Evaluation of neural reflex activation as a potential mode of action for respiratory and cardiovascular effects of fine particulate matter

OBJECTIVES

Mortality from respiratory and cardiovascular health conditions contributes largely to the total mortality that has been associated with exposure to PM2.5 in epidemiology studies. A mode of action (MoA) for these underlying morbidities has not been established, but it has been proposed that some effects of PM2.5 occur through activation of neural reflexes.

MATERIALS AND METHODS

We critically reviewed the experimental studies of PM2.5 (including ambient PM2.5, diesel exhaust particles, concentrated ambient particles, diesel exhaust, and cigarette smoke) and neural reflex activation, and applied the principles of the International Programme on Chemical Safety (IPCS) MoA/human relevance framework to assess whether they support a biologically plausible and human-relevant MoA by which PM2.5 could contribute to cardiovascular and respiratory causes of death. We also considered whether the evidence from these studies supports a non-threshold MoA that operates at low, human-relevant PM2.5 exposure concentrations.

RESULTS AND DISCUSSION

We found that the proposed MoA of neural reflex activation is biologically plausible for PM2.5-induced respiratory effects at high exposure levels used in experimental studies, but further studies are needed to fill important data gaps regarding the relevance of this MoA to humans at lower PM2.5 exposure levels. A role for the proposed MoA in PM2.5-induced cardiovascular effects is plausible for some effects but not others.

CONCLUSIONS

Further studies are needed to determine whether neural reflex activation is the MoA by which PM2.5 could cause either respiratory or cardiovascular morbidities in humans, particularly at the ambient concentrations associated with total mortality in epidemiology studies.

Factors Predicting Secondary Respiratory Morbidity Following Early-Life Respiratory Syncytial Virus Infections: Population-Based Cohort Study

Background

The association between early-life respiratory syncytial virus (RSV) infections and later respiratory morbidity is well established. However, there is limited evidence on factors that influence this risk. We examined sociodemographic and perinatal factors associated with later childhood respiratory morbidity requiring secondary care following exposure to a laboratory-confirmed RSV episode in the first 2 years.

Methods

We used a probabilistically linked whole-of-population-based birth cohort including 252 287 children born in Western Australia between 2000 and 2009 with follow-up to the end of 2012. Cox proportional hazards models estimated adjusted hazard ratios (aHRs) of the association of various risk factors with the first respiratory episode for asthma, wheezing, and unspecified acute lower respiratory infection beyond the age of 2 years.

Results

The analytic cohort included 4151 children with a confirmed RSV test before age 2 years. The incidence of subsequent respiratory morbidity following early-life RSV infection decreased with child age at outcome (highest incidence in 2-<4-year-olds: 41.8 per 1000 child-years; 95% CI, 37.5-46.6), increased with age at RSV infection (6-<12-month-olds: 23.6/1000 child-years; 95% CI, 19.9-27.8; 12-<24-month-olds: 22.4/1000 child-years; 95% CI, 18.2-22.7) and decreasing gestational age (50.8/1000 child-years; 95% CI, 33.5-77.2 for children born extremely preterm, <28 weeks gestation). Risk factors included age at first RSV episode (6-<12 months: aHR, 1.42; 95% CI, 1.06-1.90), extreme prematurity (<28 weeks: aHR, 2.22; 95% CI, 1.40-3.53), maternal history of asthma (aHR, 1.33; 95% CI, 1.04-1.70), and low socioeconomic index (aHR, 1.76; 95% CI, 1.03-3.00).

Conclusions

Our results suggest that in addition to preterm and young infants, children aged 12-<24 months could also be potential target groups for RSV prevention to reduce the burden of later respiratory morbidities associated with RSV.

Exposures to Organophosphate Esters and Respiratory Morbidity among School-Aged Children with Asthma

Organophosphate esters (OPEs) are an emerging class of chemicals used in a variety of consumer products as flame retardants, plasticizers, and additives. While prior epidemiologic studies suggest that OPEs may impact respiratory health, results remain inconclusive. We examined associations between urinary biomarkers of OPEs and symptoms of respiratory morbidity in a panel study of 147 predominantly Black school-aged children with asthma living in Baltimore City, Maryland. The study consisted of up to four seasonal, week-long, in-home visits where urine samples and self-reported asthma symptoms were collected on days 4 and 7 (n_samples = 438). We quantified concentrations of nine urinary OPE biomarkers: bis(2-chloroethyl) phosphate (BCEtp), bis(1-chloro-2-propyl) phosphate (BCPP), bis(1,3-dichloro-2-propyl) phosphate (BDCIPP), di-n-butyl phosphate (DBuP), di-benzyl phosphate (DBzP), di-o-cresylphosphate (DOCP), di-p-cresylphosphate (DPCP), di-(2-propylheptyl) phthalate (DPHP), and 2,3,4,5-tetrabromo benzoic acid (TBBA). We estimated prevalence odds ratios (POR) of respiratory morbidity symptoms using logistic regression with generalized estimating equations to account for our repeated measure design. We assessed BDCIPP and DPHP as continuous (log₂) concentrations and dichotomized exposure of BCEtP, DBuP, and DPCP (detect vs non-detect) based on their lower detection frequencies. We adjusted models for season, visit day, age, gender, caregiver education, health insurance type, exposure to household smoking, atopy, and PM_2.5. Higher DPHP concentrations were significantly associated with odds of daytime symptoms (POR: 1.26; 95% CI: 1.04-1.53; p = 0.02) where daytime symptoms consisted of trouble breathing due to asthma, reporting bother caused by asthma, and/or limitation in activities due to asthma. DBuP detection was associated with use of rescue medication on the day of sample collection (POR: 2.36; 95% CI: 1.05-5.29; p = 0.04). We also observed several consistent, albeit non-significant (p > 0.05), positive associations for BCEtP and DPCP and respiratory morbidity measures. This is the first study to evaluate the relationship between OPE biomarkers and respiratory morbidity symptoms in children with asthma, and findings suggest that further studies are warranted to confirm whether these associations are causal.

Fetal Lung Volume Appears to Predict Respiratory Morbidity in Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is associated with pulmonary hypoplasia and respiratory morbidity. To assess whether respiratory morbidity during the first 2 years of life in infants with left-sided CDH is associated with fetal lung volume (FLV) evaluated by the observed-to-expected FLV ratio (o/e FLV) on antenatal magnetic resonance imaging (MRI). In this retrospective study, o/e FLV measures were collected. Respiratory morbidity in the first 2 years of life was studied according to two endpoints: treatment with inhaled corticosteroids for >3 consecutive months and hospitalization for any acute respiratory disease. The primary outcome was a favorable progression defined by the absence of either endpoint. Forty-seven patients were included. The median o/e FLV was 39% (interquartile range, 33-49). Sixteen (34%) infants were treated with inhaled corticosteroids and 13 (28%) were hospitalized. The most efficient threshold for a favorable outcome was an o/e FLV ≥ 44% with a sensitivity of 57%, specificity of 79%, negative predictive value of 56%, and positive predictive value of 80%. An o/e FLV ≥ 44% was associated with a favorable outcome in 80% of cases. These data suggest that lung volume measurement on fetal MRI may help to identify children at lower respiratory risk and improve information during pregnancy, patient characterization, decisions about treatment strategy and research, and personalized follow-up.

Disquiet concerning cesarean birth

Cesarean birth has increased substantially in many parts of the world over recent decades and concerns have been raised about the propriety of this change in obstetric practice. Sometimes, a cesarean is necessary to preserve fetal and maternal health. But in balancing the risks of surgical intervention the implicit assumption has been that cesarean birth is an equivalent alternative to vaginal birth from the standpoint of the immediate and long-term health of the fetus and neonate. Increasingly, we realize this is not necessarily so. Delivery mode per se may influence short-term and abiding problems with homeostasis in offspring, quite independent of the indications for the delivery and other potentially confounding factors. The probability of developing various disorders, including respiratory compromise, obesity, immune dysfunction, and neurobehavioral disorders has been shown in some studies to be higher among individuals born by cesarean. Moreover, many of these adverse effects are not confined to the neonatal period and may develop over many years. Although the associations between delivery mode and long-term health are persuasive, their pathogenesis and causality remain uncertain. Full exploration and a clear understanding of these relationships is of great importance to the health of offspring.

Does antenatal corticosteroid therapy improve neonatal outcomes in late preterm birth?

BACKGROUND

Infants who are born at 34°^/7 to 36^6/7weeks of gestation (late preterm) are at greater risk for respiratory and other neonatal morbidities. The objective of this study was to examine the effects of the administration of antenatal corticosteroids (ACS) to women at risk for late preterm delivery on the incidence of neonatal outcomes.

METHOD

This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34°^/7 and 36^6/7weeks. Neonatal outcomes were compared between mothers who received ACS and those who did not. The primary outcome was the rate of composite respiratory morbidity defined as the need for treatment within 72 h of life (continuous positive airway pressure or high flow nasal cannula for least 2 h or supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least four continuous hours or mechanical ventilation).

RESULTS

During the 3-year study period, 595 subjects were included in this study, comprising 234 subjects that received ACS and 361 that did not. Administration of ACS significantly reduced the rates of composite respiratory morbidity (aOR 0.63 95% CI 0.40-0.99), the use of CPAP or HFNC for at least 2 h (aOR 0.57 95% CI 0.35-0.94), and transient tachypnea of the newborn (aOR 0.48 95% CI 0.28-0.82). Neonatal hypoglycemia was more significantly increased in the ACS group compared with controls (aOR 1.64 95% CI 1.04-2.59). We found no significant between-group differences in the rate of respiratory distress syndrome, surfactant use, need for resuscitation, jaundice requiring phototherapy, admission to neonatal intensive care or special care nursery, and duration of hospitalization.

CONCLUSION

Administration of ACS during the late preterm period decreased neonatal respiratory complications, however, increased the rate of hypoglycemia.

Respiratory and cardiovascular condition-related physician visits associated with wildfire smoke exposure in Calgary, Canada, in 2015: a population-based study

BACKGROUND

We studied the impact of fine particulate matter (PM2.5) exposure due to a remote wildfire event in the Pacific Northwest on daily outpatient respiratory and cardiovascular physician visits during wildfire (24-31 August, 2015) and post-wildfire period (1-30 September, 2015) relative to the pre-wildfire period (1-23 August, 2015) in the city of Calgary, Canada.

