Meredith C. McCormack

Neighborhood poverty, urban residence, race/ethnicity, and asthma: Rethinking the inner-city asthma epidemic.

BACKGROUNDnAlthough it is thought that inner-city areas have a high burden of asthma, the prevalence of asthma in inner cities across the United States is not known.nnnOBJECTIVEnWe sought to estimate the prevalence of current asthma in US children living in inner-city and non-inner-city areas and to examine whether urban residence, poverty, or race/ethnicity are the main drivers of asthma disparities.nnnMETHODSnThe National Health Interview Survey 2009-2011 was linked by census tract to data from the US Census and the National Center for Health Statistics. Multivariate logistic regression models adjusted for sex; age; race/ethnicity; residence in an urban, suburban, medium metro, or small metro/rural area; poverty; and birth outside the United States, with current asthma and asthma morbidity as outcome variables. Inner-city areas were defined as urban areas with 20% or more of households at below the poverty line.nnnRESULTSnWe included 23,065 children living in 5,853 census tracts. The prevalence of current asthma was 12.9% in inner-city and 10.6% in non-inner-city areas, but this difference was not significant after adjusting for race/ethnicity, region, age, and sex. In fully adjusted models black race, Puerto Rican ethnicity, and lower household income but not residence in poor or urban areas were independent risk factors for current asthma. Household poverty increased the risk of asthma among non-Hispanics and Puerto Ricans but not among other Hispanics. Associations with asthma morbidity were very similar to those with prevalent asthma.nnnCONCLUSIONSnAlthough the prevalence of asthma is high in some inner-city areas, this is largely explained by demographic factors and not by living in an urban neighborhood.

Sleep Quality and Health-Related Quality of Life in Idiopathic Pulmonary Fibrosis

BACKGROUNDnIdiopathic pulmonary fibrosis (IPF) is a progressive disorder resulting in irreversible scarring of the lung parenchyma. Although fatigue is a prominent symptom for patients with IPF, little is known about sleep quality in patients with IPF.nnnMETHODSnIn this cross-sectional study of 41 patients with IPF from a prospectively designed cohort, we ascertained sleep quality by means of the Pittsburgh sleep quality index (PSQI) and the Epworth sleepiness scale. Health status, baseline demographics, and physiologic parameters were also assessed.nnnRESULTSnPatients with IPF reported extremely poor sleep quality and high frequency of daytime sleepiness, which differs significantly from normal control populations. Further, poor sleep quality was not associated with body mass index, age, gender, or lung function. This population also demonstrated extremely poor health status in a number of domains, including physical function and vitality. Poor sleep quality (by the global PSQI) was significantly associated with decreased quality of life (QOL) in several domains, including role of physical function (r = - 0.58, p = 0.001), vitality (r = - 0.43, p = 0.015), and role of emotions (r = - 0.40, p = 0.023).nnnCONCLUSIONSnPoor sleep quality is extremely common in patients with IPF and is not predicted by variables traditionally associated with sleep-disordered breathing. Further, poor sleep quality is associated with poor QOL. These findings suggest that systematic evaluation of the cause of poor sleep quality in IPF is merited.

Asthma in the Inner City and the Indoor Environment

Inner-city residents continue to suffer disproportionate asthma morbidity despite recent progress in reducing asthma morbidity and mortality in other strata of the United States population. Studies over the past decade indicate that the indoor environment is a strong contributor to poor asthma control and asthma-related health care use in inner-city populations. Certain indoor exposures are more common and occur in higher concentrations in inner-city communities than in suburban communities. Identification of asthmagenic indoor exposures has paved the way for the development of intervention strategies aimed at reducing asthma morbidity. This article reviews the growing body of evidence that certain indoor environmental exposures contribute to the burden of asthma in the inner city.

