Lower socioeconomic status is associated with worse outcomes in pulmonary arterial hypertension

Racial disparities in treatment patterns, healthcare resource use, and outcomes in patients with pulmonary arterial hypertension in the United States

OBJECTIVE

This retrospective study using claims data compared demographics, clinical characteristics, treatment patterns, healthcare resource utilization, and clinical outcomes in Black and White patients with pulmonary arterial hypertension (PAH) in the United States.

METHODS

Patients (aged ≥18 years) had ≥1 pharmacy claim for PAH medication, ≥6 months' continuous healthcare plan enrollment, ≥1 inpatient/outpatient medical claim with a pulmonary hypertension diagnosis ≤6 months before first PAH medication, and race recorded.

RESULTS

This analysis included 836 Black and 2896 White patients. Black patients were younger, with lower levels of education and annual household income, and higher comorbidity scores versus White patients. Only ∼14% of Black and White patients received index combination therapy. Lower adherence to index treatment was observed in Black patients. Although adjusted regression analysis in the overall population showed no differences in outcomes between groups, Black patients <65 years were 36% less likely to receive index combination therapy (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.41-0.99), and 46% less likely to adhere to index treatment (OR 0.54; 95% CI 0.33-0.90). Other disparities included 24% higher all-cause health care resource utilization, 75% higher all-cause costs, and higher risk of clinical composite outcome. Social determinants of health (education, income, health insurance plan) partially mediated these race effects.

CONCLUSIONS

Differences in demographics, clinical characteristics, and treatment patterns between Black and White patients with PAH were observed. Disparities between Black and White patients <65 years were only partially mediated through social determinants of health variables, suggesting other factors may be involved.

Exploring the patient perspective in pulmonary hypertension

The global impacts of pulmonary hypertension (PH) were formally recognised in 1973 at the 1st World Health Organization meeting dedicated to primary pulmonary hypertension, held in Geneva. Investigations into disease pathogenesis and classification led to the development of numerous therapies over the ensuing decades. While the impacts of the disease have been lessened due to treatments, the symptoms and adverse effects of PH and its therapies on patients' wellbeing and mental health remain significant. As such, there is a critical need to enhance understanding of the challenges patients face on a global scale with respect to care access, multidimensional patient support and advocacy. In addition, thoughtful analysis of the potential benefits and utilisation of mechanisms for the incorporation of patient-reported outcomes into diagnosis and treatment plans is needed. A summary of these areas is included here. We present a report of global surveys of patient and provider experiences and challenges regarding care access and discuss possible solutions. Also addressed is the current state of PH patient associations around the world. Potential ways to enhance patient associations and enable them to provide the utmost support are discussed. A summary of relevant patient-reported outcome measures to assess health-related quality of life in PH is presented, with suggestions regarding incorporation of these tools in patient care and research. Finally, information on how current global threats such as pandemics, climate change and armed conflict may impact PH patients is offered, along with insights as to how they may be mitigated with advanced contingency planning.

Pulmonary Hypertension in Underrepresented Minorities: A Narrative Review

Minoritized racial and ethnic groups suffer disproportionately from the incidence and morbidity of pulmonary hypertension (PH), as well as its associated cardiovascular, pulmonary, and systemic conditions. These disparities are largely explained by social determinants of health, including access to care, systemic biases, socioeconomic status, and environment. Despite this undue burden, minority patients remain underrepresented in PH research. Steps should be taken to mitigate these disparities, including initiatives to increase research participation, combat inequities in access to care, and improve the treatment of the conditions associated with PH.

Promotion of Healthy Lifestyles Alone Might Not Substantially Reduce Socioeconomic Inequity-Related Mortality Risk in Older People in China: A Prospective Cohort Study

BACKGROUND

Whether healthy lifestyles mediate the association of socioeconomic status (SES) with mortality in older people is largely unknown.

METHODS

A total of 22,093 older participants (age ≥ 65 years) from 5 waves (2002-2014) of Chinese Longitudinal Healthy Longevity Survey cohort were included for analysis. Mediation analysis of lifestyles on the association of SES with all-cause mortality was conducted.

