25.01% lower with 10-fold increase in urinary n-desmethyl-acetamiprid (95% CI: -39.80, -6.58) among males. Serum free androgen index (FAI) was also decreased with higher urinary n-desmethyl-acetamiprid. In females, serum total testosterone was 32.91% lower with 10-fold increase in urinary total neonicotinoids (95% CI: -54.93, -0.13), 21.32% lower with 10-fold increase in urinary 5-hydroxy-imidacloprid (95% CI: -29.31, -12.42) and 15.42% lower with urinary detection of 5-hydroxy-imidacloprid (95% CI: -22.80, -7.34). FAI was likewise reduced with higher urinary levels of 5-hydroxy-imidacloprid and N-desmethyl-acetamiprid. In conclusion, this study using a sample representative of the US population is the first to report that exposure to neonicotinoids is associated with decreased serum testosterone levels in humans. However, future prospective studies are warranted to confirm these findings.

The Incidence of Ocular Complications in Candidemic Patients and Implications for the Practice of Routine Eye Exams

Background

Ocular candidiasis is a known complication of candidemia. Given the poor ocular penetration of echinocandins, there is some concern that the increasing use of echinocandins may portend an increased incidence of ophthalmic complications. We examined the changing trends in antifungal prescribing patterns and the incidence of ophthalmic complications after candidemia.

Methods

Patients with blood cultures positive for Candida species between January 2014 and June 2020 who underwent screening fundoscopic examination by an ophthalmologist were analyzed. The χ² analysis was used to compare antifungal prescriptions and ocular exam findings before and after 2016. Trend analysis was also performed to assess temporal changes in prescribing practices and eye exam findings.

Results

There were 226 candidemia cases during the study period, 129 (57.1%) of which underwent screening eye exams. From 2014 to 2015, 24 of 37 (64.5%) patients received eye-penetrating antifungals compared to 36 of 92 (39.1%) from 2016 to 2020 (P = .008). Overall, 30 of 129 (23.3%) patients had abnormal eye exams with the prevalence of abnormal findings being 7 of 37 (18.9%) before 2016 compared to 23 of 92 (25%, P = .46) thereafter. A trend analysis revealed an increase in abnormal eye findings over the study period (P = .008). Of the 30 patients who had abnormal eye exams, 9 (30%) had a change in systemic antifungal therapy from echinocandins to eye-penetrating antifungals. Echinocandin use was associated with abnormal eye findings.

Conclusions

Prescription of eye-penetrating antifungals for candidemia has trended down since 2016. This was associated with a concomitant increase in abnormal findings on screening fundoscopy. Abnormal eye exams were not uncommon throughout our study period.

1381. Do Gut Microbiome Profiles Correlate with Hospital Length of Stay During Hematopoietic Stem Cell Transplantation?

Background

Length of stay is not only an indicator of how successful a hospitalized patient’s treatment and recovery is, but is also an indicator of fiscal costs to the hospital. Hematopoietic stem cell transplants (HSCT) patients typically experience extended hospital admissions that can vary significantly patient to patient with hospital discharge dependent upon a recovered white blood cell count. Recent literature suggests a gut microbial influence on hematopoiesis. We sought to explore potential associations between gut microbiome diversity and the length of stay in patients undergoing HSCT in the inpatient setting.

Methods

Within two healthcare systems, we identified patients who would receive conditioning chemotherapy and subsequent HSCT in the inpatient setting. Pre-chemotherapy stool was collected, sequenced with shotgun metagenomics, and analyzed for gut microbial diversity using Inverse-Simpson index. The length of admission or length of stay during their transplant process was recorded. We assessed whether there was an association with gut microbial diversity and length of stay.

Results

24 patients we evaluated for diversity and length of stay. There was no significant correlation between age or gender and length of stay. Significant difference in length of stay was seen between allogenic vs autogenic transplants (p value ≤0.01). Within the 24 patients, lengths of stay ranged from 8 to 36 days with a mean average of 20.9 days. Gut diversity ranged from 1.8 to 23.9. An overall negative association between length of stay and diversity was seen, though this was determined not statistically significant (p value 0.09).

Length of Stay correlation with pre-chemotherapy Gut Microbiome diversity

Conclusion

Our study showed no significant association between gut microbial diversity and inpatient length of stay during HSCT. Overall, a trend towards increased length of stay in patients with decreased diversity was noted. Additional studies of greater participant size are necessary to confirm or further study these findings.

Disclosures

All Authors: No reported disclosures

Air pollution and the pandemic: Long-term PM2.5 exposure and disease severity in COVID-19 patients

Background and objective

Ecological studies have suggested an association between exposure to particulate matter ≤2.5 μm (PM_2.5) and coronavirus disease 2019 (COVID‐19) severity. However, these findings are yet to be validated in individual‐level studies. We aimed to determine the association of long‐term PM_2.5 exposure with hospitalization among individual patients infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2).

Methods

We estimated the 10‐year (2009–2018) PM_2.5 exposure at the residential zip code of COVID‐19 patients diagnosed at the University of Cincinnati healthcare system between 13 March 2020 and 30 September 2020. Logistic regression was used to determine the odds ratio (OR) and 95% CI for COVID‐19 hospitalizations associated with PM_2.5, adjusting for socioeconomic characteristics and comorbidities.

Results

Among the 14,783 COVID‐19 patients included in our study, 13.6% were hospitalized; the geometric mean (SD) PM_2.5 was 10.48 (1.12) μg/m³. In adjusted analysis, 1 μg/m³ increase in 10‐year annual average PM_2.5 was associated with 18% higher hospitalization (OR: 1.18, 95% CI: 1.11–1.26). Likewise, 1 μg/m³ increase in PM_2.5 estimated for the year 2018 was associated with 14% higher hospitalization (OR: 1.14, 95% CI: 1.08–1.21).

Conclusion

Long‐term PM_2.5 exposure is associated with increased hospitalization in COVID‐19. Therefore, more stringent COVID‐19 prevention measures may be needed in areas with higher PM_2.5 exposure to reduce the disease morbidity and healthcare burden.

