Integrating mangrove growth and failure in coastal flood protection designs

Mangrove forests reduce wave attack along tropical and sub-tropical coastlines, decreasing the wave loads acting on coastal protection structures. Mangrove belts seaward of embankments can therefore lower their required height and decrease their slope protection thickness. Wave reduction by mangroves depends on tree frontal surface area and stability against storms, but both aspects are often oversimplified or neglected in coastal protection designs. Here we present a framework to evaluate how mangrove belts influence embankment designs, including mangrove growth over time and failure by overturning and trunk breakage. This methodology is applied to Sonneratia apetala mangroves seaward of embankments in Bangladesh, considering forest widths between 10 and 1000 m (cross-shore). For water depths of 5 m, wave reduction by mangrove forests narrower than 1 km mostly affects the slope protection and the bank erodibility, whereas the required embankment height is less influenced by mangroves. Sonneratia apetala trees experience a relative maximum in wave attenuation capacity at 10 years age, due to their large submerged canopy area. Once trees are more than 20 years old, their canopy is emergent, and most wave attenuation is caused by trunk and roots. Canopy emergence exposes mangroves to wind loads, which are much larger than wave loads, and can cause tree failure during cyclones. These results stress the importance of including tree surface area and stability models when predicting coastal protection by mangroves.

Gas cooking indoors and respiratory symptoms in the ECRHS cohort

BACKGROUND

Gas cooking is an important source of indoor air pollutants, and there is some limited evidence that it might adversely be associated with respiratory health. Using repeated cross-sectional data from the multi-centre international European Community Respiratory Health Survey, we assessed whether adults using gas cookers have increased risk of respiratory symptoms compared to those using electric cookers and tested whether there was effect modification by a priori selected factors.

METHODS

Data on respiratory symptoms and gas cooking were collected from participants at 26-55 and 38-67 years (median time between examinations 11.4 years) from interviewer-led questionnaires. Repeated associations between gas cooking (versus electric) and respiratory symptoms were estimated using multivariable mixed-effects logistic regression models adjusted for age, sex, study arm, smoking status, education level, and included random intercepts for participants within study centres. Analyses were repeated using a 3-level variable for type of cooker and gas source. Effect modification by ventilation habits, cooking duration, sex, age atopy, asthma, and study arm were examined.

RESULTS

The sample included 4337 adults (43.7% males) from 19 centres in 9 countries. Gas cooking increased the risk of "shortness of breath whilst at rest" (OR = 1.38; 95%CI: 1.06-1.79) and "wheeze with breathlessness" (1.32; 1.00-1.74). For several other symptoms, effect estimates were larger in those who used both gas hobs and ovens, had a bottled gas source and cooked for over 60 min per day. Stratifying results by sex and age found stronger associations in females and younger adults.

CONCLUSION

This multi-centre international study, using repeat data, suggested using gas cookers in the home was more strongly associated than electric cookers with certain respiratory symptoms in adults. As gas cooking is common, these results may play an important role in population respiratory health.

Spirometric patterns in young and middle-aged adults: a 20-year European study

BACKGROUND

Understanding the natural history of abnormal spirometric patterns at different stages of life is critical to identify and optimise preventive strategies. We aimed to describe characteristics and risk factors of restrictive and obstructive spirometric patterns occurring before 40 years (young onset) and between 40 and 61 years (mid-adult onset).

METHODS

We used data from the population-based cohort of the European Community Respiratory Health Survey (ECRHS). Prebronchodilator forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were assessed longitudinally at baseline (ECRHS1, 1993-1994) and again 20 years later (ECRHS3, 2010-2013). Spirometry patterns were defined as: restrictive if FEV1/FVC≥LLN and FVC<10th percentile, obstructive if FEV1/FVC

RESULTS

Among 3502 participants (mean age=30.4 (SD 5.4) at ECRHS1, 50.4 (SD 5.4) at ECRHS3), 2293 (65%) had a normal, 371 (11%) a young restrictive, 301 (9%) a young obstructive, 187 (5%) a mid-adult onset restrictive and 350 (10%) a mid-adult onset obstructive spirometric pattern. Being lean/underweight in childhood and young adult life was associated with the occurrence of the young spirometric restrictive pattern (relative risk ratio (RRR)=1.61 95% CI=1.21 to 2.14, and RRR=2.43 95% CI=1.80 to 3.29; respectively), so were respiratory infections before 5 years (RRR=1.48, 95% CI=1.05 to 2.08). The main determinants for young obstructive, mid-adult restrictive and mid-adult obstructive patterns were asthma, obesity and smoking, respectively.

CONCLUSION

Spirometric patterns with onset in young and mid-adult life were associated with distinct characteristics and risk factors.

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Key Words

• COPD epidemiology
• Clinical Epidemiology

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MESH Headings

• Middle Aged
• Young Adult
• Humans
• Adult
• Pulmonary Disease, Chronic Obstructive
• Spirometry
• Respiratory Function Tests
• Asthma/complications
• Risk Factors
• Forced Expiratory Volume
• Vital Capacity

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Grants

• CEX2018-000806-S Spanish Ministry of Science and Innovation

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Affiliation(s)

Anne-Elie Carsin ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain Biometrics, RTI-Health Solutions, Barcelona, Spain
Judith Garcia-Aymerich ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain
Simone Accordini Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
Shyamali Dharmage Allergy and Lung Health Unit, School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
Bénédicte Leynaert Université Paris-Saclay, UVSQ, Univ Paris-Sud, Inserm, INSERM, Paris, France
Marti de Las Heras ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain
Lidia Casas Social Epidemiology and Health Policy, Department of Family Medicine and Population Health, University of Antwerp, Antwerpen, Belgium Institute for Environment and Sustainable Development (IMDO), University of Antwerp, Antwerpen, Belgium
Seraina Caviezel Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
Pascal Demoly Département de Pneumologie et Addictologie, University Hospital of Montpellier, Montpellier, France IDESP, University of Montpellier - Inserm UMR UA11, Montpellier, France
Bertil Forsberg Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
Thorarinn Gislason Department of Sleep, Landspitali University Hospital, Reykjavik, Iceland Medical Faculty, University of Iceland, Iceland, Iceland
Angelo Guido Corsico Department of Internal Medicine and Therapeutics, University of Pavia, Italy, Italy Division of Respiratory Diseases, Fondazione IRCCS Policlinico San Matteo-University of Pavia, Pavia, Italy
Christer Janson Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
Rain Jogi Lung Clinic, Tartu University Hospital, Tartu, Estonia
Jesús Martínez-Moratalla Faculty of Medicine of Albacete, General University Hospital of Albacete, Albacete, Spain
Dennis Nowak Institute and Clinic for Occupational and Environmental Medicine, University Hospital, LMU Munich, Comprehensive Pneumology Centre Munich, member DZL, German Centre for Lung Research, Munich, Germany
Leopoldo Palacios Gómez Distrito Sanitario Huelva-Costa, Huelva, Spain
Isabelle Pin Department of Pediatrics, CHU de Grenoble Alpes, Grenoble, France Inserm, UMR 1209, Institute for Advanced Biosciences, Grenoble, France
Nicole Probst-Hensch Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
Chantal Raherison-Semjen Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
Giulia Squillacioti Department of Public Health and Pediatrics, University of Turin, Torino, Piemonte, Italy
Cecilie Svanes Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
Kjell Torén Department of Occupational and Environmental, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
Isabel Urrutia Pulmonology Department, Galdakao Hospital, Biocruces Bizkaia, Spain
Ismael Huerta Epidemiological Surveillance Section, Directorate General of Public Health, Oviedo, Spain
Josep Maria Anto ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain
Debbie Jarvis National Heart and Lung Institute, Imperial College, London, UK
Stefano Guerra ISGlobal, Campus mar, Barcelona, Catalunya, Spain Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA

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Impact of outdoor air pollution on severity and mortality in COVID-19 pneumonia

