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- Inequities in Ambulatory Care and the Relationship Between Socioeconomic Status and Respiratory Hospitalizations: A Population-Based Study of a Canadian City. [JOURNAL ARTICLE]
- Ann Fam Med 2014 Sep; 12(5):402-407.
Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care-sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations.Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease-related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient's usual physician (eg, payment mechanism, sex, years in practice).We included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93).In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care-sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor.
- Genetic factors explain half of all variance in serum eosinophil cationic protein. [JOURNAL ARTICLE]
- Clin Exp Allergy 2014 Oct 29.
Eosinophil cationic protein (ECP) is one of four basic proteins of the secretory granules of eosinophils. It has a variety of functions associated with inflammatory responses. Little is known about the causes for variation in serum ECP levels.To identify factors associated with variation in serum ECP and to determine the relative proportion of the variation in ECP due to genetic and non-genetic factors, in an adult twin sample.A sample of 575 twins, selected through a proband with self-reported asthma, had serum ECP, lung function, airway responsiveness to methacholine, exhaled nitric oxide, and skin test reactivity, measured. Linear regression analysis and variance component models were used to study factors associated with variation in ECP and the relative genetic influence on ECP levels.Sex (regression coefficient =-0.107, p<0.001), BMI (0.007, p=0.028) and airway responsiveness to methacholine (0.074, p=0.001) were significantly associated with ECP. Adjusted for these factors, ECP correlated 0.53 (p<0.001) and 0.27 (p=0.001) in monozygotic and dizygotic twins, respectively (p-value for difference=0.05). According to the most parsimonious variance component model, genetic factors accounted for 57% (CI: 42-72%, p<0.001) of the variance in ECP levels, whereas the remainder (43%) was ascribable to non-shared environmental factors. The genetic correlation between ECP and airway responsiveness to methacholine was statistically non-significant (r=-0.11, p=0.50).Around half of all variance in serum ECP is explained by genetic factors. Serum ECP is influenced by sex, BMI and airway responsiveness. Serum ECP and airway responsiveness seem not to share genetic variance. This article is protected by copyright. All rights reserved.
- Increases in Exhaled Nitric Oxide After Acute Stress: Association With Measures of Negative Affect and Depressive Mood. [JOURNAL ARTICLE]
- Psychosom Med 2014 Oct 28.
Increases in fractional exhaled nitric oxide (FeNO) have been observed after acute laboratory stress, which could indicate a strengthening of immune defenses in acute stress because of the quick onset of the response and the role of nitric oxide in airway-protective functions. In addition, because sustained psychological distress and depression are known to deteriorate immune defenses systems, they may dampen the FeNO response to acute stress.FeNO and negative affect were measured before and after a speech and mental arithmetic stressor. We examined the association of stress-induced FeNO changes with momentary negative affect and questionnaires of perceived stress, anxious mood, and depressive mood in 39 asthma patients and 41 healthy controls.FeNO increased from baseline to stress in participants with asthma (from 3.38 [0.102] to 3.46 [0.103] ln(ppb)) and controls (2.86 [0.098] to 2.92 [0.099]; F(4,141) = 3.26, p = .014), but the magnitude of the FeNO response did not differ between groups (F < 1). Only low levels of depressive mood were associated with FeNO increases after stress (most pronounced at 0 minute poststress; t(76) = 3.87, p < .001). In contrast, only higher perceived stress was associated with FeNO increases (most pronounced at 0 minute poststress; t(75) = 4.09, p < .001), and momentary negative affect was associated with higher FeNO throughout assessments (β = 0.08, t(114) = 8.27, p = .005). Associations of FeNO with psychological variables were largely unrelated to asthma status and inhaled corticosteroid use.Depressive mood is associated with a reduced mobilization of airway nitric oxide in acute stress, whereas other indicators of negative affect are positively associated with overall FeNO levels and reactivity.
- Association Between Eczema and Increased Fracture and Bone or Joint Injury in Adults: A US Population-Based Study. [JOURNAL ARTICLE]
- JAMA Dermatol 2014 Oct 29.