RESULTS

During a mean follow-up period of 4.92 ± 4.03 years, 15,721 (71.76%) deaths occurred. Compared with high SES, medium SES increased the risk of mortality by 13.5% (HR [total effect]: 1.135, 95% CI 1.067-1.205, p < 0.001), and the total effect was not mediated by healthy lifestyles (mediation proportion: - 0.1%, 95% CI - 3.8 to 3.3%, p = 0.936). The total effect when participants of low SES were compared with participants of high SES was HR = 1.161 (95% CI 1.088-1.229, p < 0.001) for mortality, and the total effect was modestly mediated through healthy lifestyles (mediation proportion: - 8.9%, 95% CI - 16.6 to - 5.1%, p < 0.001). Stratification analyses by sex, age and comorbidities, as well as a series of sensitivity analyses indicated similar results. In addition, mortality risk showed a downward trend with increased number of healthy lifestyles within each SES level (all p for trend < 0.050).

CONCLUSION

Promotion of healthy lifestyles alone can only reduce a small proportion of socioeconomic inequity-related mortality risk in older Chinese people. Even so, healthy lifestyles are important in reducing the overall mortality risk within each SES level.

Long-term outcomes in health-related quality of life influence chronic disease management in patients with pulmonary hypertension

Background

Significantly improved survival in patients with pulmonary hypertension (PH) has raised interest in maintaining a good quality of long-term survivorship. In this study, health-related quality of life (HRQOL) measurement was used to assess the long-term changes of physical and mental outcomes.

Methods

A total of 559 consecutive inpatients with PH completed generic HRQOL (Short Form-36) who were diagnosed with PH by right heart catheterization. Assessments were carried out at short-term (1 year), midterm (3 years), and long-term (5 years) follow-ups.

Results

Patients with PH suffered more severe impairments in both physical and emotional domains than the U.S. population normative values. Patients with PH due to chronic lung disease had the worst physical component summary (PCS) score, but there was no difference in mental component summary (MCS) score among different PH types. A reduced PCS score was correlated with WHO FC severity and pulmonary vascular resistance (PVR). The Z score showed that the changing trend of mental conditions continuously declined from baseline to midterm and long-term follow-ups, but the PCS score seemed to be stable or improved. Cox regression analysis indicated increased baseline PVR and WHO FC III and IV, and decreased physical subscale of role physical, mental subscale of social functioning, and the MCS score have increased risk of mortality in the long-term follow-up.

Conclusion

Patients with PH have poor HRQOL. The long-term change of physical status seemed to be stable, but the mental state was continuously worse. These suggested identifying and intervening mental health progresses is a noteworthy issue in PH chronic management.

Socioeconomically disadvantaged veterans experience treatment delays for pulmonary arterial hypertension

Prompt initiation of therapy after pulmonary arterial hypertension (PAH) diagnosis is critical to improve outcomes; yet delays in PAH treatment are common. Prior research demonstrates that individuals with PAH belonging to socially disadvantaged groups experience worse clinical outcomes. Whether these poor outcomes are mediated by delays in care or other factors is incompletely understood. We sought to examine the association between race/ethnicity and socioeconomic status and time-to-PAH treatment. We conducted a retrospective cohort study of Veterans diagnosed with incident PAH between 2006 and 2019 and treated with PAH therapy. Our outcome was time-to-PAH treatment. Our primary exposures were race/ethnicity, annual household income, health insurance status, education, and housing insecurity. We calculated time-to-treatment using multivariable mixed-effects Cox proportional hazard models. Of 1827 Veterans with PAH, 27% were Black, 4% were Hispanic, 22.1% had an income < $20,000, 53.3% lacked non-VA insurance, 25.5% had Collapse

Key Words

• pulmonary arterial hypertension
• racial, ethnic, or social disparities in lung disease and treatment
• research design/program evaluation/statistical models