The relationship between exposure to air pollution and the severity of coronavirus disease 2019 (COVID-19) pneumonia and other outcomes is poorly understood. Beyond age and comorbidity, risk factors for adverse outcomes including death have been poorly studied. The main objective of our study was to examine the relationship between exposure to outdoor air pollution and the risk of death in patients with COVID-19 pneumonia using individual-level data. The secondary objective was to investigate the impact of air pollutants on gas exchange and systemic inflammation in this disease. This cohort study included 1548 patients hospitalised for COVID-19 pneumonia between February and May 2020 in one of four hospitals. Local agencies supplied daily data on environmental air pollutants (PM10, PM2.5, O3, NO2, NO and NOX) and meteorological conditions (temperature and humidity) in the year before hospital admission (from January 2019 to December 2019). Daily exposure to pollution and meteorological conditions by individual postcode of residence was estimated using geospatial Bayesian generalised additive models. The influence of air pollution on pneumonia severity was studied using generalised additive models which included: age, sex, Charlson comorbidity index, hospital, average income, air temperature and humidity, and exposure to each pollutant. Additionally, generalised additive models were generated for exploring the effect of air pollution on C-reactive protein (CRP) level and SpO2/FiO2 at admission. According to our results, both risk of COVID-19 death and CRP level increased significantly with median exposure to PM10, NO2, NO and NOX, while higher exposure to NO2, NO and NOX was associated with lower SpO2/FiO2 ratios. In conclusion, after controlling for socioeconomic, demographic and health-related variables, we found evidence of a significant positive relationship between air pollution and mortality in patients hospitalised for COVID-19 pneumonia. Additionally, inflammation (CRP) and gas exchange (SpO2/FiO2) in these patients were significantly related to exposure to air pollution.

Air pollution and health prevention: A document of reflection

Ambient air quality, pollution and its implication on health is a topic of enormous importance that is normally dealt with by major specialists in their particular areas of interest. In general, it is not discussed from multidisciplinary approaches or with a language that can reach everyone. For this reason, the Health Sciences Foundation, from its prevention area, has formulated a series of questions to people with very varied competences in the area of ambient air quality in order to obtain a global panorama of the problem and its elements of measurement and control. The answers have been produced by specialists in each subject and have been subjected to a general discussion that has allowed conclusions to be reached on each point. The subject was divided into three main blocks: external ambient air, internal ambient air, mainly in the work-place, and hospital ambient air and the consequences of its poor control. Along with the definitions of each area and the indicators of good and bad quality, some necessary solutions have been pointed out. We have tried to know the current legislation on this problem and the competences of the different administrations on it. Despite its enormous importance, ambient air quality and health is not usually a topic of frequent presence in the general media and we have asked about the causes of this. Finally, the paper addresses a series of reflections from the perspective of ethics and very particularly in the light of the events that the present pandemic raises. This work aims to provide objective data and opinions that will enable non-specialists in the field to gain a better understanding of this worrying reality.

Expert consensus recommendations for the management of asthma in older adults

Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6-10%, with a higher prevalence among women aged 64 to 75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting.

Consensus on the treatment of allergic asthma with sublingual house dust mite immunotherapy in the field of Pneumology

INTRODUCTION

: Many patients sensitized to mites remain symptomatic and uncontrolled despite traditional treatment. Sublingual immunotherapy (SLIT) has demonstrated to reduce the symptoms of allergic rhinitis, the need for additional drug treatments, and to reduce the number of moderate and severe exacerbations in patients with allergic asthma caused by mites that had not been adequately controlled.

AREAS COVERED

: After reviewing the most recent literature, a scientific committee composed by 5 pneumologists experts in asthma proposed 41 items that addressed the diagnosis of allergic asthma caused by mites, the role of house dust mite (HDM) SLIT tablet in the therapeutic plan and in the control of the disease, and the profile of patients with asthma candidates for this therapy. Through a modified Delphi method, the items were send to 106 pneumologists involved in asthma to be agreed.

EXPERT OPINION

: The high degree of consensus reached by the panel of pneumologists shows the importance of HDM SLIT tablet in the treatment of allergic asthma caused by mites, particularly taking into account that they barely use this therapy because until now they did not have a registered treatment with solid evidence of efficacy and safety.

Body mass index and weight change are associated with adult lung function trajectories: the prospective ECRHS study

BACKGROUND

Previous studies have reported an association between weight increase and excess lung function decline in young adults followed for short periods. We aimed to estimate lung function trajectories during adulthood from 20-year weight change profiles using data from the population-based European Community Respiratory Health Survey (ECRHS).

METHODS

We included 3673 participants recruited at age 20-44 years with repeated measurements of weight and lung function (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1)) in three study waves (1991-93, 1999-2003, 2010-14) until they were 39-67 years of age. We classified subjects into weight change profiles according to baseline body mass index (BMI) categories and weight change over 20 years. We estimated trajectories of lung function over time as a function of weight change profiles using population-averaged generalised estimating equations.

RESULTS

In individuals with normal BMI, overweight and obesity at baseline, moderate (0.25-1 kg/year) and high weight gain (>1 kg/year) during follow-up were associated with accelerated FVC and FEV1 declines. Compared with participants with baseline normal BMI and stable weight (±0.25 kg/year), obese individuals with high weight gain during follow-up had -1011 mL (95% CI -1.259 to -763) lower estimated FVC at 65 years despite similar estimated FVC levels at 25 years. Obese individuals at baseline who lost weight (<-0.25 kg/year) exhibited an attenuation of FVC and FEV1 declines. We found no association between weight change profiles and FEV1/FVC decline.

CONCLUSION

Moderate and high weight gain over 20 years was associated with accelerated lung function decline, while weight loss was related to its attenuation. Control of weight gain is important for maintaining good lung function in adult life.

Incidence of diabetes mellitus in Spain as results of the nation-wide cohort di@bet.es study

Our aim was to determine the incidence of type 2 diabetes mellitus in a nation-wide population based cohort from Spain (di@bet.es study). The target was the Spanish population. In total 5072 people older than 18 years,were randomly selected from all over Spain). Socio-demographic and clinical data, survey on habits (physical activity and food consumption) and weight, height, waist, hip and blood pressure were recorder. A fasting blood draw and an oral glucose tolerance test were performed. Determinations of serum glucose were made. In the follow-up the same variables were collected and HbA1c was determined. A total of 2408 subjects participated in the follow-up. In total, 154 people developed diabetes (6.4% cumulative incidence in 7.5 years of follow-up). The incidence of diabetes adjusted for the structure of age and sex of the Spanish population was 11.6 cases/1000 person-years (IC95% = 11.1–12.1). The incidence of known diabetes was 3.7 cases/1000 person-years (IC95% = 2.8–4.6). The main risk factors for developing diabetes were the presence of prediabetes in cross-sectional study, age, male sex, obesity, central obesity, increase in weight, and family history of diabetes. This work provides data about population-based incidence rates of diabetes and associated risk factors in a nation-wide cohort of Spanish population.

The role of C-reactive protein levels on the association of physical activity with lung function in adults

Objective

Regular physical activity may be associated with improved lung function via reduced systemic inflammation, although studies exploring this mechanism are rare. We evaluated the role of C-reactive protein in blood, which is a common marker of systemic inflammation, on the association of physical activity with forced expiratory volume in one second and forced vital capacity.

Methods

Cross-sectional data on spirometry, C-reactive protein levels and self-reported physical activity (yes/no; ≥2 times and ≥1hr per week of vigorous physical activity) were available in the European Community Respiratory Health Survey (N = 2347 adults, 49.3% male, 28–56 years-old). A subsample was also assessed 10 years later using the International Physical Activity Questionnaire, and tertiles of Metabolic Equivalent of Task—minutes per week spent in vigorous, moderate and walking activities were calculated (N = 671, 49.6% male, 40–67 years-old). Adjusted cross-sectional mixed linear regression models and the “mediate” package in “R” were used to assess the presence of mediation.

Results

Despite positive significant associations between nearly all physical activity metrics with forced expiratory volume in one second and forced vital capacity, there was no evidence that C-reactive protein levels played a role. An influence of C-reactive protein levels was only apparent in the smaller subsample when comparing the medium to low tertiles of moderate activity (mean difference [95% CIs]: 21.1ml [5.2, 41.9] for forced expiratory volume in one second and 17.3ml [2.6, 38.0] for forced vital capacity).

Conclusions

In a population of adults, we found no consistent evidence that the association of physical activity with forced expiratory volume in one second or forced vital capacity is influenced by the level of C-reactive protein in blood.