Assessment of Severe COVID-19 Outcomes Using Measures of Smoking Status and Smoking Intensity

Objective: Smoking status does not indicate the amount or length of tobacco use, and thus, it is an imperfect measure to assess the association between cigarette smoking and severe coronavirus disease 2019 (COVID-19) outcomes. This investigation assessed whether cigarette smoking status, intensity of smoking (i.e., average daily packs of cigarettes smoked), duration of smoking, and pack-years of smoking are associated with severe outcomes among adults diagnosed with COVID-19. Methods: We conducted a retrospective, cross-sectional study in which we identified consecutive patients diagnosed with COVID-19 at the University of Cincinnati healthcare system between 13 March 2020 and 30 September 2020 who had complete information on smoking status, severe COVID-19 outcomes, and covariates (i.e., demographics and comorbidities). We used logistic regression to evaluate the associations of smoking status and intensity of smoking with COVID-19 severity, defined as hospitalization, admission to intensive care unit (ICU), or death, adjusting for sociodemographics and comorbidities. Results: Among the 4611 COVID-19 patients included in the analysis, 18.2% were current smokers and 20.7% were former smokers. The prevalence of COVID-19 outcomes was 28.9% for hospitalization, 9.8% for ICU admission, and 1.4% for death. In the adjusted analysis, current smoking (AOR: 1.23, 95% CI: 1.02–1.49), former smoking (AOR: 1.28, 95% CI: 1.07–1.54), and pack-years of smoking (AOR: 1.09, 95% CI: 1.02–1.17) were associated with a higher prevalence of hospitalization. Average daily packs of cigarettes smoked was associated with a higher prevalence of hospitalization (AOR: 1.30, 95% CI: 1.10–1.53) and ICU admission (AOR: 1.23, 95% CI: 1.04–1.44). Conclusions: Smoking status, pack-years, and intensity of smoking were associated with hospitalizations in patients with COVID-19 and intensity of smoking was associated with ICU admission. The findings underscore the need for detailed information beyond smoking status when evaluating smokers with COVID-19 so that the potential for adverse sequelae may be optimally managed in at-risk patients.

Long-term exposure to fine particulate matter and hospitalization in COVID-19 patients

BACKGROUND

Ecological evidence suggests that exposure to air pollution affects coronavirus disease 2019 (COVID-19) outcomes. However, no individual-level study has confirmed the association to date.

METHODS

We identified COVID-19 patients diagnosed at the University of Cincinnati hospitals and clinics and estimated particulate matter ≤2.5 μm (PM_2.5) exposure over a 10-year period (2008-2017) at their residential zip codes. We used logistic regression to evaluate the association between PM_2.5 exposure and hospitalizations for COVID-19, adjusting for socioeconomic characteristics and comorbidities.

RESULTS

Among the 1128 patients included in our study, the mean (standard deviation) PM_2.5 was 11.34 (0.70) μg/m³ for the 10-year average exposure and 13.83 (1.03) μg/m³ for the 10-year maximal exposures. The association between long-term PM_2.5 exposure and hospitalization for COVID-19 was contingent upon having pre-existing asthma or chronic obstructive pulmonary (COPD) (P_interaction = 0.030 for average PM_2.5 and P_interaction = 0.001 for maximal PM_2.5). In COVID-19 patients with asthma or COPD, the odds of hospitalization were 62% higher with 1 μg/m³ increment in 10-year average PM_2.5 (odds ratio [OR]: 1.62, 95% confidence interval [CI]: 1.00-2.64) and 65% higher with 1 μg/m³ increase in 10-year maximal PM_2.5 levels (OR: 1.65, 95% CI: 1.16-2.35). However, among COVID-19 patients without asthma or COPD, PM_2.5 exposure was not associated with higher hospitalizations (OR: 0.84, 95% CI: 0.65-1.09 for average PM_2.5 and OR: 0.78, 95% CI: 0.65-0.95 for maximal PM_2.5).

CONCLUSIONS

Long-term exposure to PM_2.5 is associated with higher odds of hospitalization in COVID-19 patients with pre-existing asthma or COPD.

Is Blood Type Associated with COVID-19 Severity?

Blood type purportedly influences susceptibility to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, but whether it affects severity of coronavirus disease 2019 (COVID-19) is unclear. Therefore, we examined the association of blood type and rhesus with hospitalization and disease severity among 428 COVID-19 patients diagnosed at the University of Cincinnati health system. In the sample, 50.2% of participants had the blood type O, 38.7% had the blood type A, 17.5% had the blood type B, and 3.5% had the blood type AB. In analysis adjusted for sociodemographic characteristics and comorbidities, the blood types A (OR: 0.90, 95% CI: 0.54, 1.50), B (OR: 0.93, 95% CI: 0.51, 1.69), AB (OR: 0.69, 95% CI: 0.20, 2.41), and O (OR: 1.18, 95%: 0.74, 1.98) were not associated with hospitalization for COVID-19. Similarly, the blood types A (OR: 0.93, 95% CI: 0.52, 1.65), B (OR: 0.92, 95% CI: 0.46, 1.84), AB (OR: 0.30, 95% CI: 0.04, 2.44), and O (OR: 1.25, 95%: 0.73, 2.14) were not associated with admission to intensive care unit or death in COVID-19. In conclusion, blood type is not associated with hospitalization or disease severity in COVID-19; therefore, it may not be useful marker for identifying patients at risk for severe COVID-19.

Factors Associated with Hospitalization and Disease Severity in a Racially and Ethnically Diverse Population of COVID-19 Patients

BACKGROUND

The coronavirus disease (COVID-19) first identified in Wuhan in December 2019 became a pandemic within a few months of its discovery. The impact of COVID-19 is due to both its rapid spread and its severity, but the determinants of severity have not been fully delineated.

OBJECTIVE

Identify factors associated with hospitalization and disease severity in a racially and ethnically diverse cohort of COVID-19 patients.

METHODS

We analyzed data from COVID-19 patients diagnosed at the University of Cincinnati health system from March 13, 2020 to May 31, 2020. Severe COVID-19 was defined as admission to intensive care unit or death. Logistic regression modeling adjusted for covariates was used to identify the factors associated with hospitalization and severe COVID-19.

RESULTS

Among the 689 COVID-19 patients included in our study, 29.2% were non-Hispanic White, 25.5% were non-Hispanic Black, 32.5% were Hispanic, and 12.8% were of other race/ethnicity. About 31.3% of patients were hospitalized and 13.2% had severe disease. In adjusted analyses, the sociodemographic factors associated with hospitalization and/or disease severity included older age, non-Hispanic Black or Hispanic race/ethnicity (compared to non-Hispanic White), and smoking. The following comorbidities: diabetes, hypercholesterolemia, asthma, COPD, chronic kidney disease, cardiovascular diseases, osteoarthritis, and vitamin D deficiency were associated with hospitalization and/or disease severity. Hematological disorders such as anemia, coagulation disorders, and thrombocytopenia were associated with both hospitalization and disease severity.

CONCLUSION

This study confirms race and ethnicity as predictors of severe COVID-19. It also finds clinical risk factors for hospitalization and severe COVID-19 not previously identified such a vitamin D deficiency, hypercholesterolemia, osteoarthritis, and anemia.

Association of urinary levels of bisphenols F and S used as bisphenol A substitutes with asthma and hay fever outcomes

BACKGROUND

Bisphenols F (BPF) and S (BPS) are bisphenol A (BPA) analogs used as substitutes in consumer products. Despite previous reports of BPA's association with asthma, no studies have examined its structural analogs in relation to asthma and allergy outcomes.