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MESH Headings Collapse

Grants

• R21 HL145420 NHLBI NIH HHS
• F32 HL149236 NHLBI NIH HHS
• T32 HL007035 NHLBI NIH HHS
• R01 HL139613 NHLBI NIH HHS
• UG3 HL143192 NHLBI NIH HHS
• UL1 TR001430 NCATS NIH HHS
• U54 HL119145 NHLBI NIH HHS
• R01 HL155096 NHLBI NIH HHS
• NCATS
• NIH

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Affiliation(s)

Kari R. Gillmeyer The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA
Seppo T. Rinne The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA
Shirley X. Qian Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA VA Boston Healthcare SystemBostonMassachusettsUSA
Bradley A. Maron Department of CardiologyVA Boston Healthcare SystemBostonMassachusettsUSA Division of Cardiovascular MedicineBrigham and Women's HospitalBostonMassachusettsUSA
Shelsey W. Johnson The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA
Elizabeth S. Klings The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA
Renda S. Wiener The Pulmonary CenterBoston University School of MedicineBostonMassachusettsUSA Center for Healthcare Organization & Implementation ResearchVA Bedford Healthcare System and VA Boston Healthcare SystemBedford and BostonMassachusettsUSA

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Gender dimension in cardio-pulmonary continuum

Cardio-pulmonary diseases, which were once regarded as a man's illness, have been one of the leading causes of morbidity and mortality for both men and women in many countries in recent years. Both gender and sex influence the functional and structural changes in the human body and therefore play an important role in disease clinical manifestation, treatment choice, and/or response to treatment and prognosis of health outcomes. The gender dimension integrates sex and gender analysis in health sciences and medical research, however, it is still relatively overlooked suggesting the need for empowerment in the medical research community. Latest advances in the field of cardiovascular research have provided supportive evidence that the application of biological variables of sex has led to the understanding that heart disease in females may have different pathophysiology compared to males, particularly in younger adults. It has also resulted in new diagnostic techniques and a better understanding of symptomatology, while gender analysis has informed more appropriate risk stratification and prevention strategies. The existing knowledge in the pulmonary field shows the higher prevalence of pulmonary disorders among females, however, the role of gender as a socio-cultural construct has yet to be explored for the implementation of targeted interventions. The purpose of this review is to introduce the concept of gender dimension and its importance for the cardiopulmonary continuum with a focus on shared pathophysiology and disease presentation in addition to interrelation with chronic kidney disease. The review presents basic knowledge of what gender dimension means, and the application of sex and gender aspects in cardiovascular medicine with a specific focus on early pulmonary development, pulmonary hypertension, and chronic obstructive pulmonary disease (COPD). Early vascular aging and inflammation have been presented as a potential pathophysiological link, with further interactions between the cardiopulmonary continuum and chronic kidney disease. Finally, implications for potential future research have been provided to increase the impact of gender dimension on research excellence that would add value to everybody, foster toward precision medicine and ultimately improve human health.

Hispanic Ethnicity and Social Determinants of Health in Pulmonary Arterial Hypertension: The Pulmonary Hypertension Association Registry