Cleaning at Home and at Work in Relation to Lung Function Decline and Airway Obstruction

RATIONALE

Cleaning tasks may imply exposure to chemical agents with potential harmful effects to the respiratory system, and increased risk of asthma and respiratory symptoms among professional cleaners and in persons cleaning at home has been reported. Long-term consequences of cleaning agents on respiratory health are, however, not well described.

OBJECTIVES

This study aimed to investigate long-term effects of occupational cleaning and cleaning at home on lung function decline and airway obstruction.

METHODS

The European Community Respiratory Health Survey (ECRHS) investigated a multicenter population-based cohort at three time points over 20 years. A total of 6,235 participants with at least one lung function measurement from 22 study centers, who in ECRHS II responded to questionnaire modules concerning cleaning activities between ECRHS I and ECRHS II, were included. The data were analyzed with mixed linear models adjusting for potential confounders.

MEASUREMENTS AND MAIN RESULTS

As compared with women not engaged in cleaning (ΔFEV₁ = -18.5 ml/yr), FEV₁ declined more rapidly in women responsible for cleaning at home (-22.1; P = 0.01) and occupational cleaners (-22.4; P = 0.03). The same was found for decline in FVC (ΔFVC = -8.8 ml/yr; -13.1, P = 0.02; and -15.9, P = 0.002; respectively). Both cleaning sprays and other cleaning agents were associated with accelerated FEV₁ decline (-22.0, P = 0.04; and -22.9, P = 0.004; respectively). Cleaning was not significantly associated with lung function decline in men or with FEV₁/FVC decline or airway obstruction.

CONCLUSIONS

Women cleaning at home or working as occupational cleaners had accelerated decline in lung function, suggesting that exposures related to cleaning activities may constitute a risk to long-term respiratory health.

Effects of smoking bans on passive smoking exposure at work and at home. The European Community respiratory health survey

This longitudinal study investigated whether smoking bans influence passive smoking at work and/or at home in the same subjects. Passive smoking at work and/or at home was investigated in random population samples (European Community Respiratory Health Survey) in 1990-1995, with follow-up interviews in 1998-2003 and 2010-2014. National smoking bans were classified as partial (restricted to public workplaces) or global (extended to private workplaces). Multivariable analysis was accomplished by three-level logistic regression models, where level-1, level-2, and level-3 units were, respectively, questionnaire responses, subjects, and centers. Passive smoking at work was reported by 31.9% in 1990-1995, 17.5% in 1998-2003, and 2.5% in 2010-2014. Concurrently, passive smoking at home decreased from 28.9% to 18.2% and 8.8%. When controlling for sex, age, education, smoking status, and ECHRS wave, the odds of passive smoking at work was markedly reduced after global smoking bans (OR = 0.45, 95% CI 0.25-0.81), particularly among non-smokers, while the protective effect of global smoking bans on passive smoking at home was only detected in non-smokers. Smoking bans both in public and private workplaces were effective in reducing passive smoking at work in Europe. However, given the inefficacy of smoking bans in current smokers' dwellings, better strategies are needed to avoid smoking indoors.

Clinical Factors Associated With Overuse of Asthma Reliever Medication

OBJECTIVE

Our aim was to evaluate the relationship between the clinical factors of asthma and the use of reliever medication.

METHODS

We performed an observational cross-sectional study in Spain. The study population comprised patients aged ≥12 years diagnosed with persistent asthma according to the criteria of the Global Initiative for Asthma and receiving maintenance treatment for at least 12 months. Use of reliever medication was classified as low use of reliever medication (LURM) (≤2 times/wk) and high use of reliever medication (HURM) (≥3 times/wk). A variety of clinical variables and patient-reported outcomes (PROs) were recorded (eg, scores on the Asthma Control Questionnaire-5 [ACQ-5] and Test of Adherence to Inhalers [TAI]).

RESULTS

A total of 406 patients were recruited. Mean (SD) age was 44.3 (17.9) years, and 64% were women. Reliever medication was used ≤2 times/wk in 76.1%. Bivariate analysis showed that HURM was related to smoking habit, unscheduled emergency department visits, hospital admissions, higher doses of inhaled corticosteroid, and night awakenings in the previous 4 weeks (P<.001). The multivariate analysis showed a higher risk of using reliever medication in smokers and former smokers, when the number of night awakenings increased, in cases of self-perception of partially controlled or uncontrolled asthma, or when asthma is uncontrolled according to the ACQ-5.

CONCLUSIONS

Our study identifies the potential of poor use of reliever medication in the last week as an alarm signal for disease-related parameters such as exacerbations, poor asthma control, and disease severity.

Occupational exposures and incidence of chronic bronchitis and related symptoms over two decades: the European Community Respiratory Health Survey

OBJECTIVES

Chronic bronchitis (CB) is an important chronic obstructive pulmonary disease (COPD)-related phenotype, with distinct clinical features and prognostic implications. Occupational exposures have been previously associated with increased risk of CB but few studies have examined this association prospectively using objective exposure assessment. We examined the effect of occupational exposures on CB incidence in the European Community Respiratory Health Survey.

METHODS

Population samples aged 20-44 were randomly selected in 1991-1993, and followed up twice over 20 years. Participants without chronic cough or phlegm at baseline were analysed. Coded job histories during follow-up were linked to the ALOHA Job Exposure Matrix, generating occupational exposure estimates to 12 categories of chemical agents. Their association with CB incidence over both follow-ups was examined with Poisson models using generalised estimating equations.

RESULTS

8794 participants fulfilled the inclusion criteria, contributing 13 185 observations. Only participants exposed to metals had a higher incidence of CB (relative risk (RR) 1.70, 95% CI 1.16 to 2.50) compared with non-exposed to metals. Mineral dust exposure increased the incidence of chronic phlegm (RR 1.72, 95% CI 1.43 to 2.06). Incidence of chronic phlegm was increased in men exposed to gases/fumes and to solvents and in women exposed to pesticides.

CONCLUSIONS

Occupational exposures are associated with chronic phlegm and CB, and the evidence is strongest for metals and mineral dust exposure. The observed differences between men and women warrant further investigation.

Efficacy and Safety of Reslizumab in Patients with Severe Asthma with Inadequate Response to Omalizumab: A Multicenter, Open-Label Pilot Study

BACKGROUND

Patients with severe allergic and eosinophilic asthma could qualify for different biologic therapies.

OBJECTIVE

To evaluate the efficacy and safety of weight-based intravenous reslizumab dosing in patients who have previously failed therapy with omalizumab.

METHODS

We carried out a 24-week prospective, multicenter, open-label, single-group, self-controlled study in patients with severe eosinophilic asthma who had previously failed to respond to omalizumab. The main objective was to determine whether treatment with reslizumab significantly improved asthma symptoms assessed by the Asthma Control Test (ACT) at week 24. Secondary objectives were to evaluate symptoms at weeks 4 and 12, change in FEV₁ at week 24, and the incidence of severe exacerbations over the study period.

RESULTS

Twenty-nine patients (62.1% women, median age, 50.8 years) were included in the study. The median ACT score significantly increased from 13.0 (interquartile range, 8.0-18.0) at baseline to 21.0 (interquartile range, 14.0-24.0) at 24 weeks (P = .002). Only 2 of 29 patients developed at least 1 severe exacerbation during follow-up and none of them required hospitalization. Overall, 15 of 25 patients (60%) were considered as being controlled (ACT score of ≥20 and no exacerbations) at week 24. The percentage of patients who were receiving daily systemic corticosteroids significantly decreased from 72.4% to 52.0% (P = .019). Adverse events were mostly moderate and within the range of previously reported side effects with reslizumab.

CONCLUSION

Reslizumab is an effective and safe option for patients with severe eosinophilic asthma and a history of omalizumab failure.

A Simple Score for Future Risk Prediction in Patients with Controlled Asthma Who Undergo a Guidelines-Based Step-Down Strategy

BACKGROUND

The minimum controlling dose of treatment must be established in patients with asthma, but the outcome of step-down is unpredictable.

OBJECTIVE

To identify factors associated with risk of control loss when stepping down asthma treatment and to develop a score to predict this risk.