OBJECTIVE

To examine the association of urinary BPF, BPS, and BPA with asthma and hay fever in a US representative sample.

METHODS

We analyzed data from 3,538 participants aged 12 years or older in the 2013-2016 National Health and Nutrition Examination Survey (NHANES). Children aged 6-11 years (N = 738), who did not have all covariate data available, were analyzed separately. Covariate-adjusted logistic regression was used to assess the association of the exposures with the outcomes.

RESULTS

BPF, BPS, and BPA were detected in 57.1%, 88.4%, and 94.8% of the urine samples, respectively. Urinary BPF detection was positively associated with current asthma (odds ratio [OR]: 1.54, 95% confidence interval [CI]: 1.16-2.04) and hay fever (OR: 1.66, 95% CI: 1.12-2.46). Urinary BPS was associated with increased odds of current asthma in men (OR: 1.64, 95% CI: 1.13-2.40) and urinary BPA was associated with increased odds of asthma without hay fever in children aged 6-11 years (OR: 2.65, 95% CI: 1.05-6.68).

CONCLUSION

Our nationally-representative findings document that BPF and BPS exposure is common in the US and that exposure to these BPA analogs is associated with asthma and/or hay fever. Our results suggest that BPF and BPS may not be safe alternatives to BPA; however, prospective studies should be conducted to confirm these results.

Endotoxin clustering with allergens in house dust and asthma outcomes in a U.S. national study

BACKGROUND

Endotoxin is ubiquitous in the environment, but its clustering with indoor allergens is not well characterized. This study examined the clustering patterns of endotoxin with allergens in house dust and their association with asthma outcomes.

METHODS

We analyzed data from 6963 participants of the 2005-2006 National Health and Nutrition Examination Survey. House dust sampled from bedroom floor and bedding was evaluated for endotoxin and allergens from fungi, cockroach, dog, cat, mites, and rodents. Two-step cluster analysis and logistic regressions were performed to identify the clustering patterns and their associations with current asthma and wheeze in the past 12 months, adjusting for covariates.

RESULTS

Of the homes, 17.8% had low endotoxin and allergen levels in house dust (Cluster 1). High endotoxin level clustered with Alternaria and pet allergens in the homes of participants with a high socioeconomic status who own pets (Cluster 2) (48.9%). High endotoxin clustered with Aspergillus, dust mites, cockroach, and rodent allergens in the homes of participants with low socioeconomic status (Cluster 3) (33.3%). Compared to Cluster 1, Cluster 2 was associated with higher asthma prevalence (OR 1.42, 95% CI: 1.06-1.91) and wheeze (OR 1.32, 95% CI: 1.07-1.63). Cluster 3 was positively associated with wheeze only in participants sensitized to inhalant allergens (OR 1.42, 95% CI: 1.06-1.91) or exposed to tobacco smoke (OR 1.72, 95% CI: 1.15-2.60).

CONCLUSIONS

The clustering of endotoxin with allergens in dust from homes with pets or of people with low socioeconomic status is associated with asthma and wheeze.

Synergistic Association of House Endotoxin Exposure and Ambient Air Pollution with Asthma Outcomes

Rationale: House endotoxin and ambient air pollution are risk factors for asthma; however, the effects of their coexposure on asthma are not well characterized.Objectives: To examine potential synergistic associations of coexposure to house dust endotoxin and ambient air pollutants with asthma outcomes.Methods: We analyzed data of 6,488 participants in the National Health and Nutrition Examination Survey 2005-2006. Dust from bedding and bedroom floor was analyzed for endotoxin content. The Community Multiscale Air Quality Modeling System (CMAQ) and Downscaler Model data were used to determine annual average particulate matter ≤2.5 μm in aerodynamic diameter (PM_2.5), ozone (O₃), and nitrogen dioxide (NO₂) exposures at participants' residential locations. The associations of the coexposures with asthma outcomes were assessed and tested for synergistic interaction.Measurements and Main Results: In adjusted analysis, PM_2.5 (CMAQ) (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.07-1.18), O₃ (Downscaler Model) (OR, 1.07; 95% CI, 1.02-1.13), and log₁₀ NO₂ (CMAQ) (OR, 3.15; 95% CI, 1.33-7.45) were positively associated with emergency room visits for asthma in the past 12 months. Coexposure to elevated concentrations of house dust endotoxin and PM_2.5 (CMAQ) was synergistically associated with the outcome, increasing the odds by fivefold (OR, 5.01; 95% CI, 2.54-9.87). A synergistic association was also found for coexposure to higher concentrations of endotoxin and NO₂ in children (OR, 3.45; 95% CI, 1.65-7.18).Conclusions: Coexposure to elevated concentrations of residential endotoxin and ambient PM_2.5 in all participants and NO₂ in children is synergistically associated with increased emergency room visits for asthma. Therefore, decreasing exposure to both endotoxin and air pollution may help reduce asthma morbidity.

Household endotoxin reduction in the Louisa Environmental Intervention Project for rural childhood asthma

Endotoxin exacerbates asthma. We designed the Louisa Environmental Intervention Project (LEIP) and assessed its effectiveness in reducing household endotoxin and improving asthma symptoms in rural Iowa children. Asthmatic school children (N = 104 from 89 homes) of Louisa and Keokuk counties in Iowa (aged 5-14 years) were recruited and block-randomized to receive extensive (education + professional cleaning) or educational interventions. Environmental sampling collection and respiratory survey administration were done at baseline and during three follow-up visits. Mixed-model analyses were used to assess the effect of the intervention on endotoxin levels and asthma symptoms in the main analysis and of endotoxin reduction on asthma symptoms in exploratory analysis. In the extensive intervention group, dust endotoxin load was significantly reduced in post-intervention visits. The extensive compared with the educational intervention was associated with significantly decreased dust endotoxin load in farm homes and less frequent nighttime asthma symptoms. In exploratory analysis, dust endotoxin load reduction from baseline was associated with lower total asthma symptoms score (Odds ratio: 0.52, 95% confidence interval: 0.29-0.92). In conclusion, the LEIP intervention reduced household dust endotoxin and improved asthma symptoms. However, endotoxin reductions were not sustained post-intervention by residents.

Reduced mortality from lower respiratory tract disease in adult diabetic patients treated with metformin

BACKGROUND AND OBJECTIVE

Chronic lower respiratory diseases (CLRD) increase the risk of type 2 diabetes, which in turn may worsen lung function. Metformin, a common antidiabetic with anti-inflammatory and antioxidant properties, may improve respiratory outcomes. Therefore, we examined the association of metformin use with the risk of mortality from CLRD.