Rationale There is a noticeable underrepresentation of minorities in clinical trials and registries in pulmonary arterial hypertension (PAH). Prior studies evaluating the association between Hispanic ethnicity and clinical outcomes in patients with PAH have not assessed the socioeconomic profile of Hispanic individuals or the significance of social determinants of health in clinical outcomes. Objective To determine the association between Hispanic ethnicity, social determinants of health, and clinical outcomes in PAH. Methods Prospective cohort study of adult participants with PAH enrolled in the Pulmonary Hypertension Association Registry, a multicenter US-based registry of patients treated at Pulmonary Hypertension Care Centers. Participants were classified as Hispanics and non-Hispanic Whites, based on self-reported ethnicity. A comparison of baseline clinical and sociodemographic characteristics between groups was performed as well using absolute standardized differences (ASD). The primary outcome of the study was to assess transplant-free survival between Hispanics and non-Hispanic Whites. A Cox proportional hazards model was used for the multivariable analysis after adjusting for age, sex, PAH etiology, annual income, education level and health insurance. Results A total of 683 individuals were included, 98 (14.3%) of Hispanic ethnicity. Hispanic patients had impaired access to health care (31.6% vs. 12.9% Medicaid/uninsured; ASD 0.35), lower education level (72.6% vs. 94.0% high school graduates or higher; ASD 0.60) and lower annual income (32.0% vs. 17.4% with income <20,000 US dollars; ASD 0.47), as compared with non-Hispanic Whites. Hispanic patients had a higher frequency of ER visits and a higher number of hospitalizations, despite having similar disease severity (incidence rate ratio 1.452, 95% CI 1.326 - 1.590 and 1.428, 95% CI 1.292 - 1.577, respectively). While the unadjusted analysis showed a lower transplant/death hazard ratio for Hispanics (HR 0.47, 95% CI 0.24-0.94; p=0.032), there was no association between Hispanic ethnicity and outcome in the multivariable model after adjusting for social determinants of health and other covariates (HR 0.76, 95% CI 0.35-1.62; p=0.474). Conclusions Hispanic ethnicity was not associated with differences in survival after adjusting for social determinants of health and other factors. Social determinants of health are important to consider when assessing the association between ethnicity and outcomes in PAH.

Validity of the ESC Risk Assessment in Idiopathic Pulmonary Arterial Hypertension in China

Background: The 2015 European pulmonary hypertension (PH) guidelines recommend a risk stratification strategy for pulmonary arterial hypertension (PAH). We aimed to investigate the validation and potential prognostic information in Chinese patients. Methods: The risk assessment variables proposed by the PH guidelines were performed by using the WHO function class, 6-min walking distance, brain natriuretic peptide or its N-terminal fragment, right arterial pressure, cardiac index, mixed venous saturation, right atrium area, pericardial effusion, peak oxygen consumption, and ventilatory equivalents for carbon dioxide. An abbreviated version also was applied. Results: A total of 392 patients with idiopathic PAH (IPAH) were enrolled between 2009 and 2018. After a median interval of 13 months, re-evaluation assessments were available for 386 subjects. The PAH guidelines risk tool may effectively discriminate three risk groups and mortality (p < 0.001) both at the baseline and re-evaluation. Meanwhile, its simplified risk version was valid for baseline and accurately predicted the risk of death in all the risk groups (p < 0.001). At the time of re-evaluation, the percentage of low-risk group has an increase, but a greater proportion achieved the high-risk group and a lesser proportion maintained in the intermediate-risk group. Conclusion: The 2015 European PH guidelines and its simplified version risk stratification assessment present an effective discrimination of different risk groups and accurate mortality estimates in Chinese patients with IPAH. Changes of risk proportion at re-evaluation implicated that natural treatment decisions may not be consistently with goal-oriented treatment strategy.

Prevalence and Socioeconomic Factors of Diabetes and High Blood Pressure Among Women in Kenya: A Cross-Sectional Study

Background

The emerging burden of high blood pressure (HBP) and diabetes in sub-Saharan Africa will create new challenges to health systems in African countries. There is a scarcity of studies that have reported associations of diabetes and HBP with socioeconomic factors on women within the population. We assessed the prevalence and socioeconomic factors of diabetes and high blood pressure among women in Kenya.

Methods

We analysed cross-sectional data from the 2014 Kenya Demographic and Health Survey. Subjects were women aged 15–49 years. Self-reported status of HBP and diabetes was used to measure the prevalences. The association between educational and wealth index with HBP and diabetes was assessed by multivariable binary logistic regression.