Age- and atopy-dependent effects of vitamin D on wheeze and asthma

From Kaiser Permanente Southern California Region, San Diego, Pasadena, Harbor City, Los Angeles, and Orange County, Calif. E-mail: robert.s.zeiger@kp.org. The study was supported by an investigational grant to the Southern California Permanente Medical Group Research and Evaluation Department from Aerocrine AB, Solna, Sweden, and Panasonic Shikoku Electronics Co, Ltd, T~oon City, Ehime, Japan, with protocol development, data collection, extraction, analyses, and manuscript preparation done by investigators. Disclosure of potential conflict of interest: R. S. Zeiger is a consultant for AstraZeneca, Aerocrine, Genentech, GlaxoSmithKline, Novartis, Merck, Schering Plough, MedImmune, and Sunovion and has received research support from Aerocrine, Genentech, GlaxoSmithKline, Merck, AstraZeneca, and TEVA. M. Schatz is a consultant for Amgen, Merck, and GlaxoSmithKline and has received research support from Aerocrine, Genentech, Merck, and GlaxoSmithKline. M. S. Kaplan has received research support from Genentech and Aerocrine and is on the Asthma and Allery Foundation of America (AAFA) California Board of Directors. The rest of the authors have declared that they have no conflict of interest.

Urban residence, neighborhood poverty, race/ethnicity, and asthma morbidity among children on Medicaid

Background Although poor‐urban (inner‐city) areas are thought to have high asthma prevalence and morbidity, we recently found that inner cities do not have higher prevalent pediatric asthma. Whether asthma morbidity is higher in inner‐city areas across the United States is not known. Objective This study sought to examine relationships between residence in poor and urban areas, race/ethnicity, and asthma morbidity among children with asthma who are enrolled in Medicaid. Methods Children aged 5 to 19 enrolled in Medicaid in 2009 to 2010 were included. Asthma was defined by at least 1 outpatient or emergency department (ED) visit with a primary diagnosis code of asthma over the 2‐year period. Urbanization status was defined at the county level and neighborhood poverty at the zip‐code level. Among children with asthma, logistic models were created to examine the effects of urbanization, neighborhood poverty, and race/ethnicity on rates of asthma outpatient visits, ED visits, and hospitalizations. Results This study included 16,860,716 children (1,534,820 with asthma). Among children enrolled in Medicaid, residence in inner‐city areas did not confer increased risk of prevalent asthma in either crude or adjusted analyses, but it was associated with significantly more asthma‐related ED visits and hospitalizations among those with asthma in crude analyses (risk ratio, 1.48; 95% CI, 1.24‐1.36; and 1.97; 95% CI, 1.50‐1.72, respectively) and when adjusted for race/ethnicity, age, and sex (adjusted risk ratio, 1.23; 95% CI, 1.08‐1.15; and 1.62; 95% CI, 1.26‐1.43). Residence in urban or poor areas and non‐Hispanic black race/ethnicity were all independently associated with increased risk of asthma‐related ED visits and hospitalizations. Conclusions Residence in poor and urban areas is an important risk factor for asthma morbidity, but not for prevalence, among low‐income US children.

A Randomized Controlled Trial of the Effect of Broccoli Sprouts on Antioxidant Gene Expression and Airway Inflammation in Asthmatics

BACKGROUNDnBroccoli sprouts (BS) are the richest source of sulforaphane (SFN), which is a potent inducer of phase II enzymes, which play a critical role in preventing oxidative stress (OS) and inflammation.nnnOBJECTIVESnThe objective of this study was to determine if ingestion of whole BS improves airway inflammatory and physiologic outcomes, and OS in adults with asthma and allergic sensitization to an indoor allergen.nnnMETHODSnThe study is a double-blind, placebo-controlled, randomized trial to compare the effects of BS with placebo (alfalfa sprouts [AS]) on airway inflammation and markers of OS. Forty adults (aged 18-50 years) were randomized to eat either (a) 100 g of BS daily or (b) 100 g of AS daily for 3 days. Fractional exhaled nitric oxide (FENO), forced expiratory volume 1, nasal epithelial and PBMC gene expression, inflammatory and OS biomarkers, and symptoms were assessed both before and after ingestion of the sprouts. The primary outcome variable was the change in FENO. Secondary outcome measures included rhinitis and asthma symptoms, lung function, and OS and inflammatory biomarkers.nnnRESULTSnBS ingestion for 3 consecutive days did not reduce FENO, despite resulting in a marked increase in serum SFN concentrations (21 vs 22 parts per billion, Pxa0= .76). Furthermore, BS consumption did not induce cytoprotective antioxidant genes in either PBMCs or nasal epithelial cells, reduce OS and inflammatory markers, or improve lung function.nnnCONCLUSIONSnIngestion of whole BS for 3 days does not appear to improve eosinophilic pulmonary inflammation, inflammatory and OS biomarkers, or clinical features of asthma among atopic adults with asthma despite resulting in a marked increase in serum SFN levels.