METHODS

A quasi-Poisson regression model was used for modelling daily counts of physician visits due to PM2.5 while adjusting for day of the week (weekday versus weekend or public holiday), wildfire exposure period (before, during, after), methane, relative humidity, and wind direction. A subgroup analysis of those with pre-existing diabetes or hypertension was performed.

RESULTS

An elevated risk of respiratory disease morbidity of 33% (relative risk: RR) [95% confidence interval (CI): 10%-59%] and 55% (95% CI: 42%-69%) was observed per 10µg/m3 increase in PM2.5 level during and after wildfire, respectively, relative to the pre-wildfire time period. Increased risk was observed for children aged 0-9 years during (RR = 1.57, 95% CI: 1.21-2.02) and after the wildfire (RR = 2.11, 95% CI: 1.86-2.40) especially for asthma, acute bronchitis and acute respiratory infection. The risk of physician visits among seniors increased by 11% (95% CI: 3%-21%), and 19% (95% CI: 7%-33%) post-wildfire for congestive heart failure and ischaemic heart disease, respectively. Individuals with pre-existing diabetes had an increased risk of both respiratory and cardiovascular morbidity in the post-wildfire period (RR = 1.35, 95% CI: 1.09-1.67; RR = 1.22, 95% CI: 1.01-1.46, respectively).

CONCLUSIONS

Wildfire-related PM2.5 exposure led to increased respiratory condition-related outpatient physician visits during and after wildfires, particularly for children. An increased risk of physician visits for congestive heart failure and ischaemic heart disease among seniors in the post-wildfire period was also observed.

Optimal gestational age at delivery in isolated left-sided congenital diaphragmatic hernia

OBJECTIVE

To evaluate the morbidity and mortality of neonates with left-sided isolated congenital diaphragmatic hernia (CDH) according to gestational age at delivery.

METHODS

This was a retrospective study of fetuses diagnosed prenatally with isolated left-sided CDH that were delivered in the University Hospitals of Antoine Béclère-Bicêtre and Leuven between 1 January 2010 and 31 December 2018. The Kaplan-Meier method was used to calculate cumulative survival at 28 days after birth according to gestational age at delivery. The association between gestational age at delivery, as a continuous variable, and survival at 28 days was modeled using a fractional polynomial. Adjustment for position of the liver, management center and mode of delivery was performed. The association was also evaluated according to the severity of CDH, as defined by the observed-to-expected lung-to-head ratio (o/e-LHR), which was classified as severe (o/e-LHR < 25%), moderate (o/e-LHR between 25% and 45%) or mild (o/e-LHR > 45%).

RESULTS

We included 213 fetuses with isolated left-sided CDH, with a median gestational age at delivery of 38 + 2 weeks (interquartile range, 37 + 0 to 39 + 1 weeks). The survival rates at 28 days and at 6 months were 66.7% (142/213) and 64.3% (137/213), respectively. Kaplan-Meier analysis showed a higher survival rate at 28 days for babies delivered between 37 + 0 and 38 + 6 weeks than for those delivered at or after 39 + 0 weeks (log-rank test, P < 0.001). In the subgroup of moderate CDH, the 28-day survival rate was significantly higher in newborns delivered between 37 + 0 and 38 + 6 weeks than in those delivered at or after 39 + 0 weeks (81.5% vs 61.5%; P = 0.03), and this was also the case for survival rate at 6 months. In the subgroup with moderate CDH, 28-day survival significantly increased with advancing gestational age at birth up to about 38-39 weeks (P = 0.005), and significantly decreased from 39 weeks onwards.

CONCLUSION

Delivery between 37 + 0 and 38 + 6 weeks' gestation is associated with a higher survival rate at 28 days in neonates with isolated left-sided CDH and moderate lung hypoplasia, independently of intrathoracic liver, management center and mode of delivery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Race and neonatal respiratory morbidity in the late preterm period

BACKGROUND

Prematurity is one of the leading causes of perinatal morbidity and mortality. Some studies suggest that respiratory disease may differ by race in early preterm infants. However, the role of race in late preterm neonatal morbidity is not yet established.

OBJECTIVE

The objective of our study was to determine whether neonatal respiratory morbidity differs by race in neonates born late preterm.

STUDY DESIGN

This was a secondary analysis of a randomized trial of women at high risk for late preterm delivery (Antenatal Late Preterm Steroids). Our study was limited to women with nonanomalous, singleton gestations, delivering between 34+0 to 36+6 weeks. Women were categorized into 4 groups by race: Black, White, Asian, or other/mixed. The primary outcome was a neonatal composite of treatment in the first 72 hours (continuous positive airway pressure or high-flow nasal cannula >2 hours, oxygen >4 hours, extracorporeal membrane oxygenation or mechanical ventilation) or stillbirth or neonatal death before 72 hours. The secondary outcomes included severe respiratory morbidity (the primary outcome extending continuous positive airway pressure or high-flow nasal cannula to >12 continuous hours and oxygen to at least 24 continuous hours), respiratory distress syndrome, transient tachypnea of the newborn, apnea, neonatal intensive care unit admission, bronchopulmonary dysplasia, and surfactant administration. The primary and secondary outcomes were assessed in the active (steroid) and placebo groups separately. We fit a logistic regression model to adjust for confounders related to respiratory morbidity.

RESULTS

Of a total of 2331 included women, 26.9% (n=627) were Black/African American, 57.1% (n=1333) White, 3.56% (n=83) Asian, and 12.36% (n=288) were other/mixed. In the placebo group, the rate of the primary outcome was significantly higher in Whites (18.6%) and Asians (22.8%) compared with the African American/Black group (12.3%) (P=.03). Adjusting for confounders, the primary outcome was not significant between the groups. The primary predictor for respiratory morbidity was a prior pregnancy with neonatal respiratory morbidity. Findings were similar in the steroid group, but severe respiratory morbidity was less common in Black infants compared with White infants (adjusted odds ratio, 0.45; 95% confidence interval, 0.24-0.83). However, a prior pregnancy with neonatal respiratory complications was no longer associated with respiratory morbidity after receipt of betamethasone.

CONCLUSION

Late preterm respiratory morbidity was similar between racial groups. Although a history of pregnancy with previous neonatal respiratory disease is the strongest risk factor for recurrence, this risk factor is mitigated by the receipt of steroids.

Quality of life was similar in children with congenital diaphragmatic hernia and oesophageal atresia and related to respiratory morbidity

AIM

To assess quality of life (QoL) in children with congenital diaphragmatic hernia (CDH) and to compare it with oesophageal atresia (OA).

METHODS

A cross-sectional study in CDH children (≥7 years) was conducted in Lille University Hospital, France, from January 2013 to April 2014. History, lung function (rest, exercise) and Pediatric Quality of Life Inventory questionnaires (PedsQoL 4.0) were collected. Data of OA children were previously published.

RESULTS

Fifty-four CDH patients (male: 53%, median age: 11 years, IQR 9-14) were compared to 54 OA patients (male: 61%, median age: 13 years, IQR: 11-15). CDH children had significantly more frequent history of pneumonia (30% vs 13%), exercise limitation (54% vs 35%) and chest deformity (39% vs 11%); 46% had an obstructive pattern and 66% an abnormal cardiopulmonary exercise test. The median PedsQoL total score in children was 81 (IQR 73-90) in CDH and 81 (IQR 72-91) in OA (P = .8). In CDH, duration of neonatal oxygen therapy, hospitalisation for respiratory disease, exercise limitation, inhaled corticosteroids treatment, chest deformity, abnormal cardiopulmonary exercise test and lower forced expiratory volume in one second were significantly associated with lower QoL scores.

CONCLUSION

PedsQoL scores remained satisfactory in CDH children with CDH, with no difference compared to OA. Patients with respiratory morbidity and lung function impairment, who displayed lower scores, should be identified in order to optimise their management in reference centres.

Awareness, Prevalence and Factors Associated with Respiratory Morbidities Among Selected Petrol Pump Workers in Bengaluru City?

Introduction:

Petrol pump workers are exposed to fumes emanated during petrol filling and vehicular exhaust thus falling prey to several respiratory diseases.

Objectives:

To assess the awareness and prevalence of respiratory morbidities among petrol pump workers of selected petrol pumps in Bangalore.

Methodology:

This cross-sectional study was conducted among 158 petrol pump workers from 11 selected pumps in Bengaluru. Following IEC approval, the baseline socio-demographic data, knowledge regarding respiratory morbidities and current morbidity pattern were ascertained. Medical examination and Peak Expiratory Flow rate (PEFR) was estimated.

Results:

The 158 workers were all male, mostly between 18-27 years (65.19%) and high school educated (49.37%). Knowledge regarding respiratory morbidities was 56%, while prevalence of respiratory morbidity was 61%. Those workers who had completed their higher education (>10^th standard), earning monthly income (>Rs. 5000) had better knowledge regarding respiratory morbidities.

Recommendation:

Pre-employment and regular medical examination including lung function tests and promotion of use of PPEs to be implemented.

Occupational respiratory morbidity among hair and beauty salon workers in Udupi taluk, Karnataka, India

BACKGROUND

The Indian hair and beauty salon industry is growing rapidly due to the demand for beauty and personal care services and products. Workers in the industry are vulnerable to several occupational factors such as chemicals, confined space, and poor ventilation. Chemicals in the products used are known or suspected to cause allergies, respiratory, neurological and reproductive health problems and cancer.

METHODS

The present study was carried out to determine the factors associated with the occurrence of respiratory morbidity among hair and beauty salon workers of Udupi taluk, Karnataka, India. A total of 240 salon workers were recruited for the study. A semistructured, interviewer-led questionnaire was used to collect data. Peak expiratory flow rate (PEFR) was done using a JSB peak flow meter.

RESULTS

The frequency of respiratory morbidity among participating beauty salon workers was 19%. Men reported respiratory symptoms more frequently than women. Receiving training on work materials and practices was a significant protective factor (odds ratio = 0.3; 95% confidence interval: 0.1-0.7) for the occurrence of respiratory morbidity. The mean observed PEFR in these workers was significantly lower than their predicted values. While 61.2% of the workers were using some form of personal protective equipment, only 4% of workers used a mask or respiratory protection.