METHODS

We analysed data from the National Health and Nutrition Examination Survey during 1988-1994 and 1999-2010 for participants aged 40 years or older who had diabetes and were followed up for mortality through 2011. Information on prescription medicine was collected at baseline and CLRD-related mortality during follow-up was defined using the 10th Revision of the International Classification of Diseases (ICD-10). Cox proportional hazards modelling was used to determine the mortality hazard ratio (HR) associated with metformin use, adjusting for relevant covariates.

RESULTS

A total of 5266 participants with a median follow-up of 6.1 years were included. The prevalence of metformin use was 31.9% and 1869 participants died during follow-up, including 72 of CLRD. In the adjusted Cox proportional regression analysis, metformin was associated with a decreased risk of CLRD mortality in the overall population (HR: 0.39, 95% CI: 0.15-0.99) and among participants with baseline CLRD (HR: 0.30, 95% CI: 0.10-0.93), after adjusting for age, gender, race/ethnicity, cigarette smoking, body mass index, current asthma and chronic obstructive pulmonary disease (COPD), insulin and other diabetic medications, and glycohaemoglobin level. We found no association between other antidiabetic medications and CLRD mortality.

CONCLUSION

In this sample representative of the U.S. population, metformin was associated with lower CLRD mortality in adults with diabetes.

Osteoarthritis and risk of mortality in the USA: a population-based cohort study

Background

Osteoarthritis (OA) is the most common joint disease, but its association with mortality is unclear.

Methods

We analysed data on adult participants in the 1988–94 and 1999–2010 National Health and Nutrition Examination Surveys, followed for mortality through 2011. OA was defined by self-report, and in a subset of participants 60 years or older with knee X-rays, radiographic knee OA (RKOA) was defined as Kellgren–Lawrence score ≥2. Cox proportional hazards were used to determine the mortality hazard ratio (HR) associated with self-reported OA and RKOA, adjusting for covariates.

Results

The sample included 51 938 participants followed for a median 8.9 years; 2589 of them had knee X-rays and were followed for a median of 13.6 years. Self-reported OA and RKOA prevalences were 6.6% and 40.6%, respectively. Self-reported OA was not associated with mortality. RKOA was associated with an increased risk of mortality from cardiovascular diseases (CVD) {HR 1.43 [95% confidence interval (CI): 1.32, 1.64]}, diabetes [HR 2.04 (1.87, 2.23)] and renal diseases [HR 1.14 (1.04, 1.25)], but with a reduced risk of cancer mortality [HR 0.88 (0.80, 0.96)]. Participants with early RKOA onset (diagnosed before age 40) had a higher risk of mortality from all causes [HR 1.53 (1.43, 1.65)] and from diabetes [HR 7.18 (5.45, 9.45)]. Obese participants with RKOA were at increased risk of mortality from CVD [HR 1.89 (1.56, 2.29)] and from diabetes [HR: 3.42 (3.01, 3.88)].

Conclusions

Self-reported OA was not associated with mortality. RKOA was associated with higher CVD, diabetes and renal mortality, especially in people with early onset of the disease or with obesity.

Peroxisome Proliferator-activated Receptor gamma (PPARγ) suppresses inflammation and bacterial control during influenza bacterial super-infection

Influenza is one of the most common causes of respiratory illness worldwide and can be complicated by secondary bacterial pneumonia, which is a common cause of mortality. Influenza-induced “cytokine storm” is thought to play a role in lung pathogenesis during influenza infection. PPARγ is a member of nuclear hormone receptor superfamily that is known to enhance lipid and glucose metabolism, cellular differentiation and suppress the inflammatory immune response. Synthetic PPARγ agonists (thiazolidinedione, rosiglitazone) have been used clinically in the treatment of type II diabetes. In this study, we determined the effect of rosiglitazone in mice infected with influenza or influenza, methicillin-resistant Staphylococcus aureus (MRSA) super-infection. We found decreased influenza viral burden, decreased numbers of neutrophils and macrophages in bronchoalveolar lavage (BAL), and decreased production of IL-6, IL-12, CCL2, and CXCL10 in influenza-infected, rosiglitazone-treated mice when compared to influenza-infected control mice. However, rosiglitazone treatment compromised bacterial control during influenza-bacterial super-infection. Further, we found decreased numbers of neutrophils and decreased gene expression of neutrophil elastase and cathepsin G during super-infection in rosiglitazone-treated mice. Similarly, using data from the National Health and Nutrition Examination Survey (NHANES), we found increased influenza/pneumonia mortality in rosiglitazone-treated patients compared to other diabetic patients (adjusted hazard ratio=3.4, 95% confidence interval=1.1–10.7). Both human and mouse data suggest that rosiglitazone treatment worsens the outcome of influenza-associated pneumonia.

Prevalence and features of asthma-COPD overlap in the United States 2007-2012

BACKGROUND

Perceived to be distinct, asthma and chronic obstructive pulmonary disease (COPD) can co-exist and potentially have a worse prognosis than the separate diseases. Yet, little is known about the exact prevalence and the characteristics of the Asthma-COPD overlap (ACO) in the US population.

AIMS

To determine ACO prevalence in the United States, identify ACO predictors, examine ACO association with asthma and COPD severity, and describe distinctive spirometry and laboratory features of ACO.

METHODS

Data on adult participants to the National Health and Nutrition Examination Surveys conducted from 2007 to 2012 was analyzed. ACO was defined as current asthma and post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) <0.7.

RESULTS

Overall, 7,570 participants representing 98.58 million Americans were included in our study. From 2007 to 2012, the crude and age-standardized ACO prevalence were, respectively, 0.96% (95% CI: 0.65%-1.26%) and 1.05% (0.74%-1.37%). In asthma, ACO predictors included older age, male gender, and smoking. In COPD, ACO predictors were non-Hispanic Black race/ethnicity and obesity. ACO was associated with increased ER visits for asthma (OR = 3.46, 95% CI: 1.48-8.06]) and oxygen therapy in COPD (OR = 11.17, 95% CI: 5.17-24.12]). In spirometry, FEV1 and peak expiratory flow were lower in ACO than in asthma or COPD alone.

CONCLUSION

Age-adjusted prevalence of ACO in the United States was 1.05% in 2007-2012, representing 0.94 (95% CI: 0.62-1.26) million Americans. It is much lower than previously reported. The overlap was associated with higher asthma and COPD severity as well as decreased lung function compared with COPD or asthma alone.

House Dust Endotoxin Association with Chronic Bronchitis and Emphysema

BACKGROUND

Endotoxin has been reported to be associated with chronic bronchitis or emphysema (CBE) at high occupational exposures. However, whether levels found in domestic environments have similar effects is unknown.

OBJECTIVES

We aimed to study the association between house dust endotoxin and CBE in a sample representative of the U.S. population.