Results

The prevalences of self-reported HBP and diabetes were 9.4% and 1.3%, respectively. Women with secondary [aOR = 1.53; 95% CI = 1.15–2.02] and primary [aOR = 1.48; 95% CI = 1.15–1.92] levels of education were more likely to report having HBP, compared to those with no formal education. However, there was no significant association between educational level and self-reported diabetes. In terms of wealth quintile, we found that women with higher wealth quintile were more likely to report having HBP and diabetes compared to those with poorest wealth quintile. Specifically, the highest odds of self-reported HBP was found among women with richest wealth quintile compared to those with poorest wealth quintile [aOR = 2.22; 95% CI = 1.71–2.88]. Also, women with poorer wealth quintile were more likely to have self-reported diabetes compared to those with poorest wealth quintile [aOR = 1.89; 95% CI = 1.08–2.38].

Conclusion

The prevalence of HBP and diabetes was low among women in Kenya. Household wealth status was associated with HBP and diabetes. No causation can be inferred from the data; hence, longitudinal studies focusing on health-related behaviour associated with NCDs are recommended. Proper dissemination of health information regarding the risk factors for HBP and diabetes may prove to be beneficial for NCD prevention programmes.

RETROSPECTIVE COMPUTER-ASSISTED IMAGE ANALYSIS OF DOPPLER ECHOCARDIOGRAPHY IN PULMONARY HYPERTENSION PATIENTS

Pulmonary hypertension (PH) is diagnosed invasively by right heart catheterization (RHC), which determines patient’s mean and systolic pulmonary artery pressure (mPAP, sPAP) and pulmonary vascular resistance (PVR). This study sought to identify non-invasive echocardiography parameters useful for screening PH. Patients ([Formula: see text]; 19 normotensive; 17 pre-capillary PH; 48 post-capillary PH) who had undergone transthoracic Doppler echocardiography and RHC within 60 days of each other were identified. Tricuspid regurgitant (TR) jet velocities, velocity spectral densities, average flow rates, and Fourier transforms (FFT) of velocity waveforms were calculated via an in-house MATLAB code. Correlations were found between the FFT magnitude at 0 Hz and sPAP and mPAP for normotensive patients; between the MATLAB-calculated TR jet and sPAP and PVR for all PH patients; and between the sum of FFT magnitudes [Formula: see text][Formula: see text]Hz and mPAP, sPAP, and PVR for post-capillary PH patients. Statistical difference was found between the FFT magnitudes at 2 Hz of pre- and post-capillary PH patients ([Formula: see text]). These results suggest non-invasive parameters with clinical utility for estimating RHC measurements and discriminating between PH types, offering a path forward for less invasive and more accessible PH screening protocol.

Factors Associated with Incident Severe Pulmonary Arterial Hypertension in Systemic Autoimmune Rheumatic Diseases: a Nationwide Study

OBJECTIVES

To assess the association of severe pulmonary arterial hypertension (PAH) with particulate matter <2.5 μm (PM2.5) and clinical data in patients with systemic autoimmune rheumatic diseases (SARDs).

METHODS

We used the 2003-2017 nationwide data in Taiwan to identify patients with SARDs, including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, dermatomyositis/polymyositis and primary Sjögren's syndrome. We identified 479 cases with severe PAH and selected controls matched (1:4) for age, sex, and index-year. We used conditional logistic regression analysis to determine factors associated with risks for severe PAH shown as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We found that severe PAH was highly associated with interstitial lung disease (OR, 8.57; 95% CI, 5.52-13.32), congestive heart failure (OR, 7.62; 95% CI, 5.02-11.55), valvular heart disease (OR, 3.34; 95% CI, 2.03-5.50) and slightly associated with thyroid diseases (OR, 1.88; 95% CI, 1.18-3.00), but not the level of exposure to PM2.5. Increased risk for PAH was found in patients receiving corticosteroid (prednisolone equivalent dosage, mg/day, OR, 1.03; 95% CI, 1.01-1.05), biologics (OR, 2.18; 95% CI, 1.15-4.12) as well as immunosuppressants, including cyclosporin (OR, 2.17; 95% CI, 1.31-3.59), azathioprine (OR, 1.96; 95% CI, 1.48-2.61), cyclophosphamide (OR, 2.01; 95% CI, 1.30-3.11) and mycophenolate mofetil/mycophenolic acid (OR, 2.42; 95% CI, 1.37-4.27), and those with the highest level of insured amount (reference, lowest level; OR, 0.53; 95% CI, 0.34-0.83).