CONCLUSION

Hair and beauty salon workers are at risk of developing respiratory morbidity potentially from harmful exposures and lack of effective control measures at the workplace.

Does antenatal corticosteroid therapy improve neonatal outcomes in late preterm birth?

BACKGROUND

Infants who are born at 34^0/7 to 36^6/7 weeks of gestation (late preterm) are at greater risk for respiratory and other neonatal morbidities. The objective of this study was to examine the effects of administration of antenatal corticosteroids (ACSs) to women at risk for late preterm delivery on the incidence of neonatal outcomes.

METHODS

This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34^0/7 and 36^6/7 weeks. Neonatal outcomes were compared between mothers who received ACS and those who did not. Primary outcome was the rate of composite respiratory morbidity defined as the need for treatment within 72 h of life (continuous positive airway pressure or high flow nasal cannula for least 2 h or supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least four continuous hours or mechanical ventilation).

RESULTS

During the 3-year study period, 595 subjects were included in this study, comprising 234 subjects that received ACS and 361 that did not. Administration of ACS significantly reduced the rates of composite respiratory morbidity (adjusted odds ratio (aOR) 0.63, 95% confidence interval (CI) 0.40-0.99), the use of CPAP or HFNC for at least 2 h (aOR 0.57, 95% CI 0.35-0.94) and transient tachypnea of newborn (aOR 0.48, 95% CI 0.28-0.82). Neonatal hypoglycemia was more significantly increased in the ACS group compared with controls (aOR 1.64, 95% CI 1.04-2.59). We found no significant between-group differences in the rate of respiratory distress syndrome, surfactant use, need for resuscitation, jaundice requiring phototherapy, admission to neonatal intensive care or special care nursery and duration of hospitalization.

CONCLUSION

Administration of ACS during the late preterm period decreased neonatal respiratory complications, however, increased the rate of hypoglycemia.

Association between duration of coal dust exposure and respiratory impairment in coal miners of West Bengal, India

Purpose. The prevalence and severity of respiratory disorders are very high among coal miners as continuous exposure of workers in such an environment leads to accumulation of dust in the lungs. This study was designed to assess the prevalence of lung function impairment and to determine whether there is any correlation between dust exposure duration and lung function indices. Materials. Two hundred and thirty underground coal dust-exposed workers and 130 age-matched non-exposed workers were recruited from an underground mine in West Bengal, India. A spirometry test was performed for lung function and also basic information on personnel's dust exposure, smoking and respiratory morbidity was collected. Student's t test, Pearson's correlation coefficient (r), uncorrected Pearson's χ² test and Fischer's exact test were performed for statistical analysis. Results. Lung function indices were significantly (p < 0.050) impaired between the exposed (43.91%) and non-exposed (23.85%) groups. In addition, highly significant decrements in the pulmonary volumes of exposed subjects were also noted. Furthermore, a high negative correlation was observed between spirometric results and exposure time in the exposed group compared with the non-exposed group. Conclusion. This study suggested a positive relationship between exposure time and lung function deterioration.

Association between respiratory syncytial virus hospitalization in infancy and childhood asthma

INTRODUCTION

Respiratory syncytial virus infection in early childhood has been linked to longer-term respiratory morbidity; however, debate persists around its impact on asthma. The objective was to assess the association between respiratory syncytial virus hospitalization and childhood asthma.

METHODS

Asthma hospital admissions and medication use through 18 years were compared in children with (cases) and without (controls) respiratory syncytial virus hospitalization in the first 2 years of life. All children born in National Health Service Scotland between 1996 and 2011 were included.

RESULTS

Of 740 418 children (median follow-up: 10.6 years), 15 795 (2.1%) had a respiratory syncytial virus hospitalization at ≤2 years (median age: 143 days). Asthma hospitalizations were three-fold higher in cases than controls (8.4% vs 2.4%; relative risk: 3.3, 95% confidence interval [CI]: 3.1-3.5; P < .0001) and admission rates were four-fold higher (193.2 vs 46.0/1000). Cases had two-fold higher asthma medication usage (25.5% vs 14.7%; relative risk: 1.7, 95% CI: 1.7-1.8; P < .0001) and a three-fold higher rate of having both an asthma admission and medication (4.8% vs 1.5%; relative risk 3.1, 95% CI: 2.9-3.3; P < .0001). Admission rates and medication use remained significantly (P < .001) higher for cases than controls throughout childhood (admissions: ≥2-fold higher; medication: ≥1.5-fold higher). Respiratory syncytial virus hospitalization was the most significant risk factor for asthma hospitalizations±medication use (odds ratio: 1.9-2.8; P < .001).

CONCLUSIONS

Respiratory syncytial virus hospitalization was associated with significantly increased rates and severity of asthma throughout childhood, which has important implications for preventive strategies.

Pulmonary function in children and adolescents after esophageal atresia repair

INTRODUCTION

Respiratory morbidity after esophageal atresia (EA) is common. The aims of this study were to assess pulmonary function, to identify risk factors for pulmonary function impairment (PFI), and to investigate the relations between respiratory morbidity, defined as medical treatment for respiratory symptoms or recent pneumonia and PFI after EA repair.

MATERIAL AND METHODS

Single center retrospective observational study including patients with EA who participated in the follow-up program for 8- or 15-year old patients from 2014 to 2018 and performed pulmonary function testing by body plethysmography, dynamic spirometry, impulse oscillometry, and diffusing capacity of the lungs. Univariate and multiple stepwise logistic regression with PFI as outcome were performed. Anastomotic leak, episodes of general anesthesia, extubation day, birth weight, age at follow up, gross classification, and abnormal reflux index were independent variables.

RESULTS

In total, 47 patients were included. PFI was found in 19 patients (41%) and 16 out of 19 patients (84%) had an obstructive pattern. Respiratory morbidity was found in 23 (52%, NA = 3) of the patients with no correlation to PFI. Birth weight, age at follow-up, and episodes of general anesthesia were identified as risk factors for PFI.

CONCLUSION

Respiratory morbidity and PFI were common in children and adolescents after EA repair. The major component of PFI was obstruction of the airways. The risk for PFI increased with lower birth weight and older age at follow up. The poor correlation between respiratory morbidity and PFI motivates the need of clinical follow up including pulmonary function tests.

Elective Cesarean Section on Term Pregnancies Has a High Risk for Neonatal Respiratory Morbidity in Developed Countries: A Systematic Review and Meta-Analysis

Background: Cesarean section (CS) is one of the most recurrently carried out surgical procedures in modern obstetrics. Worldwide, about 18.5 million CSs are conducted annually. Of this, 21-33% are performed in middle-and high-income countries. The effectiveness of the CS in preventing maternal and prenatal mortality and morbidity is medically justifiable. However, cesarean delivery without demanding obstetrical indications, by mere maternal request, may expose the child to several risks over benefits. Therefore, we aim to compare spontaneous vaginal delivery (vaginal delivery other than operative vaginal deliveries) and elective CS (CS before the onset of labor, but not including emergency CS) in decreasing the risk of neonatal respiratory morbidity. Objective: To compare the risk of neonatal respiratory morbidity in ECS and spontaneous vaginal delivery. Methods: A literature search was performed through visiting an electronic database (MEDLINE, PubMed, EMBASE, and CINAHL) and gray literature sources, including Google and Google Scholar, from January 2000 to May 2018. Original observational studies that reported the risk of neonatal respiratory morbidity in relation to mode of delivery conducted in the English language were identified and screened. Joanna Briggs Institute's quality assessment tool for observational studies was used to critically appraise the methodological quality of studies. Synthesis of individual studies was conducted using the Review Manager Software version 5.3 for Windows. Heterogeneity among studies was explored using the Cochran's Q-test and the I ² statistics. Pooled effect sizes in relative risk ratios with 95% confidence intervals were calculated. The flow of the study was prepared according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist. Results: Sixteen studies were reviewed. A total of 327,272 neonates born by vaginal delivery and 55,246 born by ECS were included in this study. The risk of neonatal respiratory morbidity was increased by 95% in neonates delivered by ECS (RR = 1.95; 95% CI: 1.40-2.73) as compared with neonates born by spontaneous vaginal delivery. Conclusion: This study investigated the effect of mode of delivery on the respiratory morbidity without considering other risks and found that the ECS has a high risk of developing neonatal respiratory morbidities when compared to spontaneous vaginal delivery. So, we recommend discouraging unnecessary CS. registration: CRD42018104905.

Amniotic fluid volume at presentation with early preterm prelabor rupture of membranes and association with severe neonatal respiratory morbidity

OBJECTIVE

Amniotic fluid volume (AFV) plays an important role in early fetal lung development, and oligohydramnios in early pregnancy is associated with pulmonary hypoplasia. The aim of this study was to evaluate the association between AFV at the time of presentation with early preterm prelabor rupture of membranes (PPROM) and severe neonatal respiratory morbidity and other adverse pregnancy outcomes.

METHODS

This was a retrospective study of all women with a singleton pregnancy, admitted to a single tertiary referral center between 2004 and 2014, for expectant management of PPROM at 20 + 0 to 28 + 6 weeks' gestation. The primary exposure was AFV at presentation, classified according to sonographic maximum vertical pocket (MVP) as: normal AFV (> 2 cm), oligohydramnios (≤ 2 cm and > 1 cm) or severe oligohydramnios (≤ 1 cm). The primary outcome was a composite variable of severe respiratory morbidity, defined as either of the following: (1) need for respiratory support in the form of mechanical ventilation using an endotracheal tube for ≥ 72 h and need for surfactant; or (2) bronchopulmonary dysplasia, defined as requirement for oxygen at postmenstrual age of 36 weeks or at the time of transfer to a Level-II facility. Adjusted odds ratios (aOR) and 95% CI for the primary and secondary outcomes were calculated for each AFV-at-presentation group (using normal AFV as the reference), adjusting for gestational age (GA) at PPROM, latency period, birth weight, mode of delivery and chorioamnionitis.