METHODS

We analyzed data from 3,393 participants ≥20 y old from the National Health and Nutrition Examination Survey (NHANES) 2005-2006. House dust from bedding and from bedroom floors was analyzed for endotoxin content. NHANES participants received questionnaires and underwent examination as well as extensive laboratory testing. Logistic regression was used to examine the association of endotoxin levels with CBE diagnosis and symptoms, adjusting for covariates. The survey design and weights were applied so that estimates were nationally representative and so that statistical inferences were made appropriately.

RESULTS

The median endotoxin concentration in house dust was 14.61 EU/mg dust, and CBE was reported by 8.2% of participants. In the adjusted analysis, one unit (EU/mg) increase in log₁₀-transformed endotoxin concentrations was associated with a 27% increase in the odds of CBE diagnosis [OR=1.27 (95% CI: 1.00, 1.61)] and a 78% increase in the odds of chronic bronchitis symptoms (defined as cough and phlegm for ≥3 mo in a year for ≥2 y) [OR=1.78 (95% CI: 1.01, 3.12)]. Sensitization to inhalant allergens (p=0.001) modified the relationship between endotoxin and CBE diagnosis, with stronger associations observed in sensitized participants [OR=2.46 (95% CI: 1.72, 3.50) for a unit increase in log₁₀-endotoxin].

CONCLUSIONS

In a population-based sample of U.S. adults, endotoxin levels in homes were associated with a self-reported history of CBE diagnosis and chronic bronchitis symptoms, with stronger associations among people sensitized to inhalant allergens. https://doi.org/10.1289/EHP2452.

Endotoxin predictors and associated respiratory outcomes differ with climate regions in the U.S

RATIONALE

Although endotoxin is a recognized cause of environmental lung disease, how its relationship with respiratory outcomes varies with climate is unknown.

OBJECTIVE

To examine the endotoxin predictors as well as endotoxin association with asthma, wheeze, and sensitization to inhalant allergens in various US climate regions.

METHODS

We analyzed data on 6963 participants in the National Health and Nutrition Examination Survey. Endotoxin measurements of house dust from bedroom floor and bedding were performed at the University of Iowa. Linear and logistic regression analyses were used to identify endotoxin predictors and assess endotoxin association with health outcomes.

RESULTS

The overall median house dust endotoxin was 16.2 EU/mg; it was higher in mixed-dry/hot-dry regions (19.7 EU/mg) and lower in mixed-humid/marine areas (14.8 EU/mg). Endotoxin predictors and endotoxin association with health outcomes significantly differed across climate regions. In subarctic/very cold/cold regions, log₁₀-endotoxin was significantly associated with higher prevalence of wheeze outcomes (OR:1.48, 95% CI:1.19-1.85 for any wheeze, OR:1.48, 95% CI:1.22-1.80 for exercise-induced wheeze, OR:1.50, 95% CI:1.13-1.98 for prescription medication for wheeze, and OR:1.95, 95% CI:1.50-2.54 for doctor/ER visit for wheeze). In hot-humid regions, log₁₀-endotoxin was positively associated with any wheeze (OR:1.66, 95% CI:1.04-2.65) and current asthma (OR:1.56, 95% CI:1.11-2.18), but negatively with sensitization to any inhalant allergens (OR:0.83, 95% CI:0.74-0.92).

CONCLUSION

Endotoxin predictors and endotoxin association with asthma and wheeze differ across U.S. climate regions. Endotoxin is associated positively with wheeze or asthma in cold and hot-humid regions, but negatively with sensitization to inhalant allergens in hot-humid climates.

Staphylococcus aureus Colonization and Long-Term Risk for Death, United States

To examine the association of colonization by Staphylococcus aureus and general population mortality, we followed 10,598 adults for 8.5 years on average. Methicillin-susceptible S. aureus colonization was not associated with death. Methicillin-resistant S. aureus carriage predicted death in a crude analysis but not after adjustment for socioeconomic status and co-morbidities.

Blood biomarkers as predictors of long-term mortality in COPD

BACKGROUND

Blood biomarkers are easily accessible and might reflect chronic obstructive pulmonary disease (COPD) activity.

AIM

The aim of this study was to determine whether a panel of blood biomarkers [C-reactive protein (CRP), neutrophils, eosinophils, albumin and vitamin D] could predict mortality in COPD.

METHODS

We analyzed data from 431 COPD participants to the 2007-2010 National Health and Nutrition Examination Surveys who were followed for a median time of 36 months. COPD was defined as post-bronchodilator forced expiratory volume in 1 second (FEV1) and forced vital capacity ratio <0.70. Weibull survival analysis adjusted for covariates was performed to calculate the risk of mortality associated with the biomarkers, and C-statistics was used to assess their added predictive value.

RESULTS

During follow-up, 38 of the 431 participants died. Participants with high CRP, eosinophil count <2%, hypoalbuminemia and hypovitaminosis D had worse baseline FEV1 and subsequently higher mortality compared to controls. In adjusted analysis, increasing CRP [hazard ratio (HR): 4.45, 95% CI: 1.91-10.37] and neutrophil count (HR: 1.07, 95% CI: 1.03-1.11) as well as decreasing eosinophil count (HR: 7.03, 95% CI: 2.05-24.01) were associated with an increased risk of mortality. The addition of CRP with eosinophil and/or neutrophil count significantly improved a base model for the prediction of mortality which included age, gender, race/ethnicity, body mass index, smoking, poverty income ratio, asthma, diabetes, hypertension and history of stroke or myocardial infarction.

CONCLUSION

High CRP and neutrophils as well as low eosinophils are predictive of poor COPD prognosis. They also add significant value to prediction models of mortality in COPD.

Various Types of Arthritis in the United States: Prevalence and Age-Related Trends From 1999 to 2014

OBJECTIVES

To determine the prevalence trends of osteoarthritis (OA), rheumatoid arthritis (RA), and other types of arthritis in the United States from 1999 to 2014.

METHODS

We analyzed data on 43 706 community-dwelling adults aged 20 years and older who participated in the 1999-2014 National Health and Nutrition Examination Surveys. We accounted for survey design and sampling weights so that estimates were nationally representative. We assessed temporal trends in age-standardized arthritis prevalence by using joinpoint regression.

RESULTS

Age-adjusted prevalence of arthritis was 24.7% (OA = 9.7%; RA = 4.2%; other arthritis = 2.8%; "don't know" type = 8.0%). Prevalence of OA increased from 6.6% to 14.3%, whereas RA prevalence decreased from 5.9% to 3.8%. Increase in OA prevalence was significant in both genders; in non-Hispanic Whites, non-Hispanic Blacks, and Hispanics; and in people with high socioeconomic status. Decrease in RA prevalence was more pronounced in men, non-Hispanic Blacks, and participants with low income or obesity.