2 Respiratory Physiology in Pregnancy

Pregnancy is a normal but altered physiologic state that results in significant hormonal,mechanical, and circulatory changes. The increases in progesterone and estrogen associated with pregnancy contribute to vascular and central nervous system effects, changes in the balance of bronchoconstrictor and bronchodilator prostanoids, and increases in peptide hormones that alter connective tissue characteristics. The course of pregnancy is accompanied by structural changes to the ribcage and abdominal compartments as a consequence of the hormonal changes and the enlarged uterus. Cardiac output, pulmonary blood flow, and circulating blood volume are all increased due to increased metabolic demands. This increase in blood volume without an increase in red cell mass results in a decreased hemoglobin concentration. There is a reduction in plasma oncotic pressure due to both increased blood volume and a decrease in albumin concentration. The combination of increased pulmonary blood flow, increased pulmonary capillary blood volume, and decreased oncotic pressure all promote the formation of edema in the periphery and in the lung. Given the dramatic physical and hormonal alterations of pregnancy, perhaps the most remarkable aspect of respiratory physiology is the relatively minor impact that pregnancy has on the function of the lung. To be able to accurately identify and diagnose respiratory abnormalities in pregnant patients, the clinician must first understand normal physiologic changes of pregnancy. Over the years, there have been several excellent reviews of the effects of pregnancy on the respiratory system in health and disease (1–6). This chapter provides an updated overview of respiratory physiology in healthy pregnant women (6).

The association between asthma and allergic disease and mortality: A 30-year follow-up study

gastroesophageal reflux for certain and suggest EoE as the most likely diagnosis. EoE is currently defined as a chronic immune/antigenmediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Data from the literature show that EoE is often associated with allergic diathesis because up to 93% of pediatric and 86% of adult patients have another allergic disease. Sensitization to aeroallergens, pollens in the great majority of the cases, was observed in more than 80% of adult patients. Inhalant allergens have been demonstrated to cause experimental EoE, and some studies showed an association between the pollen season and esophageal eosinophilic infiltration, symptom exacerbation, higher incidence, and newly diagnosed cases of EoE. In contrast to these observations, esophagitis symptoms started before and recovered along with esophageal eosinophilia during the grass pollen season. In any case, seasonal variations in the incidence of EoE were not confirmed in a more recent study. In sensitized patients aeroallergens appear to have only a complementary role in EoE pathogenesis. Ingestion of plantderived food cross-reacting with pollen allergens might have a pathogenic role in triggering EoE. In fact, sensitization to cross-reactive plant-derived allergens was found in 69% of a case series of adults with EoE, and profilin, followed by pathogenesis-related proteins (Bet v 1 homologues), represented the most frequent allergens. Our patient proved sensitized to profilin. However, because no dietary restriction and no changes in the usual diet were carried out, a relationship with food seems highly improbable. In the described case grass pollen sublingual vaccine seems to be the only triggering factor of esophageal eosinophilia. In a population of pediatric patients treated with milk oral immunotherapy, some cases of likely EoE (3/110 [2.72%]) have been reported as a complication of the maintenance phase 3 and 14 months after a final dose of 200 mL was achieved. All the patients recovered after a milk-free diet. A similar case has been reported after egg oral immunotherapy. These cases led us to conjecture that repeated esophageal stimuli with a high dose of offending allergens might elicit esophageal eosinophilia, perhaps through a locally immune-mediate response. It is likely that esophageal eosinophilia represents only an extremely rare adverse reaction to pollen SLIT. It is noteworthy that mite SLIT was and even now is continued without any problem. Nevertheless, we believe that esophageal eosinophilia should be considered in all patients receiving SLITwho complain of dysphagia or other gastroesophageal symptoms. Long-term evolution of esophageal eosinophilia is not known. Therefore we suggest considering the occurrence of esophagitis symptoms with esophageal eosinophilia as an absolute contraindication to continuing sublingual therapy with the culprit vaccine.