RESULTS

In total, 580 women were included, of whom 304 (52.4%) had normal AFV, 161 (27.8%) had oligohydramnios and 115 (19.8%) had severe oligohydramnios at presentation. The rates of severe respiratory morbidity were 16.1%, 26.7% and 45.2%, respectively. Compared with normal AFV at presentation, oligohydramnios (aOR, 3.27; 95% CI, 1.84-5.84) and severe oligohydramnios (aOR, 4.11; 95% CI, 2.26-7.56) at presentation were associated independently with severe respiratory morbidity. Other variables that were associated independently with the primary outcome were GA at PPROM (aOR, 0.54; 95% CI, 0.43-0.69), latency period (aOR, 0.94; 95% CI, 0.91-0.98) and Cesarean delivery (aOR, 2.01; 95% CI, 1.21-3.32).

CONCLUSIONS

In women with early PPROM, AFV at presentation, as assessed by the MVP on ultrasound examination, is associated independently with severe neonatal respiratory morbidity. This information may be taken into consideration when counseling women with early PPROM regarding neonatal outcome and management options. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Short- and long-term respiratory outcomes in neonates with ventilator-associated pneumonia

BACKGROUND AND OBJECTIVE

Ventilator-associated pneumonia (VAP) is a common nosocomial infection in critical care settings and might have important long-term consequences in neonates. Our aim is to clarify the short- and long-term respiratory outcomes of neonates affected by VAP.

METHODS

Prospective, population-based, cohort study with 12 months follow-up based on clinical examinations and diary-based respiratory morbidity score, conducted in an academic tertiary referral neonatal unit with dedicated follow-up program.

RESULTS

A total of 199 inborn neonates consecutively ventilated for at least 48 hours were eligible for the study. One hundred fifty-one were finally enrolled and classified as "exposed" or "unexposed" to VAP, if they fulfilled (or not) VAP criteria once during their stay. Bronchopulmonary dysplasia (BPD) incidence was significantly higher in exposed (75%) than in unexposed babies (26.8%; relative risk [RR]: 2.8 [1.9-4.0]; _Adj RR: 3.5 [1.002-12.7]; P = .049; number needed to harm = 2.07), although the composite BPD/mortality did not differ. Exposed patients showed longer intensive care unit stay (87 [43-116] vs 14 [8-52] days; St.β = 0.24; P < .0001) and duration of ventilation (15 [10-25] vs 5 [4-8] days; St.β = 0.29; P < .0001) than unexposed neonates. Exposed patients also showed less ventilator-free days (11 [5-17.7] vs 22 [14-24] days; St.β = -0.15; P = .05) compared to unexposed. Respiratory infections, use of drugs, rehospitalization for respiratory reasons, home oxygen therapy, their composite outcome, and diary-based clinical respiratory morbidity score were similar between the cohorts.

CONCLUSION

Neonatal VAP seems associated to higher incidence of BPD, longer ventilation, and intensive care stay but it does not affect long-term respiratory morbidity.

Fluid Overload in Special Pediatric Cohorts With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery Following Surgical Repair

OBJECTIVE

To investigate the prevalence, risk factors, and clinical outcomes associated with early fluid overload (FO) in a special group of pediatric patients undergoing repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).

DESIGN

It was a retrospective study performed with multiple variable regression analysis.

SETTING

A single cardiac surgical institution.

PARTICIPANTS

Eighty-eight patients younger than 18 years of age undergoing ALCAPA surgical repair with cardiopulmonary bypass were recruited at the authors' institution from June 2010 to September 2017.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Of 88 pediatric patients with ALCAPA after surgical repair, 37.5% developed early FO, defined as fluid accumulation ≥5% within the period from surgery until midnight of postoperative day 1. Patients with early FO were younger, weighed less, and had worse preoperative cardiac dysfunction. With logistic regression analysis, being underweight was confirmed to be a risk factor for FO development (odds ratio, 8.66; 95% confidence interval, 2.83-26.52; p < 0.001). Early FO also predicted severe acute kidney injury, respiratory morbidity, and low cardiac output syndrome after reimplantation procedure. Patients with early FO also had significantly longer mechanical ventilation hours (p  <  0.001), intensive care unit length of stay (p = 0.003), and hospital length of stay (p = 0.009).

CONCLUSION

Early FO ≥5% has been linked to adverse postoperative outcomes in pediatric patients undergoing repair for ALCAPA. The use of restrictive fluid management is crucial for patients who have lower weight and poor myocardial function before and after complex surgical procedures such as in ALCAPA settings.

The Effect of Treatment during A Haze/Post-Haze Year on Subsequent Respiratory Morbidity Status among Successful Treatment Tuberculosis Cases

The purpose of this study was to evaluate the respiratory morbidity status within the two to three years among successful (completed/cured) treatment of tuberculosis cases during a haze year (2015) and a post-haze year (2016). The study was conducted among 133 cases of a 2015 group and 103 cases of a 2016 group between January to March 2018 in Pekanbaru city, Indonesia. The St George Respiratory Questionnaire (SGRQ) was used to assess respiratory morbidity status. A higher score corresponds to worse respiratory morbidity. Based on a directed acyclic graph, quantile regression models were constructed to assess the associations between haze/post-haze year and the SGRQ (symptom, activity, impact, and total) domains score. The subsequent respiratory morbidity status of tuberculosis (TB) cases was poorer among respondents treated during a haze year (2015). Among SGRQ domains, only the activity domain score showed significant difference, in which the median for the 2015 group was 23.7 (inter-quartile range (IQR); 17.2, 30.9) compared to 18.4 (IQR; 11.9, 24.8) for the 2016 group. The effect was limited to the 2015 group who were exposed by an average PM₁₀ index ≥ 55 during TB treatment. This raises concern for monitoring and improving the quality of life of TB patients treated during a haze year.

Fertility treatments and the risk of pediatric obstructive sleep apnea in the offspring-Results from a population-based cohort study

OBJECTIVE

While the impact of fertility treatments on the perinatal outcome is well established, the long-term effects on offspring are yet to be determined. The current study aimed to investigate the risk of long-term obstructive sleep apnea (OSA) among children born following in vitro fertilization (IVF) and ovulation induction (OI) as compared with spontaneously conceived pregnancies.

STUDY DESIGN

A retrospective population-based cohort study was performed. Exposure was defined as delivery following pregnancies conceived by IVF or OI. Incidence of OSA related hospitalizations of the offspring, up to the age of 18 years, was evaluated. A Kaplan-Meier survival curve and multivariable Cox regression models were used to assess the association.

RESULTS

During the study period, 242 187 singleton deliveries met the inclusion criteria; 1.1% were conceived following IVF (n = 2603), and 0.7% following OI (n = 1721). Offspring hospitalization rates, involving OSA (n = 1607), were higher among children conceived following IVF and OI pregnancies as compared with the rate in children conceived spontaneously (1.4% vs 1.2% vs 0.7%, respectively; P < .001). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of OSA related hospitalizations following IVF and OI (log-rank P < .001). Using multiple Cox regression models, controlled for gestational age, maternal age, maternal smoking, maternal obesity, birthweight, offspring gender and obesity, IVF as well as OI exhibited a significant and independent association with pediatric OSA in all models with adjusted hazard ratios of 2.25, (95% confidence interval [CI] = 1.6-3.1) and 1.63 (95% CI = 1.1-2.5), respectively.

CONCLUSION

Both IVF and OI treatments appear to be independently associated with OSA in the offspring.

Lung function in school-aged congenital diaphragmatic hernia patients; a longitudinal evaluation

OBJECTIVE

Children with congenital diaphragmatic hernia (CDH) are at risk for pulmonary morbidity. Data on longitudinal evaluation of lung function in CDH are scarce. We hypothesized that CDH patients would have impaired lung function that worsens over time. We evaluated lung function and its determinants at ages 8 and 12 years.

METHODS

Dynamic and static lung volumes, and diffusion capacity were measured. Extracorporeal membrane oxygenation (ECMO) treatment, the standardized European neonatal treatment protocol, patch repair, duration of ventilation, type of initial mechanical ventilation, and nitric oxide treatment were entered as covariates in linear mixed models with standard deviation score (SDS) lung function parameters (FEV₁ , FEF _25-75 , and K _CO ) as dependent variables.

RESULTS

Seventy-six children (27 ECMO-treated) born between 1999 and 2009 performed 113 reliable lung function tests. Severity of airflow obstruction deteriorated significantly from age 8 to 12 years: estimated mean difference (95% confidence interval [CI]) SDS FEV₁ was -0.57 (-0.79 to -0.36) and SDS FEF_25-75 was -0.63 (-0.89 to -0.37), both P < .001. Static lung volumes were within normal range and unchanged over time: estimated mean difference (95% CI) SDS TLC -0.27 (-0.58 to 0.04); P = .085. SDS K_CO was below normal at 8 and 12 years and remained stable: -0.06 (-0.22 to 0.35); P = .648. These observations were irrespective of ECMO treatment. FEV₁ and FEF_25-75 were negatively associated with duration of ventilation (P < .001). Baseline data were not related with TLC or K_CO. CONCLUSIONS: CDH patients should be followed into adulthood as they are at risk for worsening airflow obstruction and decreased diffusion capacity at school age, irrespective of ECMO treatment.

Neonatal respiratory status predicts longitudinal respiratory health outcomes in preterm infants

OBJECTIVES

To examine the relationship between neonatal respiratory status and longitudinal respiratory health outcomes in preterm infants with very low birth weight (VLBW, birth weight <1500 g).

METHODS

A total of 109 VLBW preterm infants were prospectively assessed for respiratory status using the Toce clinical and radiographic scoring method on a postnatal day 28, and severity of bronchopulmonary dysplasia (BPD) at 36-weeks postmenstrual age (PMA), respiratory morbidity within 1 year of corrected age (CA), pulmonary function test, and six-minute walk test at 4 years of age.

RESULTS

A high Toce clinical score on day 28 was associated with the occurrence of respiratory morbidity within 1 year of CA and poor pulmonary function and functional exercise performance at 4 years of age in VLBW preterm infants (all P < 0.05). BPD at 36-weeks PMA was associated with an increased risk of respiratory morbidity within 1 year of CA and its negative impact on pulmonary function and functional exercise performance at 4 years of age was most pronounced in the severe form (all P < 0.05).

CONCLUSIONS

Early assessments of neonatal respiratory status including Toce clinical score and the severity of BPD are valid to identify VLBW preterm infants who are at risk of adverse longitudinal respiratory health outcomes.