CONCLUSIONS

Between 1999 and 2014, nearly one quarter of American adults reported arthritis. The prevalence of OA has more than doubled over time, whereas RA prevalence has declined.

Endotoxin exposure, serum vitamin D, asthma and wheeze outcomes

BACKGROUND

Endotoxin has been shown to induce neutrophilic asthma and wheeze after binding toll-like receptor 4 to produce pro-inflammatory cytokines. Animal models have demonstrated that vitamin D might inhibit lipopolysaccharide-induced cytokines. However, whether endotoxin exposure and serum vitamin D deficiency interact to affect asthma and wheeze in humans has never been investigated in an epidemiological study.

METHODS

Joint associations of house dust endotoxin and vitamin D with asthma and wheeze were examined using logistic regression adjusted for covariates in 5924 US participants of the National Health and Nutrition Examination Survey (NHANES). Interactions were assessed on the multiplicative as well as additive scale using the relative excess risk, the attributable portion due to additive interaction, and the synergy index.

RESULTS

The median endotoxin concentration was 19.1 EU/mg. Prevalence of vitamin D inadequacy (20-30 ng/ml) and deficiency (<20 ng/ml) were respectively 42.9 and 33.4%. The combination of high endotoxin and low vitamin D was associated with current asthma (OR: 1.56, 95% CI: 1.09, 2.23), wheeze in the past 12 months (OR: 1.72, 95% CI: 1.10, 3.71), recurrent wheeze (OR: 1.97, 95% CI: 1.00, 4.00), asthma diagnosis or recurrent wheeze (OR: 1.88, 95% CI: 1.33, 2.66), and current asthma or recurrent wheeze (OR:1.81, 95% CI: 1.23, 2.68) when compared to low endotoxin and normal vitamin D. The interactions between the exposures were not significant on the multiplicative or additive scale for any of the outcomes.

CONCLUSIONS

Combination of high endotoxin exposure and low vitamin D increases the odds of asthma and wheeze, but the exposures do not interact or modify each other's effect in the NHANES cohort.

Endotoxin Exposure: Predictors and Prevalence of Associated Asthma Outcomes in the United States

RATIONALE

Inhaled endotoxin induces airway inflammation and is an established risk factor for asthma. The 2005-2006 National Health and Nutrition Examination Survey included measures of endotoxin and allergens in homes as well as specific IgE to inhalant allergens.

OBJECTIVES

To understand the relationships between endotoxin exposure, asthma outcomes, and sensitization status for 15 aeroallergens in a nationally representative sample.

METHODS

Participants were administered questionnaires in their homes. Reservoir dust was vacuum sampled to generate composite bedding and bedroom floor samples. We analyzed 7,450 National Health and Nutrition Examination Survey dust and quality assurance samples for their endotoxin content using extreme quality assurance measures. Data for 6,963 subjects were available, making this the largest study of endotoxin exposure to date. Log-transformed endotoxin concentrations were analyzed using logistic models and forward stepwise linear regression. Analyses were weighted to provide national prevalence estimates and unbiased variances.

MEASUREMENTS AND MAIN RESULTS

Endotoxin exposure was significantly associated with wheeze in the past 12 months, wheeze during exercise, doctor and/or emergency room visits for wheeze, and use of prescription medications for wheeze. Models adjusted for age, sex, race and/or ethnicity, and poverty-to-income ratio and stratified by allergy status showed that these relationships were not dependent upon sensitization status but were worsened among those living in poverty. Significant predictors of higher endotoxin exposures were lower family income; Hispanic ethnicity; participant age; dog(s), cat(s), cockroaches, and/or smoker(s) in the home; and carpeted floors.

CONCLUSIONS

In this U.S. nationwide representative sample, higher endotoxin exposure was significantly associated with measures of wheeze, with no observed protective effect regardless of sensitization status.

Falls, physical limitations, confusion and memory problems in people with type II diabetes, undiagnosed diabetes and prediabetes, and the influence of vitamins A, D and E

AIMS

To examine the association between type II diabetes, prediabetes and undiagnosed diabetes with falls, physical limitations, confusion and memory problems, and to evaluate the effects of vitamins A, D and E levels on the associations.

METHODS

Data from 37,973 participants of the National Health and Nutrition Examination Survey was analyzed.

RESULTS

The participants' mean age was 46±17years, 20% had diabetes of which 17% were unaware of their condition (undiagnosed diabetes), and 21% had prediabetes. Diabetes was significantly associated with falls, difficulties in stooping, crouching, kneeling, completing house chores, getting in and out bed, standing and sitting for long periods, reaching over head, grasping, holding objects, and attending social events. The association between diabetes and confusion or memory problems was stronger for those diagnosed before age 40. Memory problems were reported only by people with diabetes with lower vitamin D levels. Vitamin A and E levels did not modify the association between diabetes and falls or any of the physical functions, confusion or memory problems. Prediabetes was only associated with difficulty standing for long periods.

CONCLUSIONS

Diabetes was associated with falls, difficulties in physical functioning and attending social events. Vitamin D levels modified the effects on confusion and memory problems.

Chikungunya outbreak in Montpellier, France, September to October 2014

In October 2014, an outbreak of 12 autochthonous chikungunya cases, 11 confirmed and 1 probable, was detected in a district of Montpellier, a town in the south of France colonised by the vector Aedes albopictus since 2010. A case returning from Cameroon living in the affected district was identified as the primary case. The epidemiological investigations and the repeated vector control treatments performed in the area and around places frequented by cases helped to contain the outbreak. In 2014, the chikungunya and dengue surveillance system in mainland France was challenged by numerous imported cases due to the chikungunya epidemic ongoing in the Caribbean Islands. This first significant outbreak of chikungunya in Europe since the 2007 Italian epidemic, however, was due to an East Central South African (ECSA) strain, imported by a traveller returning from West Africa. Important lessons were learned from this episode, which reminds us that the threat of a chikungunya epidemic in southern Europe is real.

Immediate rather than delayed memory impairment in older adults with latent toxoplasmosis

The neurotropic parasite Toxoplasma gondii infects one third of the world population, but its effect on memory remains ambiguous. To examine a potential relationship of the infection with immediate and delayed memory, a population-based study was conducted in 4485 participants of the Third National Health and Nutrition Examination Survey aged 60years and older. Serum anti-Toxoplasma IgG antibodies were measured by enzyme immune assay and verbal memory was assessed using the Mini-Mental State Examination and the East Boston Memory Test. The prevalence of latent toxoplasmosis was 41%; in one way analysis of variance, anti-Toxoplasma IgG antibody levels significantly differed across tertiles for immediate (P=0.006) but not delayed memory scores (P=0.22). In multinomial logistic regression adjusting for covariates, Toxoplasma seropositivity was associated with lower immediate memory performance (OR: 0.65, 95% CI: 0.44, 0.97 for medium tertile and OR: 0.61, 95% CI: 0.37, 0.98 for highest tertile in reference to the lowest tertile), especially in non-Hispanic Whites (OR: 0.56, 95% CI: 0.36, 0.88 for medium tertile and OR: 0.51, 95% CI: 0.30, 0.87 for highest tertile in reference to the lowest tertile). However, no relationship with delayed memory was observed. In conclusion, latent toxoplasmosis is widespread in older adults and may primarily affect immediate rather than delayed memory, particularly in White Americans.