Adults with eczema have multiple risk factors for accidental injury. However, little is known about the risk of injury in adult patients with eczema.To determine whether adult eczema is associated with an increased risk of injury.A prospective questionnaire-based study using the 2012 National Health Interview Survey among a nationally representative sample of 34 500 adults aged 18 to 85 years with a history of eczema in the past 12 months.History of fracture and bone or joint injury (FBJI) and other injury causing limitation.The prevalences of eczema and any injury causing limitation were 7.2% (95% CI, 6.9%-7.6%) and 2.0% (95% CI, 1.9%-2.2%), respectively. An FBJI causing limitation was reported by 1.5% (95% CI, 1.3%-1.7%), while other types of injury causing limitation occurred in 0.6% (95% CI, 0.5%-0.7%). Adults with eczema had higher odds of any injury causing limitation (survey logistic regression adjusted odds ratio [aOR], 1.44; 95% CI, 1.07-1.94), particularly FBJI (aOR, 1.67; 95% CI, 1.21-2.33), in models controlling for sociodemographics, asthma, hay fever, food allergies, and psychiatric and behavioral disorders. The prevalence of FBJI causing limitation increased gradually with age, peaking at 50 to 69 years and decreasing thereafter. Significant interactions were observed between eczema and fatigue or sleep symptoms, such that adults with eczema and fatigue (aOR, 1.59; 95% CI, 1.16-2.19), daytime sleepiness (aOR, 1.81; 95% CI, 1.28-2.55), or insomnia (aOR, 1.74; 95% CI, 1.28-2.37) had higher rates of FBJI compared with those with sleep symptoms and no eczema. Adults with both eczema and psychiatric and behavioral disorders (aOR, 2.15; 95% CI, 1.57-2.93) had higher rates of FBJI compared with those with eczema (aOR, 1.39; 95% CI, 1.19-1.61) or psychiatric and behavioral disorders (aOR, 1.58; 95% CI, 1.36-1.83) alone.The results of this study suggest that eczema in adulthood is a previously unrecognized risk factor for fracture and other injury causing limitation. Future studies are needed to confirm these associations. The findings may warrant the development of preventive measures for injury risk reduction in adult patients with eczema.
- Vitamin D Receptor ApaI a Allele Is Associated with Better Childhood Asthma Control and Improvement in Ability for Daily Activities. [JOURNAL ARTICLE]
- OMICS 2014 Oct 29.
Abstract Vitamin D levels have been suggested as a marker of disease severity in asthmatic children. Our aim was to investigate possible associations between the vitamin D receptor (VDR) FokI, BsmI, ApaI, and TaqI polymorphisms and asthma susceptibility and control in children. 127 Greek children with asthma and 91 healthy controls were genotyped for VDR FokI, BsmI ApaI, and TaqI polymorphisms using Sequenom MassARRAY iPLEX platform. Asthma control was assessed according to the Global Initiative for Asthma guidelines (GINA) and Childhood Asthma Control Test (C-ACT) and, for the first time, tested for its possible association with VDR SNPs. Asthmatic children were grouped as "controlled (n=49)", "partially controlled (n=38)," and "uncontrolled (n=40)," according to GINA classification. No association was found between VDR polymorphisms and asthma prevalence. Asthmatic children with the VDR ApaI aa genotype had significantly higher C-ACT score compared with asthmatic children carrying the AA/AC VDR ApaI genotypes (p=0.011). The frequency of VDR ApaI aa genotype was significantly higher in controlled asthma group (n=92) than uncontrolled asthma group (n=35), according to C-ACT (24.5% vs 0.0%, p<0.001) and GINA (32.7% vs 7.5%, p=0.001). Also, VDR ApaI aa genotype was negatively associated with limitation in daily activities because of asthma (p=0.004). VDR ApaI aa genotype was positively associated with well-controlled asthma according to GINA and C-ACT questionnaire and negatively associated with decreased limitation in daily activities in asthmatic children, further supporting the importance of Vitamin D pathway in asthma.
- Guanylyl Cyclase Activation Reverses Resistive Breathing-induced Lung Injury and Inflammation. [JOURNAL ARTICLE]
- Am J Respir Cell Mol Biol 2014 Oct 29.
Rationale: Inspiratory resistive breathing (RB), encountered in obstructive lung diseases, induces lung injury. Soluble Guanylyl Cyclase (sGC)/cGMP pathway is downregulated in chronic and acute animal models of RB such as asthma, COPD and in endotoxin-induced acute lung injury. Objectives: i) To characterize the effects of increased concurrent inspiratory and expiratory resistance in mice, via tracheal banding, ii) To investigate the contribution of the sGC/cGMP pathway in in RB-induced lung injury. Methods and Main Results: Anesthetized C57BL/6 mice underwent RB achieved by restricting tracheal surface area to 50% (tracheal banding). RB for 24 hours resulted in increased bronchoalveolar lavage fluid cellularity and protein content, in marked leukocyte infiltration in the lungs and perturbed respiratory mechanics (increased tissue resistance and elasticity, shifted static pressure volume curve right and downwards, decreased static compliance), consistent with the presence of acute lung injury. RB downregulated the sGC expression in the lung. All manifestations of lung injury caused by RB were exacerbated by the administration of the sGC inhibitor, ODQ, or when RB was performed using sGC α1 knockout mice. Conversely, restoration of sGC signalling by prior administration of the sGC activator BAY 58-2667 prevented the RB-induced lung injury. Strikingly, direct pharmacological activation of sGC with BAY 58-2667 24h post-RB reversed, within 6 hours, the established lung injury. Conclusions: These findings raise the possibility that pharmacological targeting of the sGC/cGMP axis could be used to ameliorate lung dysfunction in obstructive lung diseases.