Respiratory Morbidity of Roadside Shopkeepers Exposed to Traffic-related Air Pollution in Bhopal, India

BACKGROUND

Traffic-related air pollution (TRAP) is a major source of ambient air pollution in urban areas. Shopkeepers of heavily trafficked roadside shops are persistently exposed to high levels of TRAP.

OBJECTIVES

To estimate the prevalence of respiratory morbidity in shopkeepers of shops in heavily trafficked roadside areas in Bhopal city (India) and to determine any association with long term exposure to TRAP.

METHODS

This cross-sectional study was conducted among 251 shopkeepers working in roadside shops of three major traffic corridors in Bhopal city. The demographic profile and prevalence of respiratory morbidity were collected by administering a validated questionnaire. The total exposure period (TEP) to TRAP was calculated for each individual by multiplying their work duration (in years) and average working hours per day. Odds ratios were calculated to estimate the association of TEP with respiratory morbidity.

RESULTS

The age of the study population was 44.8±13.5 years old and 95% were male. Nearly 55% of the shopkeepers reported at least one respiratory symptom. The prevalence of bronchial asthma, chronic bronchitis, breathlessness, and cough was 3.6% (95% confidence interval (CI): 1.9-6.7), 13.9% (95% CI: 10.2-18.8), 41.8% (95% CI: 35.9-48.0), and 18.3% (95% CI: 14.0-23.6), respectively. The adjusted risk ratios of bronchial asthma 2.17 (95% CI: 0.35-13.41), chronic bronchitis 1.42 (95% CI: 0.58-3.48), breathlessness 1.71 (95% CI: 0.94-3.11), and cough 0.97 (95% CI: 0.47-2.03) for those with a TEP over 100.

CONCLUSIONS

Shopkeepers working in heavily trafficked roadside shops suffer from respiratory morbidity and the risk increases with higher TEP. Total exposure period is a valuable indicator to estimate the effects of long-term TRAP exposure.

INFORMED CONSENT

Obtained.

ETHICS APPROVAL

The study was approved by the Institutional Ethics Committee of the National Institute for Research in Environmental Health (Bhopal, India).

COMPETING INTERESTS

The authors declare no competing financial interests.

Combined effect of coal dust exposure and smoking on the prevalence of respiratory impairment among coal miners of West Bengal, India

Accelerating prevalence of coal workers pneumoconiosis is considered as a serious occupational health problem. This cross-sectional study was designed to determine the prevalence of lung function impairment of underground coal miners in West Bengal, India. A total of 230 underground coal dust-exposed subjects and 130 nonexposed subjects were examined for lung function test and also information on sociodemographic characteristics, addiction, respiratory morbidity, personnel protective equipment and dust exposure were collected. Lung function impairment was significantly higher in exposed group than nonexposed group and personnel dust exposure level were exceeded above the NIOSH recommended level. In addition, respiratory ailments were found to be higher in exposed group than the nonexposed group. So, this study has established the need for an advanced understanding of the quantifiable and measurable remedies for protection of lung disorder of coal mine workers.

Respiratory Morbidity and Lung Function Analysis During the First 36 Months of Life in Infants With Bronchopulmonary Dysplasia (BPD)

Purpose: To explore the lung function of bronchopulmonary dysplasia (BPD) in premature infants to guide clinical prevention, early diagnosis and treatment. Methods: Thirty infants with BPD at 4-36 months of corrected gestational age were enrolled and divided into mild BPD and moderate and severe BPD groups. Thirty full-term healthy infants, and 30 non-BPD infants at 4-36 months of corrected gestational age were included as controls. Clinical information, including respiratory infections and re-hospitalization, was compared among these groups. Furthermore, lung function analysis was performed in the infants. Results: The upper respiratory tract infection rate and re-hospitalization rate were significantly higher in the infants with BPD than in the non-BPD infants. The tidal volume/kg, proportion of time to reach peak tidal expiratory flow/total expiratory time, tidal volume exhaled at peak tidal expiratory flow/total tidal volume in BPD group were significantly lower in the BPD group than those in non-BPD group. These values gradually decreased as the severity of BPD increased. The respiratory rate (RR) in BPD group was significantly higher than that in non-BPD group. As the severity of the BPD increased, slope of the descending branch of expiration of tidal breathing flow capacity ring (TBFVL) increased. Conclusion: There is a correlation between the severity of BPD and a poor prognosis of respiratory system. TBFVL can directly reflect the characteristics of Tidal Pulmonary Function in children with different degrees of BPD.

Fetal pulmonary artery acceleration/ejection time prognostic accuracy for respiratory complications in preterm prelabor rupture of membranes

Objective: To determine the prognostic accuracy of the fetal pulmonary artery acceleration time/ejection time (PATET) for the prediction of neonatal respiratory complications (NRCs) in pregnancies with preterm premature rupture of membranes (PPROM).Methods: This is a prospective cohort of singleton pregnancies complicated by PPROM managed in our institution from October 2015 to April 2018. Inclusion criteria included mothers from 13 to 46 years of age and singleton pregnancies with PATET measurements <7 days prior to delivery. PATET was obtained by placing the Doppler caliper in the main pulmonary artery proximal to the bifurcation of this vessel. NRC was defined as: need for ventilatory support, respiratory distress syndrome (RDS), or lung hypoplasia. Logistic regression models and area under the receiver operating characteristic curves (ROC) were utilized to determine the prognostic accuracy of PATET and gestational age for NRC and RDS.Results: Of 95 patients included, 46 had NRC (RDS = 33). PATET was a significant predictor of NRC (AUC 0.74; 95%CI: 0.61-0.83; p < .001) and RDS (AUC 0.69; 95%CI: 0.57-0.80; p = .021) in PPROM. Gestational age at delivery and gestational age at PPROM were also significantly associated with NRC and RDS. Their predictive accuracy for NRC was 0.87 and 0.84, and for RDS 0.85 and 0.86, respectively.Conclusions: PATET is a statistically significant predictor for NRC in pregnancies with PPROM; however, its clinical use may be limited as gestational age is a better predictor of these outcomes.Rationale: NRCs are common in pregnancies complicated by preterm prelabor rupture of membranes (PPROM). We aim to determine the prognostic accuracy of the fetal PATET for the prediction of neonatal NRC in these pregnancies. Our results indicate that PATET is a statistically significant predictor for NRC in pregnancies with PPROM; however, its clinical use may be limited, as gestational age is a better predictor of these outcomes.

Respiratory Morbidity Following Foreign Body Aspiration Among South Indian Children: A Descriptive Study

Aim

Our work aimed to study the clinical features and radiological signs of foreign body aspiration in South Indian children.

Materials and methods

We conducted this prospective cross-sectional study for one year in the Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India in 56 cases. Our study included children younger than 14 years attending our hospital with a history of foreign body aspiration with or without respiratory distress, suspected cases of foreign body aspiration showing evidence of unilateral hyperinflation with or without evidence of collapse of the opposite lungs on chest X-ray (posterior-anterior view), and unexplained cough associated with X-ray evidence of unilateral hyperinflation or bronchiectasis. Emergency and elective rigid bronchoscopy were performed as per the clinical scenario, and patients were discharged from the hospital after stabilization. They were asked to return for two-week, three-month, and six-month follow-up evaluations.

Results

The most common age group of patients with foreign body aspiration was six to 18 months old. A definite history of foreign body aspiration was obtained in only 32 patients (57%). Most patients (n = 22; 68.75%) presented to the hospital within one to seven days of the foreign body aspiration. Respiratory distress was the most common clinical feature, present in 96% of our patients. The most common radiographic feature in our study was obstructive emphysema, seen in 33 patients (58.9%). Foreign bodies were retrieved from 40 patients (71.4%), and no foreign body could be found via bronchoscopy in 16 patients. The most common foreign body was groundnut (n = 27; 67.5%). Only four patients had inorganic foreign bodies. The most common site of aspirated foreign bodies was the right main bronchus (n = 14; 35%). Only two patients (3.57%) had persistent pneumonia that cleared up radiologically after three months and was culture negative for bacteria.

Conclusions

Strong clinical suspicion of foreign body aspiration based on history and early bronchoscopy can reduce the morbidity and mortality due to foreign body aspiration in children.

Association of air quality with respiratory and cardiovascular morbidity rate in Delhi, India

The present study reports short-term impact of poor air quality on cardiovascular and respiratory morbidity rate in Delhi. The data on monthly count of patients visiting Out Patient Department (OPD) and hospital admission due to respiratory and cardiovascular illnesses from hospitals along with daily air quality data from air quality monitoring stations of Central Pollution Control Board (CPCB), Government of India, across Delhi were collected for the period 2008 to 2012. A semi-parametric Quasi-Poisson regression model was used to examine the association of high pollution episodes with relative risk of hospital OPD visit and hospital admission due to respiratory and cardiovascular diseases. This study has confirmed the substantial adverse health effects due to air pollution across criterion air pollutants. The study reports the short-term effects of air pollution on morbidity from a time-series study first time in India. The study findings illustrate the evidence of adverse health impact of air pollution from India to the global pool and can influence the policy makers to implement better air quality management system for Indian cities.

ABBREVIATIONS

OPD: Out Patient Department; IPD: Inpatient Department; RD: Respiratory Disease; CVD: Cardiovascular Disease; COPD: Chronic Obstructive Pulmonary Disease; CPCB: Central Pollution Control Board; NAAQMP: National Ambient Air Quality Monitoring Programme; NAAQS: National Ambient Air Quality Standards; RR; Relative Risk; IMD: Indian Meteorological Department; PM₁₀: Particulate Matter less than 10 μm in aerodynamic diameter; SO₂: Sulphur dioxide; NO₂: Nitrogen dioxide; CO: Carbon Monoxide; O₃: Ozone; DCE: Delhi College of Engineering; GTB Hospital: Guru Teg Bahadur Hospital; VPCH: Vallabhbhai Patel Chest Hospital; RMLH: Ram Manohar Lohia Hospital; SJH: Safdarjung Hospital; LNJPH: Lok Narayan Jai Prakash Hospital; GTBH: Guru Teg Bahadur Hospital; AH: Ambedkar Hospital; HRH: Hindu Rao Hospital; ESIH: ESI Hospital; SGRH: Sir Ganga Ram Hospital.