METHODS

A prospective, multicenter study including adults with well-controlled asthma was performed. Treatment was stepped up or stepped down over a 12-month period to maintain asthma control. We determined associations between clinical and functional variables and step-down failure. Finally, we derived a score to predict loss of control in 1 cohort and validated it in an independent cohort.

RESULTS

The derivation cohort consisted of 228 patients; 218 completed at least 1 step-down episode and a total of 495 step-down episodes were evaluated. A medical-record documented postbronchodilator spirometry result of <70% forced expiratory volume in 1 second (FEV₁)/forced vital capacity (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.26-3.43), current FEV₁ < 80% (OR = 1.80; 95% CI: 1.03-3.14), ≥1 severe exacerbation in the previous 12 months (OR = 2.43; 95% CI: 1.48-4.01), and Asthma Control Test score < 25 (OR = 2.30; 95% CI: 1.35-3.92) were independently associated with failure. The score showed an area under the curve of 0.690 (95% CI: 0.633-0.747; P < .05) in the derivation cohort and 0.76 (95% CI: 0.643-0.882; P < .001) in a validation cohort of 114 patients. A score <4.5 implies a low risk of failure (<20%), whereas a score >8 implies a high risk (>40%).

CONCLUSION

This score can facilitate the prediction of step-down failure before medication taper in patients with well-controlled asthma.

Airway responsiveness to methacholine and incidence of COPD: an international prospective cohort study

Background

It has been debated, but not yet established, whether increased airway responsiveness can predict COPD. Recognising this link may help in identifying subjects at risk.

Objective

We studied prospectively whether airway responsiveness is associated with the risk of developing COPD.

Methods

We pooled data from two multicentre cohort studies that collected data from three time points using similar methods (European Community Respiratory Health Survey and Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults). We classified subjects (median age 37 years, 1st–3rd quartiles: 29–44) by their level of airway responsiveness using quintiles of methacholine dose–response slope at the first examination (1991–1994). Then, we excluded subjects with airflow obstruction at the second examination (1999–2003) and analysed incidence of COPD (postbronchodilator FEV₁/FVC below the lower limit of normal) at the third examination (2010–2014) as a function of responsiveness, adjusting for sex, age, education, body mass index, history of asthma, smoking, occupational exposures and indicators of airway calibre.

Results

We observed 108 new cases of COPD among 4205 subjects during a median time of 9 years. Compared with the least responsive group (incidence rate 0.6 per 1000/year), adjusted incidence rate ratios for COPD ranged from 1.79 (95% CI 0.52 to 6.13) to 8.91 (95% CI 3.67 to 21.66) for increasing airway responsiveness. Similar dose–response associations were observed between smokers and non-smokers, and stronger associations were found among subjects without a history of asthma or asthma-like symptoms.

Conclusions

Our study suggests that increased airway responsiveness is an independent risk factor for COPD. Further research should clarify whether early treatment in patients with high responsiveness can slow down disease progression.

Occupational exposures and 20-year incidence of COPD: the European Community Respiratory Health Survey

BACKGROUND

Occupational exposures have been associated with an increased risk of COPD. However, few studies have related objectively assessed occupational exposures to prospectively assessed incidence of COPD, using postbronchodilator lung function tests. Our objective was to examine the effect of occupational exposures on COPD incidence in the European Community Respiratory Health Survey.

METHODS

General population samples aged 20-44 were randomly selected in 1991-1993 and followed up 20 years later (2010-2012). Spirometry was performed at baseline and at follow-up, with incident COPD defined using a lower limit of normal criterion for postbronchodilator FEV1/FVC. Only participants without COPD and without current asthma at baseline were included. Coded job histories during follow-up were linked to a Job-Exposure Matrix, generating occupational exposure estimates to 12 categories of agents. Their association with COPD incidence was examined in log-binomial models fitted in a Bayesian framework.

FINDINGS

3343 participants fulfilled the inclusion criteria; 89 of them had COPD at follow-up (1.4 cases/1000 person-years). Participants exposed to biological dust had a higher incidence of COPD compared with those unexposed (relative risk (RR) 1.6, 95% CI 1.1 to 2.3), as did those exposed to gases and fumes (RR 1.5, 95% CI 1.0 to 2.2) and pesticides (RR 2.2, 95% CI 1.1 to 3.8). The combined population attributable fraction for these exposures was 21.0%.

INTERPRETATION

These results substantially strengthen the evidence base for occupational exposures as an important risk factor for COPD.

Fibromyalgia as a cause of uncontrolled asthma: a case-control multicenter study

BACKGROUND

Fibromyalgia can affect the control of asthma when both diseases are present in a single patient.

OBJECTIVES

To characterize asthma in patients with concomitant fibromyalgia to assess whether fibromyalgia is an independent factor of asthma severity that influences poor asthma control. We also evaluated how dyspnea is perceived by patients in order to demonstrate that alterations in the perception of airway obstruction may be responsible for poor asthma control.

METHODS

This was a cross-sectional case-control multicenter study, in which 56 patients in the asthma and fibromyalgia group were matched to 36 asthmatics by sex, approximate age, and asthma severity level. All patients were women. Study variables included the Asthma Control Test (ACT), the Mini Asthma Quality of Life Questionnaire (MiniAQLQ), the Nijmegen hyperventilation syndrome questionnaire, the Hospital Anxiety and Depression Scale, and perception of dyspnea after acute bronchoconstriction.

RESULTS

Although patients in both study groups showed similar asthma severity and use of anti-asthmatic drugs, patients in the asthma and fibromyalgia group showed lower scores on the ACT and MiniAQLQ questionnaires, and higher scores of anxiety and depression as well as hyperventilation compared to asthma patients without fibromyalgia. All these differences were statistically significant.

CONCLUSIONS

Fibromyalgia in patients with asthma influences poor control of the respiratory disease and is associated with altered perception of dyspnea, hyperventilation syndrome, high prevalence of depression and anxiety, and impaired quality of life.

CLINICAL IMPLICATIONS

Fibromyalgia may be considered a risk factor for uncontrolled asthma in patients suffering from asthma and fibromyalgia concomitantly.

Prevalence of asthma-like symptoms with ageing

Background

Change in the prevalence of asthma-like symptoms in populations of ageing adults is likely to be influenced by smoking, asthma treatment and atopy.

Methods

The European Community Respiratory Health Survey collected information on prevalent asthma-like symptoms from representative samples of adults aged 20–44 years (29 centres in 13 European countries and Australia) at baseline and 10 and 20 years later (n=7844). Net changes in symptom prevalence were determined using generalised estimating equations (accounting for non-response through inverse probability weighting), followed by meta-analysis of centre level estimates.

Findings

Over 20 years the prevalence of ‘wheeze’ and ‘wheeze in the absence of a cold’ decreased (−2.4%, 95% CI −3.5 to −1.3%; −1.5%, 95% CI −2.4 to −0.6%, respectively) but the prevalence of asthma attacks, use of asthma medication and hay fever/nasal allergies increased (0.6%, 95% CI 0.1 to 1.11; 3.6%, 95% CI 3.0 to 4.2; 2.7%, 95% CI 1.7 to 3.7). Changes were similar in the first 10 years compared with the second 10 years, except for hay fever/nasal allergies (increase seen in the first 10 years only). Decreases in these wheeze-related symptoms were largely seen in the group who gave up smoking, and were seen in those who reported hay fever/nasal allergies at baseline.

Interpretation

European adults born between 1946 and 1970 have, over the last 20 years, experienced less wheeze, although they were more likely to report asthma attacks, use of asthma medication and hay fever. Decrease in wheeze is largely attributable to smoking cessation, rather than improved treatment of asthma. It may also be influenced by reductions in atopy with ageing.

Absolute values of lung function explain the sex difference in breathlessness in the general population

Activity-related breathlessness is twice as common among females as males in the general population and is associated with adverse health outcomes. We tested whether this sex difference is explained by the lower absolute forced expiratory volume in 1 s (FEV1) or forced vital capacity (FVC) in females.