- Canadian hereditary angioedema guideline. [Journal Article]
- Allergy Asthma Clin Immunol 2014; 10(1):50.
Hereditary angioedema (HAE) is a disease which is associated with random and often unpredictable attacks of painful swelling typically affecting the extremities, bowel mucosa, genitals, face and upper airway. Attacks are associated with significant functional impairment, decreased Health Related Quality of Life, and mortality in the case of laryngeal attacks. Caring for patients with HAE can be challenging due to the complexity of this disease. The care of patients with HAE in Canada is neither optimal nor uniform across the country. It lags behind other countries where there are more organized models for HAE management, and where additional therapeutic options are licensed and available for use. The objective of this guideline is to provide graded recommendations for the management of patients in Canada with HAE. This includes the treatment of attacks, short-term prophylaxis, long-term prophylaxis, and recommendations for self-administration, individualized therapy, quality of life, and comprehensive care. It is anticipated that by providing this guideline to caregivers, policy makers, patients and their advocates, that there will be an improved understanding of the current recommendations regarding management of HAE and the factors that need to be considered when choosing therapies and treatment plans for individual patients. The primary target users of this guideline are healthcare providers who are managing patients with HAE. Other healthcare providers who may use this guideline are emergency physicians, gastroenterologists, dentists and otolaryngologists, who will encounter patients with HAE and need to be aware of this condition. Hospital administrators, insurers and policy makers may also find this guideline helpful.
- Risk factors for asthma exacerbation in patients presenting to an emergency unit of a national referral hospital in Kampala, Uganda. [Journal Article]
- Afr Health Sci 2014 Sep; 14(3):707-15.
Asthma exacerbations are caused by a variety of risk factors. Reducing exposure to these risk factors improves the control of asthma and reduces medication needs. Knowledge of the particular risk factors is essential in formulating controlling and treatment protocols. This study set out to determine the risk factors for asthma exacerbations in patients presenting to the emergency unit of Mulago Hospital.An unmatched case-control study involving 43 cases and 43 controls was conducted from November 2011 through February 2012. Asthma patients with exacerbations presenting to Mulago hospital's emergency unit were chosen as cases. The controls were asthma patients recruited from the hospital's outpatient department who had not had an exacerbation in the past 7 days. The study variables were age, sex, level of education, adherence to treatment, exercise, upper respiratory tract infections, household pets, smoking, strong emotions, exposure to in house wood or charcoal burning, weather, use of corticosteroids, beta-blockers and non-steroidal anti-inflammatory drugs. Univariate and multivariate statistical analysis was done using SPSS version 16 to identify independent risk factors for exacerbations.Lack of corticosteroid use (OR =22.109; 95% Confidence interval 6.952 to 70.315; p<0.001) and presence of upper respiratory tract infections (OR 4.516; CI 1.258-16.213; p=0.018) were significantly associated with exacerbations.Lack of corticosteroid use and upper respiratory tract infections are associated with exacerbations in asthma patients presenting to the Emergency unit of Mulago Hospital.
- [Non-invasive ventilation.] [JOURNAL ARTICLE]
- Ugeskr Laeger 2014 May 26; 176(22)
Within the last decade the use of non-invasive ventilation has expanded. This article reviews the studies on non-invasive ventilation in the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary oedema, acute respiratory distress syndrome, asthma and neuromuscular disease. Its beneficial effect has primarily been found in exacerbations of COPD where it reduces mortality with a number needed to treat of ten when added to standard medical treatment. No other conclusive evidence of the superiority of non-invasive ventilation compared to other modalities has been shown.
- Characterization of cleaning and disinfecting tasks and product use among hospital occupations. [JOURNAL ARTICLE]
- Am J Ind Med 2014 Oct 28.
Healthcare workers have an elevated prevalence of asthma and related symptoms associated with the use of cleaning/disinfecting products. The objective of this study was to identify and characterize cleaning/disinfecting tasks and products used among hospital occupations.Workers from 14 occupations at five hospitals were monitored for 216 shifts, and work tasks and products used were recorded at five-minute intervals. The major chemical constituents of each product were identified from safety data sheets.Cleaning and disinfecting tasks were performed with a high frequency at least once per shift in many occupations. Medical equipment preparers, housekeepers, floor strippers/waxers, and endoscopy technicians spent on average 108-177 min/shift performing cleaning/disinfecting tasks. Many occupations used products containing amines and quaternary ammonium compounds for >100 min/shift.This analysis demonstrates that many occupations besides housekeeping incur exposures to cleaning/disinfecting products, albeit for different durations and using products containing different chemicals. Am. J. Ind. Med. © 2014 Wiley Periodicals, Inc.