Prospective study of cytomegalovirus seropositivity and risk of mortality from diabetes

Cytomegalovirus (CMV) infects 40 % of the world population and has been suggested to be associated with diabetes; however, no prospective study has ever examined diabetes mortality associated with the infection. A cohort of 14,404 non-diabetic adult participants aged 17-90 years from the Third National Health and Nutrition Examination Survey (1988-1994) was prospectively followed for mortality through 2006. CMV immunoglobulin G was measured by enzyme-linked immunosorbent assay and immunofluorescence assay. Diabetes death was assessed with death records from the National Death Index. Cox proportional hazards modeling was used to determine diabetes mortality risk associated with CMV infection, adjusting for socio-demographics, diabetes risk factors, and comorbidities. At baseline, 76.8 % of subjects were CMV seropositive, and after an average follow-up of 13.7 years, diabetes mortality rate per 10,000 person-years was 6.8 (95 % CI 5.7, 8.0). Among seropositive participants, the diabetes death rate (8.4, 95 % CI 7.0, 9.9) was more than four times the rate in seronegative ones (2.0, 95 % CI 1.1, 3.6) (P value for the difference <0.001). In the adjusted Cox proportional hazards analysis, CMV seropositivity more than doubled the risk of diabetes mortality (HR 2.06, 95 % CI 1.05, 4.06). CMV infection may thus predict future mortality from diabetes in non-diabetic people.

Low blood lead concentrations and thyroid function of American adults

Lead is often present in our environment, but its effect on thyroid function is still unclear. In this study, multiple linear regressions were performed between log-transformed blood lead levels and thyroid function parameters of 4652 adults from the 2007-2008 National Health and Nutrition Examination Survey. The models were adjusted for age, gender, race/ethnicity, smoking, alcohol consumption, body mass index, physical activity, iodine intake, medications, and bone mineral density. Blood lead concentrations (mean: 1.52 ± 1.20 μg/dL [range 0.18-33.12]) were inversely associated with total thyroxine (regression coefficients [β]: -0.22 [95% CI: -0.34, -0.09] in the general population, but were not correlated with thyroid stimulating hormone, total or free triiodothyronine, nor free thyroxine. Blood lead may have no effect on the thyroid function; however, it could be associated with decreased concentrations in thyroid-binding proteins.

Probiotic administration in early life, atopy, and asthma: a meta-analysis of clinical trials

BACKGROUND AND OBJECTIVE

Probiotics may reduce the risk of atopy and asthma in children. However, results from clinical trials have been conflicting, and several of them may have been underpowered. We performed a meta-analysis of randomized, placebo-controlled trials to assess the effects of probiotic supplementation on atopic sensitization and asthma/wheeze prevention in children.

METHODS

Random-effects models were used to calculate pooled risk estimates. Meta-regression was conducted to examine the effect of potential factors on probiotics efficacy.

RESULTS

Probiotics were effective in reducing total immunoglobulin E (IgE) (mean reduction: -7.59 U/mL [95% confidence interval (CI): -14.96 to -0.22]; P = .044). Meta-regression showed that the reduction in IgE was more pronounced with longer follow-up. Probiotics significantly reduced the risk of atopic sensitization when administered prenatally (relative risk: 0.88 [95% CI: 0.78 to 0.99]; P = .035 for positive result on the skin prick test and/or elevated specific IgE to common allergens) and postnatally (relative risk: 0.86 [95% CI: 0.75 to 0.98]; P = .027 for positive result on skin prick test). Administration of Lactobacillus acidophilus, compared with other strains, was associated with an increased risk of atopic sensitization (P = .002). Probiotics did not significantly reduce asthma/wheeze (relative risk: 0.96 [95% CI: 0.85 to 1.07]).

CONCLUSIONS

Prenatal and/or early-life probiotic administration reduces the risk of atopic sensitization and decreases the total IgE level in children but may not reduce the risk of asthma/wheeze. Follow-up duration and strain significantly modified these effects. Future trials for asthma prevention should carefully select probiotic strain and consider longer follow-up.

Macrolides for the long-term management of asthma--a meta-analysis of randomized clinical trials

BACKGROUND

Macrolide antibiotics, which have anti-inflammatory and immune modulatory effects, have been studied as adjuncts for the management of asthma. However, results have been contradictory and trials underpowered. We therefore sought to conduct a meta-analysis of randomized controlled trials (RCT).

METHODS

All RCT of prolonged macrolides (3+ weeks) for asthma treatment, published up to January 2013 in MEDLINE, Scopus, CINAHL, Highwire, and The Cochrane Collaboration Library, were included. Fixed- or random-effects models were used to calculate pooled weighted or standard mean differences (WMD or SMD, respectively).

RESULTS

A total of 12 studies were included for analysis. The pooled effect of macrolides on FEV1 (eight trials, 381 subjects) was not significant (SMD 0.05, 95% CI -0.14-0.25), but there was a significant increase in peak expiratory flow (four trials, 419 subjects; WMD 6.7, 95% CI 1.35-12.06). Pooled analysis also showed significant improvements in symptom scores (eight studies, 478 subjects; WMD -0.46, 95% CI -0.60 to -0.32), quality of life (five trials, 346 subjects; WMD 0.18, 95% CI 0.001-0.37), and airway hyper-reactivity (two trials, 131 subjects; SMD 1.99, 95% CI 0.46-3.52). Post hoc evaluation showed limited statistical power to detect significant differences in FEV1.

CONCLUSIONS

Macrolide administration for asthma for three or more weeks was not associated with improvement in FEV1, but produced significant improvements in peak expiratory flow, symptoms, quality of life, and airway hyper-reactivity. Macrolides may therefore be beneficial as adjunct asthma therapy. Future trials, focusing on long-term safety and effectiveness, should use standardized outcomes and procedures.

Motor vehicle air pollution and asthma in children: a meta-analysis

BACKGROUND

Asthma affects more than 17 million people in the United States;1/3 of these are children. Children are particularly vulnerable to airborne pollution because of their narrower airways and because they generally breathe more air per pound of body weight than adults, increasing their exposure to air pollutants. However, the results from previous studies on the association between motor vehicle emissions and the development of childhood wheeze and asthma are conflicting. Therefore, we conducted a meta-analysis to clarify their potential relationship.