This was a cross-sectional analysis of 3250 subjects (51% female) aged 38−67 years across 13 countries in the population-based third European Community Respiratory Health Survey. Activity-related breathlessness was measured using the modified Medical Research Council (mMRC) scale. Associations with mMRC were analysed using ordered logistic regression clustering on centre, adjusting for post-bronchodilator spirometry, body mass index, pack-years smoking, cardiopulmonary diseases, depression and level of exercise.

Activity-related breathlessness (mMRC ≥1) was twice as common in females (27%) as in males (14%) (odds ratio (OR) 2.21, 95% CI 1.79−2.72). The sex difference was not reduced when controlling for FEV1 % predicted (OR 2.33), but disappeared when controlling for absolute FEV1 (OR 0.89, 95% CI 0.69−1.14). Absolute FEV1 explained 98−100% of the sex difference adjusting for confounders. The effect was similar within males and females, when using FVC instead of FEV1 and in healthy never-smokers.

The markedly more severe activity-related breathlessness among females in the general population is explained by their smaller spirometric lung volumes.

Prevalence of diabetes mellitus and impaired glucose metabolism in the adult population of the Basque Country, Spain

AIMS

To assess the prevalence of diabetes mellitus and impaired glucose metabolism in the Basque Country and their relationship with cardiovascular risk factors.

METHODS

A population-based, cross-sectional, cluster sampling design study was carried out in an adult (≥18 years) Basque population. A total of 847 participants completed a questionnaire on personal and family medical history and lifestyle. Anthropometric variables and blood pressure were measured and biochemical analysis and an oral glucose tolerance test (75 g) were also performed.

RESULTS

The total prevalence of diabetes was 10.6% (95% CI 8.65-12.95). Among them 6.3% (95% CI 4.79-8.22) had previously been diagnosed and 4.3% (95% CI 3.04-5.92) were not aware that they had diabetes. Impaired glucose tolerance was present in 7.2% (95% CI 5.53-9.15) and impaired fasting glucose in 3.8% (95% CI 2.64-5.37) of the population. In total, 21.6% of the population had some type of glucose metabolism disturbance, with a higher rate among men (28.3 vs 16.3%; P<0.001) and with the rate increasing with age. Risk factors independently associated with the development of diabetes were: male sex [odds ratio 4.58 (95% CI 2.34-8.97)]; abdominal obesity [odds ratio 2.80 (95% CI 1.47-5.36)]; high triglyceride levels [odds ratio 2.46 (95% CI 1.26-4.81)]; hypertension [odds ratio 2.40 (95% CI 1.16-4.96)]; family history of diabetes [odds ratio 2.30 (95% CI 1.25-4.24)]; high LDL cholesterol levels [odds ratio 1.83 (95% CI 1.01-3.31)] and older age [odds ratio 1.08 (95% CI 1.05-1.10)].

CONCLUSIONS

The prevalence of diabetes in the Basque Country was lower than in Spain and was independently associated with family history of diabetes and with cardiovascular risk factors such as abdominal obesity, hypertension, high LDL cholesterol levels and high triglyceride levels, which were also observed in those with prediabetes.

Clinical and genetic characterization of congenital hyperinsulinism in Spain

CONTEXT

Congenital hyperinsulinism (CHI) is a clinically and genetically heterogeneous disease characterized by severe hypoglycemia caused by inappropriate insulin secretion by pancreatic β-cells.

OBJECTIVE

To characterize clinically and genetically CHI patients in Spain.

DESIGN AND METHODS

We included 50 patients with CHI from Spain. Clinical information was provided by the referring clinicians. Mutational analysis was carried out for KCNJ11, ABCC8, and GCK genes. The GLUD1, HNF4A, HNF1A, UCP2, and HADH genes were sequenced depending on the clinical phenotype.

RESULTS

We identified the genetic etiology in 28 of the 50 CHI patients tested: 21 had a mutation in KATP channel genes (42%), three in GLUD1 (6%), and four in GCK (8%). Most mutations were found in ABCC8 (20/50). Half of these patients (10/20) were homozygous or compound heterozygous, with nine being unresponsive to diazoxide treatment. The other half had heterozygous mutations in ABCC8, six of them being unresponsive to diazoxide treatment and four being responsive to diazoxide treatment. We identified 22 different mutations in the KATP channel genes, of which ten were novel. Notably, patients with ABCC8 mutations were diagnosed earlier, with lower blood glucose levels and required higher doses of diazoxide than those without a genetic diagnosis.

CONCLUSIONS

Genetic analysis revealed mutations in 56% of the CHI patients. ABCC8 mutations are the most frequent cause of CHI in Spain. We found ten novel mutations in the KATP channel genes. The genetic diagnosis is more likely to be achieved in patients with onset within the first week of life and in those who fail to respond to diazoxide treatment.

What pulmonologists think about the asthma-COPD overlap syndrome

BACKGROUND

Some patients with COPD may share characteristics of asthma; this is the so-called asthma-COPD overlap syndrome (ACOS). There are no universally accepted criteria for ACOS, and most treatments for asthma and COPD have not been adequately tested in this population.

MATERIALS AND METHODS

We performed a survey among pulmonology specialists in asthma and COPD aimed at collecting their opinions about ACOS and their attitudes in regard to some case scenarios of ACOS patients. The participants answered a structured questionnaire and attended a face-to-face meeting with the Metaplan methodology to discuss different aspects of ACOS.

RESULTS

A total of 26 pulmonologists with a mean age of 49.7 years participated in the survey (13 specialists in asthma and 13 in COPD). Among these, 84.6% recognized the existence of ACOS and stated that a mean of 12.6% of their patients might have this syndrome. In addition, 80.8% agreed that the diagnostic criteria for ACOS are not yet well defined. The most frequently mentioned characteristics of ACOS were a history of asthma (88.5%), significant smoking exposure (73.1%), and postbronchodilator forced expiratory volume in 1 second/forced vital capacity <0.7 (69.2%). The most accepted diagnostic criteria were eosinophilia in sputum (80.8%), a very positive bronchodilator test (69.2%), and a history of asthma before 40 years of age (65.4%). Up to 96.2% agreed that first-line treatment for ACOS was the combination of a long-acting β2-agonist and inhaled steroid, with a long-acting antimuscarinic agent (triple therapy) for severe ACOS.

CONCLUSION

Most Spanish specialists in asthma and COPD agree that ACOS exists, but the diagnostic criteria are not yet well defined. A previous history of asthma, smoking, and not fully reversible airflow limitation are considered the main characteristics of ACOS, with the most accepted first-line treatment being long-acting β2-agonist/inhaled corticosteroids.

Relation between circulating CC16 concentrations, lung function, and development of chronic obstructive pulmonary disease across the lifespan: a prospective study

BACKGROUND

Low concentrations of the anti-inflammatory protein CC16 (approved symbol SCGB1A1) in serum have been associated with accelerated decline in forced expiratory volume in 1 s (FEV1) in patients with chronic obstructive pulmonary disease (COPD). We investigated whether low circulating CC16 concentrations precede lung function deficits and incidence of COPD in the general population.

METHODS

We assessed longitudinal data on CC16 concentrations in serum and associations with decline in FEV1 and incidence of airflow limitation for adults who were free from COPD at baseline in the population-based Tucson Epidemiological Study of Airway Obstructive Disease ([TESAOD] n=960, mean follow-up 14 years), European Community Respiratory Health Survey ([ECRHS-Sp] n=514, 11 years), and Swiss Cohort Study on Air Pollution and Lung Diseases in Adults ([SAPALDIA] n=167, 8 years) studies. Additionally, we measured circulating CC16 concentrations in samples from children aged 4-6 years in the Tucson Children's Respiratory Study (n=427), UK Manchester Asthma and Allergy Study (n=481), and the Swedish Barn/children, Allergy, Milieu, Stockholm, Epidemiological survey (n=231) birth cohorts to assess whether low CC16 concentrations in childhood were predictive for subsequent lung function.