The association between gender and pediatric respiratory morbidity

OBJECTIVE

To evaluate the association between newborn gender and the risk for later pediatric respiratory morbidity.

STUDY DESIGN

A population based cohort analysis was performed by comparing the risk of long-term respiratory morbidity (until 18 years of age) according to gender. Respiratory morbidity included hospitalizations involving pneumonia, asthma, bronchitis, bronchiolitis, upper respiratory tract infection (URTI), influenza, and bronchiectasis. Deliveries occurred between the years 1991 and 2014 in a tertiary medical center. Kaplan-Meier survival curves were constructed to compare cumulative respiratory morbidity. A Cox proportional hazards model controlled for confounders.

RESULTS

During the study period 240 953 newborns met the inclusion criteria. Among them, 118 113 were females (49.0%) and 122 840 were males (51.0%). During the 18 years of follow-up, 13 719 (5.7%) different newborns were hospitalized with respiratory related morbidity. Males had significantly higher rates of respiratory morbidity as compared with females (6.4% vs 4.9% respectively, P < 0.001, OR 1.32, 95% CI 1.28-1.37). Specifically, pneumonia, bronchitis, asthma, bronchiolitis, and URTI were significantly more common in males. Males exhibited higher total cumulative respiratory morbidity (log rank P < 0.001), as well as higher cumulative morbidity in several sub-categories. These sub-categories included pneumonia, bronchitis, asthma, bronchiolitis, and URTI (P < 0.05 in all). The Cox regression model demonstrated male gender to be an independent risk factor for pediatric respiratory morbidity while adjusting for gestational age, birthweight, and other confounders (HR 1.29, 95% CI 1.25-1.34, P < 0.001).

CONCLUSIONS

Males are at an increased risk for pediatric respiratory morbidity, independent of obstetrical characteristics such as gestational age and birthweight.

Predictors of prolonged length of hospital stay or readmissions for acute viral lower respiratory tract infections among infants with a history of bronchopulmonary dysplasia

Length of hospital stay and readmissions are outcome measures that have been largely overlooked in many studies that have evaluated the clinical evolution of pediatric patients with bronchopulmonary dysplasia (BPD). The aim of the present study was to identify predictors of prolonged hospitalizations or readmissions for acute lower respiratory infections (ALRIs) in infants with BPD. In a prospective cohort study, we determined independent predictors of prolonged hospitalizations or readmissions for ALRIs during the first 2 years of life in a population of infants with BPD living in Bogota, Colombia. Of a total of 138 patients included in the study, 83 (60.1%) had at least one hospitalization for ALRI during the follow-up period. After controlling for potential confounders, we found that independent predictors of prolonged hospitalizations or readmissions for ALRIs included male gender (OR = 3.09; CI 95% 1.27-7.52; P = 0.013), ambulatory oxygen therapy between 90 and 119 days (OR = 3.21; CI 95% 1.00-10.24; P = 0.049), ambulatory oxygen therapy equal to or greater than 120 days (OR = 5.73; CI 95% 2.01-16.32; P = 0.001), gestational age at birth (OR = 1.35; CI 95% 1.03-1.76; P = 0.026), birth weight (OR = 0.997; CI 95% 0.996-0.999; P = 0.010), and duration of breastfeeding equal to or greater than 6 months (OR = 0.39; CI 95% 0.16-0.96; P = 0.039). The factors identified can be taken into account when planning policies to reduce duration of hospital stay and readmissions in infants with BPD.

Respiratory Morbidity in Children with Repaired Congenital Esophageal Atresia with or without Tracheoesophageal Fistula

Congenital esophageal atresia with or without tracheoesophageal fistula (CEA ± TEF) is a relatively common malformation that occurs in 1 of 2500–4500 live births. Despite the refinement of surgical techniques, a considerable proportion of children experience short- and long-term respiratory complications, which can significantly affect their health through adulthood. This review focuses on the underlying mechanisms and clinical presentation of respiratory morbidity in children with repaired CEA ± TEF. The reasons for the short-term pulmonary impairments are multifactorial and related to the surgical complications, such as anastomotic leaks, stenosis, and recurrence of fistula. Long-term respiratory morbidity is grouped into four categories according to the body section or function mainly involved: upper respiratory tract, lower respiratory tract, gastrointestinal tract, and aspiration and dysphagia. The reasons for the persistence of respiratory morbidity to adulthood are not univocal. The malformation itself, the acquired damage after the surgical repair, various co-morbidities, and the recurrence of lower respiratory tract infections at an early age can contribute to pulmonary impairment. Nevertheless, other conditions, including smoking habits and, in particular, atopy can play a role in the recurrence of infections. In conclusion, our manuscript shows that most children born with CEA ± TEF survive into adulthood, but many comorbidities, mainly esophageal and respiratory issues, may persist. The pulmonary impairment involves many underlying mechanisms, which begin in the first years of life. Therefore, early detection and management of pulmonary morbidity may be important to prevent impairment in pulmonary function and serious long-term complications. To obtain a successful outcome, it is fundamental to ensure a standardized follow-up that must continue until adulthood.

Should delivery timing for repeat cesarean be reconsidered based on dating criteria?

PURPOSE

We sought to examine if the method of pregnancy dating at five increasing term gestational ages is associated with increasing neonatal morbidity.

MATERIALS AND METHODS

A cohort of women who underwent elective repeat cesarean delivery at ≥37 weeks' gestation were identified from the NICHD MFMU Network registry. We excluded women who were in labor, those carrying a fetus with a congenital anomaly, those with a non-reassuring fetal heart tracing, and those with preeclampsia, preexisting chronic hypertension or diabetes. Composite neonatal morbidity was defined for our study as any of the following: NICU admission, hypotonia, meconium aspiration, seizures, need for ventilator support, NEC, RDS, TTN, hypoglycemia, or neonatal death. We compared composite neonatal morbidity rates among infants born at five different gestational age cutoffs according to their method of pregnancy dating.

RESULTS

At 39 and 40 weeks' gestation, the lowest rate of neonatal complications was seen in pregnancies dated by first trimester ultrasound (5.8% and 5.5%, respectively), while those with the highest neonatal morbidity rates were seen when dated by a second or third trimester ultrasound (8.1% and 6.0%, respectively); p < .001. Additionally within each pregnancy dating category, the neonatal morbidity rates declined from 37 to 40 weeks' gestation and then significantly increased at 41 + 0 weeks' gestation.

CONCLUSION

Even with suboptimal dating methods, amongst women undergoing elective repeat cesarean delivery, neonatal morbidity was lowest when delivery occurred between 40 and 40 + 6 weeks gestation.

Antenatal corticosteroids in the late preterm period: A prospective cohort study

OBJECTIVE

The study objective was to examine the effect of antenatal corticosteroids on the incidence of short-term neonatal morbidities in singletons born during the late preterm period.

STUDY DESIGN

This was a prospective cohort study of singleton gestations at risk of imminent delivery between 34 0/7 and 36 6/7 weeks. Short-term neonatal morbidities were compared between the corticosteroid exposed and non-exposed groups. The rates of Neonatal Morbidity Composite and Any Adverse Neonatal Morbidity were then compared between the two groups.

RESULTS

During the two-year study period, a total of 295 subjects were included. Of those, 74 were exposed to antenatal corticosteroids, while 221 cases constituted the non-exposed group. There was no statistically significant difference in the rate of Any Adverse Neonatal Morbidity (47.3% vs. 40.7% , p = 0.32) or the rate of Neonatal Morbidity Composite (34.4% vs. 37.8% , p = 0.59) between the two groups. Additionally, there was no statistically significant difference in the rates of neonatal intensive care unit admission, respiratory distress syndrome, transient tachypnea of the newborn, hypothermia, and need for phototherapy.

CONCLUSION

Administration of antenatal corticosteroids to parturients at risk of imminent delivery during the late preterm period does not appear to reduce short-term neonatal morbidities.

Gender Differences in Respiratory Morbidity and Mortality of Preterm Neonates

For the past century, researchers have underscored the "disadvantage" observed in respiratory morbidity and mortality of male newborns. In this contemporary review, we examine gender differences in preterm infant respiratory morbidity and mortality specifically appraising differences in the very low birth weight (VLBW) population as well as the late preterm (LPT) population. In the era of postnatal surfactant and antenatal corticosteroids, the gender gap in neonatal outcomes has not narrowed. Structural, physiologic, and hormonal sex differences may be at the root of this disparity. Further exploration into the origin of gender differences in respiratory morbidity and neonatal mortality will shape future therapies. These therapies may need to be gender specific to close the gender gap.

Late preterm neonatal morbidity in hypertensive versus normotensive women

OBJECTIVE

We estimated risks of late preterm (LP, 34°(/7)-36(6/7) weeks) delivery and neonatal respiratory and non-respiratory morbidity in women with mild and severe hypertension, in both low-risk and high-risk (history of chronic hypertension, preeclampsia (PE), or insulin-dependent diabetes in current pregnancy) cohorts.

STUDY DESIGN

This is a secondary analysis of two Maternal-Fetal Medicine Units Network randomized trials of aspirin to prevent PE. Women with non-anomalous singleton gestations delivered at ≥34 weeks were divided into three groups: normotensive, mild PE/gestational hypertension (GH), and severe PE/GH. Primary outcomes were respiratory (respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), or intubation) and non-respiratory (intraventricular hemorrhage, retinopathy of prematurity, small for gestational age (SGA) <10%, neonatal intensive care unit (NICU) admission, perinatal death, pulmonary hypertension, seizures, and 5 min Apgar <5) morbidity. Associations between LP delivery and risks of respiratory and non-respiratory morbidity were evaluated by fitting log-Binomial regression models before and after adjusting potential confounders.

RESULTS

Of 2781 women in the low-risk trial, mild and severe hypertension were diagnosed in 8.5% (n = 235) and 3.3% (n = 92), respectively. Respiratory morbidity was similar in all groups. Risks of non-respiratory morbidity were higher in the severe PE/GH group compared with normotensive women (28.3% vs. 16.8%, risk ratio 1.5, 95% confidence interval 1.1, 2.1). When restricting the analysis to late preterm infants, this risk was no longer present. Of the 1542 women in the high-risk trial, mild and severe hypertension were present in 16.6% (n = 256) and 11.9% (n = 184), respectively. Respiratory morbidity was again similar. Risks of non-respiratory morbidity were also not significantly increased in the high-risk cohort.