CONCLUSION

The population-based study identified risks for severe PAH in patients with SARDs, and these findings provide evidence for PAH risk stratification in patients with SARDs.

Impact of patient characteristics and perceived barriers on referral to exercise rehabilitation among patients with pulmonary hypertension in the United States

Exercise rehabilitation is underutilized in patients with pulmonary arterial hypertension despite improving exercise capacity and quality of life. We sought to understand the association between (1) patient characteristics and (2) patient-perceived barriers and referral to exercise rehabilitation. We performed a cross-sectional survey of patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension attending an International PAH meeting. Predictors of referral considered included gender, body mass index, subjective socioeconomic status, insurance type, age, and World Health Organization functional class and perceived barriers assessed using the Cardiac Rehabilitation Barriers Scale. Among 65 participants, those in the lowest subjective socioeconomic status tertile had reduced odds of referral compared to the highest tertile participants (odds ratio 0.22, 95% confidence interval: 0.05–0.98, p = 0.047). Several patient-perceived barriers were associated with reduced odds of referral. For every 1-unit increase in a reported barrier on a five-point Likert scale, odds of referral were reduced by 85% for my doctor did not feel it was necessary; 85% for prefer to take care of my health alone, not in a group; 78% many people with heart and lung problems don’t go, and they are fine; and 78% for I didn’t know about exercise therapy. The lack of perceived need subscale and overall barriers score were associated with a 92% and 77% reduced odds of referral, respectively. These data suggest the need to explore interventions to promote referral among low socioeconomic status patients and address perceived need for the therapy.

Social deprivation in Scottish populations with pulmonary hypertension secondary to connective tissue disease and chronic thromboembolic disease

Socioeconomic factors have been shown to have an adverse impact on survival in some respiratory diseases. Studies from the USA and China have suggested worse survival in idiopathic pulmonary arterial hypertension in low socioeconomic groups. We looked at the effect of deprivation on the outcomes in patients with connective tissue disease-associated pulmonary hypertension (CTDPH) and chronic thromboembolic pulmonary hypertension (CTEPH) in a retrospective observational study.

Data were obtained from 232 patients with CTDPH and 263 with CTEPH who were under the care of the Scottish Pulmonary Vascular Unit, Glasgow, UK. We used Cox proportional hazards regression to assess for a relationship between deprivation and survival.

We found no difference in survival across deprivation quintiles in the CTDPH (p=0.26) or CTEPH cohorts (p=0.18). We constructed multivariate models using enrolment time, age, sex and body mass index, with no significant change in findings. There was no difference between expected and observed population distribution of CTDPH (p=0.98) and CTEPH (p=0.36). Whilst there was no difference in presenting functional class in the CTDPH group, the CTEPH patients in more deprived quintiles presented in a worse functional class (p=0.032). There was no difference between quintiles of CTEPH patients who had distal or proximal disease (p=0.75), or who underwent surgery (p=0.5).

Increased social deprivation is not associated with worse survival in patients with CTDPH and CTEPH managed in the Scottish National Health Service. Whilst there is no evidence of referral barriers in CTDPH, this may not be the case in CTEPH, as lower deprivation was associated with worse functional class at presentation.

Increased social deprivation is not associated with worse survival in patients with connective tissue disease-associated pulmonary hypertension or chronic thromboembolic pulmonary hypertension managed in the Scottish NHShttps://bit.ly/32KbzSv

Socioeconomic status and survival in patients with pulmonary hypertension

In a publicly funded healthcare system, no evidence of survival disparities across socioeconomic classes among patients with pulmonary hypertension was observed, underscoring the importance of eliminating financial barriers to medical care and treatment https://bit.ly/2Eb1ju2.