FINDINGS

After adjustment for sex, age, height, smoking status and intensity, pack-years, asthma, and FEV1 at baseline, we found an inverse association between CC16 concentration and decline in FEV1 in adults in TESAOD (4·4 mL/year additional FEV1 decline for each SD decrease in baseline CC16 concentration, p=0·0014) and ECRHS-Sp (2·4 mL/year, p=0·023); the effect in SAPALDIA was marginal (4·5 mL/year, p=0·052). Low CC16 concentration at baseline was also associated with increased risk of incident stage 2 airflow limitation (ratio of FEV1 to forced expiratory volume [FEV1/FVC] less than 70% plus FEV1 % predicted less than 80%) in TESAOD and ECRHS-Sp. In children, the lowest tertile of CC16 concentrations was associated with a subsequent FEV1 deficit of 68 mL up to age 16 years (p=0·0001), which was confirmed in children who had never smoked by age 16 years (-71 mL, p<0·0001).

INTERPRETATION

Low concentrations of CC16 in serum are associated with reduced lung function in childhood, accelerated lung function decline in adulthood, and development of moderate airflow limitation in the general adult population.

FUNDING

National Heart, Lung, and Blood Institute and European Union Seventh Framework Programme.

Mean properties and free energy of a few hard spheres confined in a spherical cavity

We use analytical calculations and event-driven molecular dynamics simulations to study a small number of hard sphere particles in a spherical cavity. The cavity is also taken as the thermal bath so that the system thermalizes by collisions with the wall. In that way, these systems of two, three, and four particles, are considered in the canonical ensemble. We characterize various mean and thermal properties for a wide range of number densities. We study the density profiles, the components of the local pressure tensor, the interface tension, and the adsorption at the wall. This spans from the ideal gas limit at low densities to the high-packing limit in which there are significant regions of the cavity for which the particles have no access, due the conjunction of excluded volume and confinement. The contact density and the pressure on the wall are obtained by simulations and compared to exact analytical results. We also obtain the excess free energy for N = 4, by using a simulated-assisted approach in which we combine simulation results with the knowledge of the exact partition function for two and three particles in a spherical cavity.

Occupational exposures and uncontrolled adult-onset asthma in the European Community Respiratory Health Survey II

Occupational exposure is a well-recognised modifiable risk factor for asthma, but the relationship between occupational exposure and asthma control has not been studied. We aimed to study this association among working-age adults from the European Community Respiratory Health Survey (ECRHS). Data were available for 7077 participants (mean age 43 years, 45% never-smokers, 5867 without asthma and 1210 with current asthma). Associations between occupational exposure to specific asthmagens and asthma control status (33% with uncontrolled asthma, based on the Global Initiative for Asthma guidelines) were evaluated using logistic and multinomial regressions, adjusted for age, sex and smoking status, with study areas included as a random effect. Statistically significant positive associations were observed between uncontrolled adult-onset asthma and both past 12-month and 10-year exposure to any occupational asthmagens (OR (95% CI) 1.6 (1.0-2.40) and 1.7 (1.2-2.5), respectively); high (1.7 (1.0-2.8) and 1.9 (1.3-2.9), respectively) and low (1.6 (1.0-2.7) and 1.8 (1.2-2.7), respectively) molecular weight agents; and cleaning agents (2.0 (1.1-3.6) and 2.3 (1.4-3.6), respectively), with stronger associations for long-term exposures. These associations were mainly explained by the exacerbation domain of asthma control and no associations were observed between asthmagens and partly controlled asthma. These findings suggest that occupational exposure to asthmagens is associated with uncontrolled adult-onset asthma. Occupational risk factors should be quickly identified to prevent uncontrolled asthma.

Two short interventions to reduce health care requirements in asthma patients. A multicentre controlled study (ASTHMACAP II)

BACKGROUND AND OBJECTIVE

Asthma control is suboptimal. The objective of this study was to reduce health care requirements and work absenteeism.

MATERIAL AND METHODS

Multicenter randomized controlled study investigating asthma control, educational parameters, health service use, and absenteeism. After adjusting treatment according to GINA recommendations, control group patients (CG) followed their physician's recommendations, while intervention group (IG) patients additionally underwent a 5-minute educational intervention. This protocol was repeated at 3 months, and a final assessment was carried out at 6 months.

RESULTS

479 patients (mean age 40 (SD 17) years) were recruited from primary care, and 334 completed the study. Comparatively, IG patients showed an improvement at the 3- and 6-month evaluations in the six educational parameters (P<0.001) and required fewer urgent visits to the GP for exacerbations [RR=0.49 (95% CI 0.26-0.90); P<0.04], and before the third evaluation, also in urgent GP visits [RR=0.25 (95% CI 0.12-0.52); P<0.001]. Before this third evaluation, IG had fewer scheduled visits to the GP [RR=0.48 (95% CI 0.28-0.82); P<0.003], and fewer visits to the primary care [RR=0.40 (95% CI 0.18-0.87); P<0.05], and to hospital emergency rooms [RR=0.13 (95% CI 0.04-0.42); P<0.001]. In addition, before the third evaluation, IG patients were less often absent from work [RR=0.22 (95% CI 0.05-0.98); P<0.03] or unable to work at home [RR=0.31 (95% CI 0.12-0.82); P<0.02].

CONCLUSIONS

Two short educational interventions improved asthma education and decreased the use of health resources and work absenteeism.

The relation of circulating YKL-40 to levels and decline of lung function in adult life

BACKGROUND

YKL-40 is a chitinase-like protein that, in cross-sectional clinical studies, has been associated with severe asthma and COPD in smokers.

AIM

To determine the longitudinal relation of circulating YKL-40 to levels and decline of lung function in the general population.

METHODS

We used longitudinal data from up to 13 surveys from the population-based TESAOD study which was conducted in Tucson, Arizona between 1972 and 1996. In cross-sectional analyses, we also used data from 3 Spanish centers of the multicenter ECRHS study (ECRHS-Sp). Serum YKL-40 was measured at baseline in TESAOD and in survey 2 in ECRHS-Sp using ELISAs. Multivariate linear regression was used to test associations of serum YKL-40 to concomitant lung function. In TESAOD, random coefficients models were used to test associations of serum YKL-40 to subsequent decline of lung function.

RESULTS

Data on YKL-40 and lung function were available from 1088 TESAOD and 854 ECRHS-Sp adult participants (59% and 51% females; respectively). In adjusted multivariate meta-analyses, being in the highest YKL-40 quartile was associated cross-sectionally with significant deficits in FEV1 and FVC %predicted. In adjusted longitudinal analyses, TESAOD participants in the top YKL-40 quartile had an FEV1 decline that was 5 ml/yr (p = 0.05) faster than subjects in the third quartile, 5 ml/yr (p = 0.02) faster than subjects in the second quartile, and 10 ml/yr (p < 0.001) faster than subjects in the lowest YKL-40 quartile. These longitudinal effects were particularly strong in smokers and absent in never smokers. After adjusting for covariates, as compared with the other three quartiles combined, the top YKL-40 quartile was associated with a 9 ml/yr (p = 0.001) faster FEV1 decline among smokers, while no significant effects were found among never smokers (2 ml/yr, p = 0.35).

CONCLUSIONS

Circulating YKL-40 is associated with levels and decline of lung function in the general population and may be a biomarker of susceptibility to the long-term effects of cigarette smoking.

Predictors of respiratory sickness absence: an international population-based study

BACKGROUND

Respiratory tract-related occupational disability is common among adults of working age. We examined occupational vapors, gas, dust, or fume (VGDF) exposure as a predictor of disability, based on respiratory sickness absence among the actively employed, at an early point at which prevention may be most relevant.

METHODS

Currently employed European Community Respiratory Health Survey II participants (n = 6,988) were classified into three mutually exclusive, condition/symptom-based categories: physician-diagnosed asthma, self-reported rhinitis, and wheeze/breathlessness (n = 4,772). Logistic regression analysis estimated the odds of respiratory sickness absence (past 12 months) by VGDF exposure.

RESULTS

In the condition/symptom groups, 327 (6.9%) reported respiratory sickness absence. Exposure to VGDF was associated with increased odds of respiratory sickness absence: asthma odds ratio [OR] 2.0 (95% confidence interval [CI] 1.1-3.6), wheeze/breathlessness OR 2.2 (95% CI 1.01-4.8); rhinitis OR 1.9 (95% CI 1.02-3.4).

CONCLUSION

One in 15 currently employed with asthma, breathlessness, or rhinitis reported respiratory sickness absence. VGDF exposure doubled the odds of respiratory sickness absence, suggesting a focus for disability prevention.