Guideline-Recommended Fractional Exhaled Nitric Oxide Is a Poor Predictor of Health-care Use Among Inner-city Children and Adolescents Receiving Usual Asthma Care

BACKGROUNDnAmerican Thoracic Society guidelines support using fractional exhaled nitric oxide (FENO) measurements in patients with asthma and highlight gaps in the evidence base. Little is known about the use of FENO levels to predict asthma exacerbations among high-risk, urban, minority populations receiving usual care.nnnMETHODSnChildren with persistent asthma (n = 138) were enrolled in a prospective, observational cohort study and skin tested at baseline (a wheal ≥ 3 mm indicated a positive skin-prick test). FENO levels, lung function, and asthma-related health-care use were assessed at baseline and every 3 months thereafter for 1 year. Relationships between FENO levels and health-care use in the subsequent 3 months were examined. Final models accounted for repeated outcome measures and were adjusted for age, sex, and lung function.nnnRESULTSnThe mean age of the children was 11 years (range, 5-17 years), and most were male (57%), black (91%), and atopic (90%). At baseline, the median FENO level was 31.5 parts per billion (interquartile range, 16-61 ppb) and mean FEV1/FVC was 80.7% (SD, ± 9.6%). There were 237 acute asthma-related health-care visits, 105 unscheduled doctor visits, 125 ED visits, and seven hospitalizations during the follow-up period. FENO level was not a significant predictor of acute visits, ED visits, unscheduled doctor visits, or hospitalization in either unadjusted or adjusted analyses. Use of recommended cut points did not improve the predictive value of the FENO level (positive predictive value, 0.6%-32.8%) nor did application of the guideline-based algorithm to assess change over time.nnnCONCLUSIONSnFENO level may not be a clinically useful predictor of health-care use for asthma exacerbations in urban minority children with asthma.

Neighbourhood characteristics and health outcomes: evaluating the association between socioeconomic status, tobacco store density and health outcomes in Baltimore City

Introduction Several studies suggest that the health of an individual is influenced by the socioeconomic status (SES) of the community in which he or she lives. This analysis seeks to understand the relationship between SES, tobacco store density and health outcomes at the neighbourhood level in a large urban community. Methods Data from the 55 neighbourhoods of Baltimore City were reviewed and parametric tests compared demographics and health outcomes for low-income and high-income neighbourhoods, defined by the 50th percentile in median household income. Summary statistics are expressed as median. Tobacco store density was evaluated as both an outcome and a predictor. Association between tobacco store densities and health outcomes was determined using Moran’s I and spatial regression analyses to account for autocorrelation. Results Compared with higher-income neighbourhoods, lower-income neighbourhoods had higher tobacco store densities (30.5 vs 16.5 stores per 10u2009000 persons, P=0.01), lower life expectancy (68.5 vs 74.9 years, P<0.001) and higher age-adjusted mortality (130.8 vs 102.1 deaths per 10u2009000 persons, P<0.001), even when controlling for other store densities, median household income, race, education status and age of residents. Conclusion In Baltimore City, median household income is inversely associated with tobacco store density, indicating poorer neighbourhoods in Baltimore City have greater accessibility to tobacco. Additionally, tobacco store density was linked to lower life expectancy, which underscores the necessity for interventions to reduce tobacco store densities.