CONCLUSION

In both low- and high-risk women, mild PE/GH at ≥34 weeks is not associated with an increased risk of neonatal morbidity compared with normotensive women. Increased risk of composite neonatal morbidity related to severe PE/GH is confined to the subgroup of infants with non-respiratory morbidity, and disappears when including only late preterm infants.

Association Between Expiratory Central Airway Collapse and Respiratory Outcomes Among Smokers

IMPORTANCE

Central airway collapse greater than 50% of luminal area during exhalation (expiratory central airway collapse [ECAC]) is associated with cigarette smoking and chronic obstructive pulmonary disease (COPD). However, its prevalence and clinical significance are unknown.

OBJECTIVE

To determine whether ECAC is associated with respiratory morbidity in smokers independent of underlying lung disease.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of paired inspiratory-expiratory computed tomography images from a large multicenter study (COPDGene) of current and former smokers from 21 clinical centers across the United States. Participants were enrolled from January 2008 to June 2011 and followed up longitudinally until October 2014. Images were initially screened using a quantitative method to detect at least a 30% reduction in minor axis tracheal diameter from inspiration to end-expiration. From this sample of screen-positive scans, cross-sectional area of the trachea was measured manually at 3 predetermined levels (aortic arch, carina, and bronchus intermedius) to confirm ECAC (>50% reduction in cross-sectional area).

EXPOSURES

Expiratory central airway collapse.

MAIN OUTCOMES AND MEASURES

The primary outcome was baseline respiratory quality of life (St George's Respiratory Questionnaire [SGRQ] scale 0 to 100; 100 represents worst health status; minimum clinically important difference [MCID], 4 units). Secondary outcomes were baseline measures of dyspnea (modified Medical Research Council [mMRC] scale 0 to 4; 4 represents worse dyspnea; MCID, 0.7 units), baseline 6-minute walk distance (MCID, 30 m), and exacerbation frequency (events per 100 person-years) on longitudinal follow-up.

RESULTS

The study included 8820 participants with and without COPD (mean age, 59.7 [SD, 6.9] years; 4667 [56.7%] men; 4559 [51.7%] active smokers). The prevalence of ECAC was 5% (443 cases). Patients with ECAC compared with those without ECAC had worse SGRQ scores (30.9 vs 26.5 units; P < .001; absolute difference, 4.4 [95% CI, 2.2-6.6]) and mMRC scale scores (median, 2 [interquartile range [IQR], 0-3]) vs 1 [IQR, 0-3]; P < .001]), but no significant difference in 6-minute walk distance (399 vs 417 m; absolute difference, 18 m [95% CI, 6-30]; P = .30), after adjustment for age, sex, race, body mass index, forced expiratory volume in the first second, pack-years of smoking, and emphysema. On follow-up (median, 4.3 [IQR, 3.2-4.9] years), participants with ECAC had increased frequency of total exacerbations (58 vs 35 events per 100 person-years; incidence rate ratio [IRR], 1.49 [95% CI, 1.29-1.72]; P < .001) and severe exacerbations requiring hospitalization (17 vs 10 events per 100 person-years; IRR, 1.83 [95% CI, 1.51-2.21]; P < .001).

CONCLUSIONS AND RELEVANCE

In a cross-sectional analysis of current and former smokers, the presence of ECAC was associated with worse respiratory quality of life. Further studies are needed to assess long-term associations with clinical outcomes.

Childhood Respiratory Morbidity after Late Preterm and Early Term Delivery: a Study of Medicaid Patients in South Carolina

BACKGROUND

There is a growing body of research documenting an increased risk of neonatal morbidity for late preterm infants (LPI, 34(0/7) weeks to 36(6/7) weeks) and early term infants (ETI, 37(0/7) weeks to 38(6/7) weeks) compared with term infants (TI, 39(0/7) to 41(6/7) ); however, there has been little research on outcomes beyond the first year of life. In this study, we examined respiratory outcomes of LPI and ETI in early childhood.

METHODS

South Carolina Medicaid claims data for maternal delivery and infant birth hospitalisations were linked to vital records data for the years 2000 through 2003. Medicaid claims for all infants were then followed until their fifth birthday or until a break in their eligibility. Infants born between 34(0/7) and 41(6/7) weeks were eligible. Infants with congenital anomaly, birthweight below 500 g or above 6000 g, and multiple births were excluded. We fit Cox proportional hazard models from which adjusted hazard ratio (HR) and 95% confidence interval (CI) were derived.

RESULTS

A total of 3476 LPI, 12 398 ETI, and 25 975 term infants were included. Both LPI and ETI were associated with an increased risk for asthma (LPI: HR 1.24, 95% CI 1.10, 1.40; ETI: HR 1.12, 95% CI 1.06, 1.19), and bronchitis (LPI: HR 1.15, 95% CI 1.00, 1.34; ETI: HR 1.13, 95% CI 1.05, 1.2) at 3 to 5 years of age.

CONCLUSIONS

Late preterm infants and early term infants are at increased risk for asthma and bronchitis.

Respiratory outcomes of the surfactant positive pressure and oximetry randomized trial (SUPPORT)

OBJECTIVE

To explore the early childhood pulmonary outcomes of infants who participated in the National Institute of Child Health and Human Development's Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial (SUPPORT), using a factorial design that randomized extremely preterm infants to lower vs higher oxygen saturation targets and delivery room continuous positive airway pressure (CPAP) vs intubation/surfactant.

STUDY DESIGN

The Breathing Outcomes Study, a prospective secondary study to the Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial, assessed respiratory morbidity at 6-month intervals from hospital discharge to 18-22 months corrected age (CA). Two prespecified primary outcomes-wheezing more than twice per week during the worst 2-week period and cough longer than 3 days without a cold-were compared for each randomized intervention.

RESULTS

One or more interviews were completed for 918 of the 922 eligible infants. The incidences of wheezing and cough were 47.9% and 31.0%, respectively, and did not differ between the study arms of either randomized intervention. Infants randomized to lower vs higher oxygen saturation targets had a similar risk of death or respiratory morbidity (except for croup and treatment with oxygen or diuretics at home). Infants randomized to CPAP vs intubation/surfactant had fewer episodes of wheezing without a cold (28.9% vs 36.5%; P<.05), respiratory illnesses diagnosed by a doctor (47.7% vs 55.2%; P<.05), and physician or emergency room visits for breathing problems (68.0% vs 72.9%; P<.05) by 18-22 months CA.

CONCLUSION

Treatment with early CPAP rather than intubation/surfactant is associated with less respiratory morbidity by 18-22 months CA. Longitudinal assessment of pulmonary morbidity is necessary to fully evaluate the potential benefits of respiratory interventions for neonates.

Chronic effects of ambient air pollution on respiratory morbidities among Chinese children: a cross-sectional study in Hong Kong

BACKGROUND

The chronic health effects from exposure to ambient air pollution are still unclear. This study primarily aims to examine the relationship between long-term exposure to ambient air pollution and respiratory morbidities in Chinese children.

METHODS

A cross-sectional study was conducted among 2,203 school children aged 8-10 in three districts with different air pollution levels in Hong Kong. Annual means for ambient PM10, SO2, NO2 and O3 in each district were used to estimate participants' individual exposure. Two questionnaires were used to collect children's respiratory morbidities and other potential risk factors. Multivariable logistic regression was fitted to estimate the risks of air pollution for respiratory morbidities.

RESULTS

Compared to those in the low-pollution district (LPD), girls in the high-pollution district (HPD) were at significantly higher risk for cough at night (ORadj. = 1.81, 95% CI: 1.71-2.78) and phlegm without colds (ORadj. = 3.84, 95% CI: 1.74-8.47). In addition, marginal significance was reached for elevated risks for asthma, wheezing symptoms, and phlegm without colds among boys in HPD (adjusted ORs: 1.71-2.82), as well as chronic cough among girls in HPD (ORadj. = 2.03, 95% CI: 0.88-4.70).

CONCLUSIONS

Results have confirmed certain adverse effects on children's respiratory health from long-term exposure to ambient air pollution. PM10 may be the most relevant pollutant with adverse effects on wheezing and phlegm in boys. Both PM10 and NO2 may be contributing to cough and phlegm in girls.

Effect of reductions in biomass fuel exposure on symptoms of sleep apnea in children living in the peruvian andes: a preliminary field study

BACKGROUND

Multiple studies have evaluated the prevalence of sleep apnea in pediatric populations. Although environmental exposures to cigarette smoke (ECS) increase the risk of habitual snoring, no studies have thus far examined the potential contribution of indoor pollution in children.

OBJECTIVE

To determine the frequency of symptoms associated with sleep apnea in children exposed to traditional wood-burning stoves to open fire, and assess whether symptoms subside following implementation of improved less environmentally contaminating stoves.

METHODS AND MATERIALS

Residents of the communities of Chucllapampa, Sayhuapata, and Alparcuna in Cangallo province, department of Ayacucho, Peru were surveyed on two occasions within 12 months before and after the installation of an improved Inkawasi wood stove. The frequency of symptoms associated with sleep apnea was assessed in all children <15 years of age using a previously validated questionnaire.

RESULTS

Parents of 59 children (62.7% males; mean age 7.76 ± 4.2 years) were interviewed representing >97% of the children in those small villages. The most common symptoms included nighttime awakenings, habitual snoring, repetitive movements during sleep, nasal congestion, and sore throat. After implementation of improved stoves in the homes, snoring (52.5% vs. 18.2%, P < 0.0001) nasal congestion (33.9% vs. 1.8%, P < 0.0001), behavioral hyperactivity (28.8% vs. 3.8%, P < 0.002), nighttime awakenings (42.4% vs. 1.7%, P < 0.0001), sore throat (38.2% vs. 5.5% P < 0.0001), breathing through the mouth during the day (33.9% vs. 1.8%, P < 0.001), daytime sleepiness (21.1% vs. 1.8%, P < 0.003), and falling asleep at school (14.6% vs. 0%, P < 0.03) were all significantly improved.