Knowledge, attitude and adherence of Spanish healthcare professionals to asthma management recommendations during pregnancy

BACKGROUND

The aim of the present study was to evaluate the knowledge, attitude and adherence to asthma management recommendations during pregnancy of Spanish health care professionals.

METHODS

A multiple choice survey with 14 questions was designed. Items assessed opinion about asthma guidelines and attitudes towards treatment, spirometry, specific immunotherapy and labour in pregnant asthmatic patients. Test completion was voluntary, individual, and anonymous.

RESULTS

A total of 1000 questionnaires were fulfilled: respiratory medicine specialists (19.8%); allergy specialists (17.2%); primary care physicians (46.1%); and gynaecologists/obstetricians (16.9%). Guidelines were considered useful by 96.5% although 64% admitted that they followed them seldom or never. Most physicians (55.9%) answered that they would maintain asthma therapy in clinically stable patients. Almost 30% of physicians would not perform spirometry in pregnant asthma patients. 19% declared they would interrupt specific immunotherapy which had proven safe and effective. Univariate analysis revealed low adherence to be associated with the following variables: age, primary care or gynaecology/obstetrician specialisation, number of asthmatics attended per month, and declared use of guidelines for pregnant asthmatic patients. Multivariate analysis showed that being a primary care physician and a gynaecologist/obstetrician, attending a low number of asthma patients per month, and poor use of spirometry during pregnancy are associated to low adherence to asthma guidelines.

CONCLUSION

Even though the majority of Spanish physicians surveyed seem to consider guidelines useful, their adherence to those is very low if translated to managing pregnant asthmatic patients. Educational strategies seem unavoidable and should be targetted mainly to primary care and gynaecology/obstetrician physicians.

Impact of anxiety and depression on disease control and quality of life in asthma patients

INTRODUCTION

Patients with asthma also tend to have anxiety and depression. These comorbidities may affect asthma control and quality of life. The objective of this study was to assess the impact of anxiety and depression on asthma control and quality of life.

PATIENTS AND METHODS

Cross-sectional study of asthma outpatients was conducted at two hospitals in the Basque Country (northern Spain). Data collected included sociodemographic variables, asthma symptoms, treatment, number of exacerbations, level of control, quality of life, presence of psychological morbidities, and level of physical activity. Spirometry was performed in accordance with the recommendations of the Spanish Society of Pneumology and Thoracic Surgery.

RESULTS

Among 354 asthmatics, 77% had poor or partial control of their condition, 31% had anxiety alone, 2% had depression alone, and 10% had anxiety plus depression. Poor asthma control was associated with anxiety plus depression (odds ratio (OR): 3.61; 95% confidence interval (CI): 1.05-12.41) as well as with female patients (OR: 1.85; 95% CI: 1.11-3.10). Anxiety had an independent effect on reduced quality of life across all domains; anxiety plus depression had an even greater effect.

CONCLUSION

Among patients with asthma, anxiety and depression adversely affect asthma control and quality of life, raising the possibility that treating these psychological comorbidities could improve asthma control and quality of life.

Diagnostic utility of components in allergy to Anisakis simplex

BACKGROUND

In our region, Anisakis allergy is responsible for 8% of acute urticarial reactions, 25% of which progress to anaphylactic shock. The poor specificity of skin tests and in vitro specific immunoglobulin (Ig) E means that Anisakis allergy is frequently overdiagnosed.

OBJECTIVE

We studied the diagnostic value of 2 Anisakis allergens: rAni s 1 and rAni s 3.

METHODS

Skin tests, the basophil activation test (BAT), and specific IgE determination were performed with rAni s 1 and 3 in 25 patients allergic to Anisakis, 17 atopic controls, and 10 controls with acute urticaria and positive skin test and sIgE results for Anisakis, but no allergy to Anisakis.

RESULTS

For rAni s1, skin tests had a sensitivity and specificity of 100% and specific IgE had a sensitivity and specificity of 100% in the atopic control group and 90% in the urticaria control group. BAT had a sensitivity of 96.8% and a specificity of 100% in the atopic control group and 66.7% in the urticaria control group. For rAni s 3, only 1 patient had positive specific IgE results to rAni s 3. All other techniques gave negative results in patients and controls

CONCLUSIONS

rAni s 1 is the major allergen of Anisakis and the target allergen when diagnosing allergy to Anisakis, rAni s 3 is not relevant when attempting to explain false-positive results.

Prevalence of silicosis in a marble factory after exposure to quartz conglomerates

In this note we present the increased prevalence of silicosis found in a marble factory after exposure to a new presentation of silica. A prospective, observational study was conducted on 11 workers who were exposed to different presentations of quartz surfaces since 1995. The jobs were divided into two groups: 4 subjects worked in the cutting workshop; the rest of the workers worked in assembly. Up to that date they had not used any specific respiratory protection apparatus. Six cases of silicosis have been diagnosed, which assumes a disease prevalence in this environment of 54.5%. Of the 6 affected, 5 (83.3% are assemblers. We highlight the high risk of developing silicosis in the handling of different products which make up the range of quartz surfaces.

The occupational contribution to severe exacerbation of asthma

The goal of this study was to identify occupational risk factors for severe exacerbation of asthma and estimate the extent to which occupation contributes to these events. The 966 participants were working adults with current asthma who participated in the follow-up phase of the European Community Respiratory Health Survey. Severe exacerbation of asthma was defined as self-reported unplanned care for asthma in the past 12 months. Occupations held in the same period were combined with a general population job-exposure matrix to assess occupational exposures. 74 participants reported having had at least one severe exacerbation event, for a 1-yr cumulative incidence of 7.7%. From regression models that controlled for confounders, the relative risk (RR) was statistically significant for low (RR 1.7, 95% CI 1.1-2.6) and high (RR 3.6, 95% CI 2.2-5.8) biological dust exposure, high mineral dust exposure (RR 1.8, 95% CI 1.02-3.2), and high gas and fumes exposure (RR 2.5, 95% CI 1.2-5.5). The summary category of high dust, gas, or fumes exposure had RR 3.1 (95% CI 1.9-5.1). Based on this RR, the population attributable risk was 14.7% among workers with current asthma. These results suggest occupation contributes to approximately one in seven cases of severe exacerbation of asthma in a working population, and various agents play a role.

[Changes in the prevalence of asthma in the Spanish cohort of the European Community Respiratory Health Survey (ECRHS-II)]

OBJECTIVE

The rise in the prevalence of asthma in the second half of the 20th century has not been evenly distributed according to recent surveys. We assessed changes in the prevalence of asthma after a period of 9 to 10 years in a cohort of young adults in the Spanish arm of the European Community Respiratory Health Survey (ECRHS).

MATERIAL AND METHODS

The ECRHS-II is a multicenter cohort study taking place in 27 centers around Europe, with Spanish centers located in Albacete, Barcelona, Galdakao, Huelva, and Oviedo. The ECRHS questionnaire was administered to individuals who had participated in the first phase of the survey; spirometry and methacholine challenge tests were also performed according to the published protocol.

RESULTS

Among new smokers, the prevalence of wheezing in the last 12 months increased from 10% to 33%, while the frequency of phlegm production rose from 8% to 22% (P< .05). In ex-smokers, the prevalences of wheezing and phlegm production decreased from 21% to 12% and from 15% to 8%, respectively (P< .05). Symptom prevalences remained similar for never smokers, although the frequency of diagnosed asthma rose from 4% to 7% (P< .05). After adjusting for smoking, age, sex, and center, we found no significant differences in the frequency of symptoms or asthma, even when the phrase bronchial hyperreactivity was included in the definition. However, the rate of reported asthma rose annually by 0.34% (95% confidence interval [CI], 0.20%-0.48%), while diagnosed asthma rose by 0.26% (95% CI, 0.13%-0.39%) and treated asthma by 0.16% (95% CI, 0.07%-0.25%).

CONCLUSIONS

Increased prevalence rates of asthma diagnosis and treatment have been detected, but the rates of reported symptoms have remained similar, consistent with the assumption that more persons are being classified as asthmatics.