Educational differences in mortality associated with central obesity: Decomposing the contribution of risk and prevalence

Thousands of preventable deaths are attributed to obesity in the United States. However, the harmfulness of obesity varies across the population; individuals' education determines access to healthful resources and exposure to competing risks, dampening/amplifying obesity-associated mortality risk. Using restricted U.S. National Health and Nutrition Examination Survey data (N = 40,058; 1988-2015), this study estimates educational differences in mortality attributable to central obesity (waist-to-height ratio ≥0.5) - a dangerous form of abdominal adiposity. Over 30% of excess deaths are attributable to central obesity among college-educated adults, compared to 1-10% among their less-educated counterparts. This difference is larger for cardiometabolic-related mortality, as central obesity may explain 60-70% of excess deaths among college-educated adults. Decomposition analyses show differences are driven by greater obesity-associated risk among college-educated adults, rather than prevalence. Policies targeting health disparities should recognize central obesity as a key risk among highly-educated adults, but only one of many encountered by those with less education.

Deprivation and prognosis in patients with pulmonary arterial hypertension: missing the effect of deprivation on a rare disease?

In this journal, Pellino et al. [1] presented a survival analysis to assess how deprivation affects prognosis in patients with pulmonary arterial hypertension (PAH). Their conclusions were that social deprivation is not a significant referral barrier or prognostic factor for idiopathic (I)PAH or heritable (H)PAH in Scotland. This may appear surprising, given the wider context of literature describing outcomes stratified by social deprivation. The authors were thorough on using both the address at time of diagnosis and at time of censoring to assign deprivation scores and compare the two, finding no significant differences between the two approaches. They also compared deprivation assigned to PAH cases to expected deprivation based on Scottish citizenry as a whole, and found that PAH patients are more socially deprived than expected. Finally, they used the same survival univariate analysis adjusting for age and sex to assess how several clinical variables are associated with prognosis.

No association was found between deprivation and mortality for PAH patients in England and Wales. The association found between risk stratification at baseline and deprivation suggests that the issue of deprivation and outcomes in PAH may be more nuanced. https://bit.ly/2y8WgqB

Outcomes of Pulmonary Arterial Hypertension Are Improved in a Specialty Care Center

BACKGROUND

Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressures and is managed by vasodilator therapies. Current guidelines encourage PAH management in specialty care centers (SCCs), but evidence is sparse regarding improvement in clinical outcomes and correlation to vasodilator use with referral.

RESEARCH QUESTION

Is PAH management at SCCs associated with improved clinical outcomes?

STUDY DESIGNAND METHODS

A single-center, retrospective study was performed at the University of Pittsburgh Medical Center (UPMC; overseeing 40 hospitals). Patients with PAH were identified between 2008 and 2018 and classified into an SCC or non-SCC cohort. Cox proportional hazard modeling was done to compare for all-cause mortality, as was negative binomial regression modeling for hospitalizations. Vasodilator therapy was included to adjust outcomes.

RESULTS

Of 580 patients with PAH at UPMC, 455 (78%) were treated at the SCC, comprising a younger (58.8 vs 64.8 years; P < .001) and more often female (68.4% vs 51.2%; P < .001) population with more comorbidities without differences in race or income. SCC patients demonstrated improved survival (hazard ratio, 0.68; P = .012) and fewer hospitalizations (incidence ratio, 0.54; P < .001), and provided more frequent disease monitoring. Early patient referral to SCC (< 6 months from time of diagnosis) was associated with improved outcomes compared with non-SCC patients. SCC patients were more frequently prescribed vasodilators (P < .001) and carried more diagnostic PAH coding (P < .001). Vasodilators were associated with improved outcomes irrespective of location but without statistical significance when comparing between locations (P > .05).

INTERPRETATION

The UPMC SCC demonstrated improved outcomes in mortality and hospitalizations. The SCC benefit was multifactorial, with more frequent vasodilator therapy and disease monitoring. These findings provide robust evidence for early and regular referral of patients with PAH to SCCs.

Life Course Socioeconomic Status and Hypertension in African American Adults: The Jackson Heart Study

BACKGROUND

Limited research has examined the association of life-course socioeconomic status (SES) with hypertension prevalence and incidence in a large cohort of African Americans.