CONCLUSIONS

Children exposed to traditional biomass fuel stoves had a higher frequency of symptoms related to sleep apnea, which decrease with improvements in biomass pollution.

Respiratory morbidity among welders in the shipbuilding industry, Goa

Context:

Welding is pivotal in shipbuilding. The fumes and gases involved in welding may cause respiratory morbidity.

Aim:

To study the prevalence of respiratory morbidity (RM) among welders vis à vis among nonwelders and its association with certain relevant factors.

Settings and Design:

A cross-sectional study of 276 welders and 276 nonwelders was conducted in the shipbuilding industry.

Materials and Methods:

An interviewer-administered questionnaire was followed by spirometric examination.

Statistical Analysis:

Odds ratio and its 95% CI and two-way ANOVA.

Results:

Prevalence of RM was found to be significantly higher among welders compared to nonwelders (who were comparable in age, duration of employment (DOE) and smoking habits,) with odds ratio (OR) of 1.78 (95% confidence interval (CI):1.20-2.63). Obstructive type of RM was predominant in both welders (26% (n = 73)) and nonwelders (17% (n = 49)) with welders being at a significantly higher risk (OR = 1.66 (95%: 1.10-2.49)). RM was commoner after the 40 years of age or after 20 years of employment in both groups. Smoking was associated with RM among welders (OR = 1.48, 95% CI: 1.24-1.75) as well as nonwelders (OR = 2.83, 95% CI: 2.26-3.54). Work-related respiratory symptoms (WRRS) was not found to be related to RM (OR = 1.69, 95% CI: 1.00-2.84). Consistent use of personal protective equipment (PPE) was protective against RM in welders (OR = 0.33, 95% CI: 0.28-0.37).

Conclusion:

Welders had a greater burden of RM and this was related to increasing age, DOE, smoking and inconsistent use of PPE. WRRS were not indicative of RM.

Respiratory morbidity due to ammonia exposure among the employees of a urea manufacturing industry located in western part of India

Ammonia is produced in the fertilizer industry. The amount of ammonia inhaled by employees of a urea manufacturing industry is very high. It would be interesting to study whether such an amount has any impact on the employees working there for many years. This study explores the magnitude of respiratory morbidity among employees of a urea manufacturing industry and to establish its association with exposure to ammonia. Data was collected related to significant respiratory illnesses of all the employees over a period of 10 years using computer-based medical record system of the industry′s hospital. The results obtained from the data analysis showed that there is no cause and effect relationship between exposure to ammonia and respiratory morbidity. Thus it was advised to the medical authority at industry to go for mass treatment with anthelmintics and that all the employees should be screened for specific allergens and this information should be used while managing respiratory morbidity.

The lag structure and the general effect of ozone exposure on pediatric respiratory morbidity

Up to now no study has investigated the lag structure of children's respiratory morbidity due to surface ozone. In the present study, we investigate the lag structure and the general effect of surface ozone exposure on children and adolescents' respiratory morbidity using data from a particularly well suited area in southern Europe to assess the health effects of surface ozone. The effects of surface ozone are estimated using the recently developed distributed lag non-linear models, allowing for a relatively long timescale, while controlling for weather effects, a range of other air pollutants, and long and short term patterns. The public health significance of the estimated effects is higher than has been previously reported in the literature, providing evidence contrary to the conjecture that the surface ozone-morbidity association is mainly due to short-term harvesting. In fact, our data analysis reveals that the effects of surface ozone at medium and long timescales (harvesting-resistant) are substantially larger than the effects at shorter timescales (harvesting-prone), a finding that is consistent with all children and adolescents being affected by high surface ozone concentrations, and not just the very frail.

Incidence of silicosis in flourmill workers

BACKGROUND

Silicosis is an ancient occupational illness reported in silica mill workers, agate stone workers, slate pen workers and mining industry. However its association in flour mill workers has not been established.

AIMS

To study the incidence of silicosis and respiratory morbidity in flour mill workers.

SETTINGS AND DESIGN

A prospective study of 56 flour mill workers working with open silica grinding stones was undertaken.

MATERIALS AND METHODS

56 flour mill workers who volunteered following information regarding the study purpose were recruited from the community. Detailed clinical and occupational history, lung functions, chest x-ray, and high resolution computed tomography (HRCT) were done. Diagnosis was made on the basis of radiological findings.

STATISTICAL ANALYSIS

Data analysis was done with the help of the statistical package for social sciences software. The Chi-square test was used for determining the relationship between qualitative data and descriptive statistics was used where required.

RESULTS

93% had respiratory symptoms that included cough (66.1%), dyspnea (75%), chest pain (17.1%), and rhinorrhea (46.4%). Radiological abnormalities were noted in chest X-ray (60.7%) and HRCT (81.48%). A significant correlation was seen between duration of exposure and HRCT abnormalities. Lung functions revealed obstruction in 28.5% subjects, restriction in 19%, mixed ventilatory defects in 21.4%, while 18.9% had a reduced diffusion capacity.

CONCLUSION

Incidence of silicosis in our study on flour mill workers working with silica containing grinding stones was 30.4%. They had high respiratory morbidity (93%) cough and dyspnea being predominant symptoms. Duration of exposure correlates with radiological findings and increased incidence of silicosis.

Respiratory morbidity and lung function in preterm infants of 32 to 36 weeks' gestational age

Normal lung development follows a series of orchestrated events. Premature birth interrupts normal in utero lung development, which results in significant alterations in lung function and physiology. Increasingly, there are reports documenting the broad range of complications experienced by infants aged 34 to 36 weeks' gestational age (GA). Our objective was to summarize the evidence demonstrating respiratory system vulnerability in infants aged 34 to 36 weeks' GA and to review the developmental and physiologic principles that underlie this vulnerability. A comprehensive search for studies that reported epidemiologic data and respiratory morbidity was conducted on the PubMed, Medline, Ovid Biosis, and Embase databases from 2000 to 2009 by using medical subject headings "morbidity in late preterm infants," "preterm infants and lung development," "prematurity and morbidity," and "prematurity and lung development." Because the number of studies exclusive to infants aged 34 to 36 weeks' GA was limited, selected studies also included infants aged 32 to 36 weeks' GA. Of the 24 studies identified, 16 were retrospective population-based cohort studies; 8 studies were observational. These studies consistently revealed that infants born at 32 to 36 weeks' GA, including infants of 34 to 36 weeks' GA, experience substantial respiratory morbidity compared with term infants. Levels of morbidity were, at times, comparable to those observed in very preterm infants. The developmental and physiologic mechanisms that underlie the increased morbidity rate and alterations in respiratory function are discussed. We also present evidence to demonstrate that the immaturity of the respiratory system of infants 34 to 36 weeks' GA at birth results in increased morbidity in infancy and leads to deficits in lung function that may persist into adulthood.

Daycare attendance and risk for respiratory morbidity among young very low birth weight children

Daycare attendance and very low birth weight (VLBW, < or =1,500 g) are associated with respiratory morbidity during childhood. The objective of this study was to evaluate whether daycare attendance is associated with even higher risk for respiratory problems among VLBW children. We hypothesized that VLBW children attending daycare, in a private home or daycare center, are at higher risk for respiratory problems than VLBW children not attending daycare. We also investigated whether the effect of daycare is independent or synergistic with respiratory risk resulting from being VLBW, as indicated by having bronchopulmonary dysplasia (BPD) as a neonate. We conducted a prospective study of VLBW children followed from birth to age 2-3 (N = 715). Logistic regression was used to evaluate the relationship between daycare attendance and respiratory problems, adjusting for known neonatal risk factors for poor respiratory outcomes. Attending daycare in either a private home or in a daycare center was significantly associated with higher risk of lower respiratory infections than never attending. Attending a daycare center was also associated with higher risk for wheezy chest, cough without a cold, and respiratory medication use. While having BPD was associated with increased risk for respiratory problems, daycare attendance and BPD were not found to be synergistic risk factors for respiratory problems among VLBW children, but acted independently to increase risk. This implies that the increase in risk for respiratory problems associated with daycare attendance may be similar among VLBW children and those of normal birth weight.

Symptoms and medication use in children with asthma and traffic-related sources of fine particle pollution

BACKGROUND

Exposure to ambient fine particles [particulate matter < or = 2.5 microm diameter (PM(2.5))] is a potential factor in the exacerbation of asthma. National air quality particle standards consider total mass, not composition or sources, and may not protect against health impacts related to specific components.

OBJECTIVE

We examined associations between daily exposure to fine particle components and sources, and symptoms and medication use in children with asthma.

METHODS

Children with asthma (n = 149) 4-12 years of age were enrolled in a year-long study. We analyzed particle samples for trace elements (X-ray fluorescence) and elemental carbon (light reflectance). Using factor analysis/source apportionment, we identified particle sources (e.g., motor vehicle emissions) and quantified daily contributions. Symptoms and medication use were recorded on study diaries. Repeated measures logistic regression models examined associations between health outcomes and particle exposures as elemental concentrations and source contributions.

RESULTS

More than half of mean PM(2.5) was attributed to traffic-related sources motor vehicles (42%) and road dust (12%). Increased likelihood of symptoms and inhaler use was largest for 3-day averaged exposures to traffic-related sources or their elemental constituents and ranged from a 10% increased likelihood of wheeze for each 5-microg/m(3) increase in particles from motor vehicles to a 28% increased likelihood of shortness of breath for increases in road dust. Neither the other sources identified nor PM(2.5) alone was associated with increased health outcome risks.

CONCLUSIONS

Linking respiratory health effects to specific particle pollution composition or sources is critical to efforts to protect public health. We associated increased risk of symptoms and inhaler use in children with asthma with exposure to traffic-related fine particles.

Neonatal morbidity and mortality after elective cesarean delivery

This article explores the effects of elective cesarean delivery (ECD) at term on neonatal morbidity and mortality. Available data have limitations, and do not provide conclusive evidence regarding the safety of planned ECD versus planned vaginal delivery. Some data suggest an association between ECD and increased neonatal respiratory morbidity and lacerations, and possibly decreased central and peripheral nervous system injury. Potentially increased risks of neonatal mortality with ECD at term may be counterbalanced by risks for fetal demise in ongoing pregnancies. Patients and physicians considering ECD should review competing risks and benefits; further research is needed to inform these discussions.