[Longitudinal incidence of tuberculosis in a cohort of contacts: factors associated with the disease]

OBJECTIVE

To investigate the incidence of tuberculosis (TB) in a cohort of contacts and to analyze the variables associated with the disease.

METHODS

A prospective analysis was undertaken of all the contact investigations carried out in a health district in the Basque Country in northern Spain between January 1, 1995 and December 31, 2004. The dependent variable was the number of cases of TB detected among the contacts. Independent variables were age, sex, tuberculin skin test result, and the degree of contact. In index cases, additional variables were the site of the disease and smear test result.

RESULTS

Analysis of 5444 contacts of 596 patients with TB yielded 66 secondary cases of TB (40 at the time of the contact investigation and 26 at a later stage); the majority (73%) developed the disease within 12 months. Multivariate analysis revealed a significant relationship between the detection of secondary cases and the following variables: close contact (odds ratio [OR], 3.05; 95% confidence interval [CI], 1.75-5.31), positive smear test (OR, 8.54; 95% CI, 2.06-35.43), induration of 10 mm or larger (OR, 10.18; 95% CI, 4.27-24.26), and age under 30 years (OR, 3.35; 95% CI, 1.88-5.98). The final predictive model constructed on the basis of these 3 variables had a sensitivity of 77.4%, a specificity of 80.3%, and an area under the curve of 0.83 (95% CI, 0.78-0.88).

CONCLUSIONS

The contact investigation is a valid strategy for the detection of new cases of TB. Prophylactic treatment should be implemented at an early stage and priority should be given to young contacts of smear positive patients using an induration size of 10 mm or more as a reference.

Exposure to substances in the workplace and new-onset asthma: an international prospective population-based study (ECRHS-II)

BACKGROUND

The role of exposure to substances in the workplace in new-onset asthma is not well characterised in population-based studies. We therefore aimed to estimate the relative and attributable risks of new-onset asthma in relation to occupations, work-related exposures, and inhalation accidents.

METHODS

We studied prospectively 6837 participants from 13 countries who previously took part in the European Community Respiratory Health Survey (1990-95) and did not report respiratory symptoms or a history of asthma at the time of the first study. Asthma was assessed by methacholine challenge test and by questionnaire data on asthma symptoms. Exposures were defined by high-risk occupations, an asthma-specific job exposure matrix with additional expert judgment, and through self-report of acute inhalation events. Relative risks for new onset asthma were calculated with log-binomial models adjusted for age, sex, smoking, and study centre.

FINDINGS

A significant excess asthma risk was seen after exposure to substances known to cause occupational asthma (Relative risk=1.6, 95% CI 1.1-2.3, p=0.017). Risks were highest for asthma defined by bronchial hyper-reactivity in addition to symptoms (2.4, 1.3-4.6, p=0.008). Of common occupations, a significant excess risk of asthma was seen for nursing (2.2, 1.3-4.0, p=0.007). Asthma risk was also increased in participants who reported an acute symptomatic inhalation event such as fire, mixing cleaning products, or chemical spills (RR=3.3, 95% CI 1.0-11.1, p=0.051). The population-attributable risk for adult asthma due to occupational exposures ranged from 10% to 25%, equivalent to an incidence of new-onset occupational asthma of 250-300 cases per million people per year.

INTERPRETATION

Occupational exposures account for a substantial proportion of adult asthma incidence. The increased risk of asthma after inhalation accidents suggests that workers who have such accidents should be monitored closely.

Lung Function Decline, Chronic Bronchitis, and Occupational Exposures in Young Adults

RATIONALE

Occupational exposures to vapors, gas, dust, or fumes have been shown to be a risk factor of airway obstruction in cross-sectional studies in the general population.

OBJECTIVES

Our aim was to study the relationships between specific occupations and occupational exposures during a 9-yr follow-up period and changes in lung function and symptoms of chronic bronchitis.

METHODS

Subjects from the general population aged 20 to 45 yr were randomly selected in 1991-1993 within the European Community Respiratory Health Survey. Follow-up took place from 1998 to 2002 among 4,079 males and 4,461 females in 27 study centers. A total of 3,202 men and 3,279 women twice completed lung function measurements. Job history during follow-up was linked to a job exposure matrix and consequently translated into cumulative exposure estimates.

MAIN RESULTS

Individuals exposed to dusts, gases, and fumes during the period of follow-up did not have a steeper decline of FEV1 than did individuals with consistently white-collar occupations without occupational exposures (relative change among men and women, + 1.4 and -3.1 ml/yr, respectively; p > 0.2), nor an increase of prevalence or incidence of airway obstruction defined as an FEV1/FVC ratio of less than 0.7. The incidence of chronic phlegm increased in men exposed to mineral dust (relative risk, 1.94 [1.29-2.91]) and gases and fumes (relative risk, 1.53 [0.99-2.36]), which was not modified by smoking.

CONCLUSION

Occupational exposures to dusts, gases, and fumes occurring during the 1990s are associated with incidence of chronic bronchitis, although these did not impair lung function in a population of relatively young age.

Smoking habit, respiratory symptoms and lung function in young adults

BACKGROUND

Smoking is the primary cause of deterioration in forced expiratory volume (FEV(1)) and the development of chronic obstructive lung disease. This study assessed the independent association of smoking with respiratory symptoms and lung function in young adults who took part in the European Community Respiratory Health Survey (ECRHS-I).

METHODS

Cross-sectional multi-centre survey of a general population of young adults aged 20(44 years in the ECRHS(I conducted in five Spanish centres. Several groups were created in an exclusive and descendent manner from the subjects who completed the questionnaire in accordance with how they had answered the questions: asthma-related symptoms; chronic bronchitis symptoms; minor respiratory symptoms; chronic cough; and no respiratory symptoms. Among a subset of the population, forced spirometry tests were performed. Linear and logistical regression models were used to assess the relationship of smoking in the presence of symptoms and its impact on lung function, adjusted by other important variables.

RESULTS

The prevalence of respiratory symptoms was higher among smokers. After adjusting for geographical area, total IgE, age, sex, and FEV(1), smoking was associated with an increased risk of chronic bronchitis and other respiratory symptoms. These risks increased with increasing number of cigarettes smoked per day. A deterioration of FEV(1) and the FEV(1)/FVC ratio was also directly associated with the number of cigarettes smoked per day.

CONCLUSION

Even among young adults, smoking confers a high risk of developing a number of respiratory symptoms and the deterioration of the ventilatory function.

The flow-cytometric determination of basophil activation induced by aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) is useful for in vitro diagnosis of the NSAID hypersensitivity syndrome

BACKGROUND

Hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAIDs), manifested by cutaneous symptoms and/or airway manifestations represent 20-25% of all hypersensitivity reactions to drugs. Today, it is still claimed that no in vitro diagnostic tests exist for that condition and that the only way to confirm the diagnosis is a provocation challenge.

OBJECTIVE

The objective of this study was to assess whether NSAIDs may provoke blood basophil activation in vitro in such patients, as detected by a flowcytometric technique.

METHODS

Sixty NSAID hypersensitive patients (38 with cutaneous, 20 with airway and two with cutaneous and airway symptoms) and 30 control patients (15 asthmatics) were selected. Their hypersensitivity was confirmed by documented history indicating at least two clinical episodes to two or more different NSAIDs or by positive oral provocation challenge. Isolated buffy coat leukocytes were stimulated in vitro with aspirin, paracetamol, metamizol, diclofenac, and naproxen. The percentage of activated basophils was evaluated by an anti-CD63.

RESULTS

Aspirin showed a sensitivity of 43.3%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 99.4%. For the other NSAIDs, the sensitivity and specificity values were: for paracetamol 11.7% and 100%, for metamizol 15% and 100%, for diclofenac 43.3% and 93.3% and for naproxen 54.8% and 74.1%. When considering the first four NSAIDs, the global sensitivity raised to 63.3% and specificity to 93.3%. If the number of tests is to be limited for practical reasons, the combination of acetylsalicylic acid and diclofenac at two concentrations yields a sensitivity of 58.3% and a specificity of 93.3%.

CONCLUSIONS

Flowcytometric determinations of basophil activation following stimulation with NSAIDs show a high sensitivity (60-70%) with specificity above 90%. So this test may help avoiding some cumbersome and dangerous provocation challenges.