METHODS

MEDLINE, Highwire, and The Cochrane Library databases were searched for relevant studies. Adjusted odds ratio (OR) with corresponding 95% confidence interval (CI) for the association between traffic air pollutants and wheeze or asthma were retrieved from individual studies and pooled to generate summary effect estimates (meta-OR) in STATA 11.1.

RESULTS

Nineteen studies were included in the meta-analysis. Exposure to nitrogen dioxide (meta-OR: 1.05, 95% CI: 1.00-1.11), nitrous oxide (meta-OR: 1.02, 95% CI: 1.00-1.04), and carbon monoxide (meta-OR: 1.06, 95% CI: 1.01-1.12) were positively associated with a higher prevalence of childhood asthma. Exposure to sulfur dioxide (meta-OR: 1.04, 95% CI: 1.01-1.07) was positively associated with a higher prevalence of wheeze in children. Exposure to nitrogen dioxide was positively associated with a higher incidence of childhood asthma (meta-OR: 1.14, 95% CI: 1.06-1.24), and exposures to particulate matter was positively associated with a higher incidence of wheeze in children (meta-OR: 1.05, 95% CI: 1.04-1.07).

CONCLUSIONS

Living or attending schools near high traffic density roads exposes children to higher levels of motor vehicle air pollutants, and increases the incidence and prevalence of childhood asthma and wheeze.

Can falls risk prediction tools correctly identify fall-prone elderly rehabilitation inpatients? A systematic review and meta-analysis

BACKGROUND

Falls of elderly people may cause permanent disability or death. Particularly susceptible are elderly patients in rehabilitation hospitals. We systematically reviewed the literature to identify falls prediction tools available for assessing elderly inpatients in rehabilitation hospitals.

METHODS AND FINDINGS

We searched six electronic databases using comprehensive search strategies developed for each database. Estimates of sensitivity and specificity were plotted in ROC space graphs and pooled across studies. Our search identified three studies which assessed the prediction properties of falls prediction tools in a total of 754 elderly inpatients in rehabilitation hospitals. Only the STRATIFY tool was assessed in all three studies; the other identified tools (PJC-FRAT and DOWNTON) were assessed by a single study. For a STRATIFY cut-score of two, pooled sensitivity was 73% (95%CI 63 to 81%) and pooled specificity was 42% (95%CI 34 to 51%). An indirect comparison of the tools across studies indicated that the DOWNTON tool has the highest sensitivity (92%), while the PJC-FRAT offers the best balance between sensitivity and specificity (73% and 75%, respectively). All studies presented major methodological limitations.

CONCLUSIONS

We did not identify any tool which had an optimal balance between sensitivity and specificity, or which were clearly better than a simple clinical judgment of risk of falling. The limited number of identified studies with major methodological limitations impairs sound conclusions on the usefulness of falls risk prediction tools in geriatric rehabilitation hospitals.

Urinary heavy metals and associated medical conditions in the US adult population

Health effects of heavy metals have been widely investigated, but further evaluation is required to comprehensively delineate their toxicity. Using data from the 2007-2008 National Health and Nutrition Examination Survey, a multivariate logistic regression analysis was performed on 1,857 adults to examine the relationship between urinary heavy metals and various medical conditions. Cardiovascular diseases were correlated to cadmium (OR: 4.94, 95% CI: 1.48-16.56) and lead (OR: 5.32, 95% CI: 1.08-26.21). Asthma was related to tungsten (OR: 1.72, 95% CI: 1.15-2.59) and uranium (OR: 1.52, 95% CI: 1.01-2.28). Hepatotoxicity was associated with molybdenum (OR: 3.09, 95% CI: 1.24-7.73) and uranium (OR: 4.79, 95% CI: 1.74-13.19). Surprising inverse relationships occurred for excessive weight with lead (OR: 0.72, 95% CI: 0.52-0.98), reduced visual acuity with cobalt (OR: 0.65, 95% CI: 0.44-0.95) and cesium (OR: 0.52, 95% CI: 0.35-0.77). This study supports some previous evidence of potential relationships and provides insights for future research.

Endotoxin exposure and childhood wheeze and asthma: a meta-analysis of observational studies

BACKGROUND

Exposure to endotoxin has been widely investigated as a potential factor for asthma and associated symptoms in children with different results. To clarify a potential relationship, we performed the present meta-analysis to integrate the results of studies examining the association of endotoxin exposure with wheeze and asthma in children.

METHODS

A search for relevant studies and reviews was conducted in MEDLINE, Highwire, CINAHL, and The Cochrane Library databases. Adjusted odds ratio (OR) with corresponding 95% confidence interval (CI) for endotoxin exposure and wheeze or asthma were retrieved and pooled to generate summary effect estimates in STATA 11.1.

RESULTS

Nineteen studies were included in the meta-analysis. The summary estimates suggested that endotoxin was positively associated with wheeze in infants and toddlers (meta-OR: 1.48, 95% CI: 1.10-1.98), but negatively related to asthma in school-aged children (meta-OR: 0.82, 95% CI: 0.69-0.97 for endotoxin concentration and 0.68, 95% CI: 0.50-0.93 for endotoxin load).

CONCLUSIONS

Based on the studies evaluated, endotoxin is a risk factor for wheeze in younger children, but a protective factor for asthma in older children. Thus, this study supports the "hygiene hypothesis."

[Late diagnosis of HIV infection in the Fann, Dakar clinic of infectious diseases: testing circumstances, therapeutic course of patients, and determining factors]

BACKGROUND AND METHODOLOGY

The delay in the diagnosis of HIV infection is a major obstacle to optimal care for this disease. To deal with this problem, we conducted this study among newly diagnosed HIV patients hospitalized in the Fann University Hospital Infectious Diseases Clinic in Dakar. The epidemiological, clinical, biological and outcome aspects are described and patient history reviewed. A qualitative socio-anthropological study was made to understand and describe the logic of the decision processes in the patient's search for treatment.

RESULTS

One hundred patients were included, with a mean age of 39.5+/-11.1 years and a sex-ratio: 1.08. The transmission was mainly heterosexual (90%), and chronic diarrhea (64%) and/or chronic cough (66%) were the principal symptoms leading to diagnosis. The mean delay before diagnosis was 5+/-4.27 months. The major opportunistic diseases were tuberculosis (44 cases) and infectious diarrhea (23 cases). Most patients were diagnosed at the AIDS stage (97%) and the death rate was 30% among hospitalized patients after admission. Sixty-eight percent of patients had consulted at least three times, generally a "traditional practitioner", at first and 43% had been hospitalized at least once. The qualitative investigation revealed that the "representation" or the "feeling of severity" of the disease were the principal justifications for consulting the "traditional practitioner" or the physician, respectively.

CONCLUSION

Better information for health workers and global population is necessary for an earlier diagnosis of HIV infection in Dakar.