METHODS

Among 4,761 participants from the Jackson Heart Study (JHS), we examined the association of SES indicators with prevalent and incident hypertension. We used multivariable Poisson regression to estimate prevalence ratios (PR, 95% confidence interval-CI) of baseline (2000-2004) hypertension by adult (education, income, occupation, wealth) and childhood (mother's education) SES. Cox proportional hazards regression was used to estimate hazard ratios (HR, 95% CI) of incident hypertension by adult and childhood SES (2005-2013; 7.21 median years of follow-up). We also examined the association of childhood-to-adult SES mobility (parent-to-adult education) with prevalent and incident hypertension. Model 1 adjusted for age and sex. Model 2 added waist circumference, behaviors (smoking, alcohol, physical activity, diet), and diabetes prevalence.

RESULTS

High (vs. low) adult SES measures were associated with a lower prevalence of hypertension, with the exception of having a college degree and upper-middle income (PR: 1.04, 95% CI: 1.01, 1.07; PR: 1.05, 95% CI: 1.01, 1.09, respectively). Higher childhood SES was associated with a lower prevalence and risk of hypertension (PR: 0.83, 95%: CI 0.75, 0.91; HR: 0.76, 95% CI: 0.65, 0.89, respectively). Upward mobility and consistent high SES (vs. consistent low SES) from childhood to adulthood was associated with a greater prevalence, but lower incidence of hypertension.

CONCLUSION

Efforts to prevent hypertension among African Americans should consider childhood and current SES status.

Effects of individual and neighborhood socioeconomic status on antiretroviral therapy adherence: The role of adherence self-efficacy

This study aimed to examine the potential mediation effect of adherence self-efficacy on the associations between individual and neighborhood socioeconomic status and antiretroviral therapy adherence in a sample of 337 people living with HIV in South Carolina, United States. Results showed that there were no direct effects of individual or neighborhood socioeconomic status on antiretroviral therapy adherence, whereas both individual socioeconomic status and neighborhood socioeconomic status were associated with adherence self-efficacy, which in turn were related to antiretroviral therapy adherence. These findings suggest that interventions targeting adherence self-efficacy may improve antiretroviral therapy adherence among people living with HIV with low socioeconomic status or those living in socioeconomically disadvantaged neighborhoods.

Impact of Pituitary-Gonadal Axis Hormones on Pulmonary Arterial Hypertension in Men

The association of sex hormone (estradiol, testosterone, and progesterone) with cardiopulmonary disease has already attracted great attention, especially in pulmonary arterial hypertension (PAH). However, the impact of sex hormones and their pituitary stimulators (follicle-stimulating hormone and luteinizing hormone) on PAH in men remains unclear. We conducted a prospective cohort study recruiting 95 patients with idiopathic PAH from 2008 to 2014 and following up for a median of 65 months for death. Compared with control, abnormal plasma levels of sex hormones were more common in patients with PAH. Higher estradiol and estradiol/testosterone levels were associated with risk of PAH diagnosis (odds ratio per ln estradiol, 3.55; P<0.001; odds ratio per ln estradiol/testosterone, 4.30; P<0.001), whereas higher testosterone and progesterone were associated with a reduced risk (odds ratio per ln testosterone, 0.48; P=0.003; odds ratio per ln progesterone, 0.09; P<0.001). Fifty patients died during follow-up. Men with higher estradiol had increased mortality (hazard ratio per ln estradiol, 2.02; P=0.007), even after adjustment for baseline characteristics and PAH treatment. According to receiver operating characteristic analysis, patients with PAH with higher estradiol level (≥145.55 pmol/L) had worse 5-year survival rate compared with those with lower estradiol (38.6% versus 68.2%; log-rank test P=0.001). Therefore, our data show higher estradiol, estradiol/testosterone ratio, lower testosterone, and progesterone were associated with increased risk of PAH. Meanwhile, higher estradiol was independently associated with higher mortality in men with PAH. Further studies are needed to explain the origin of these hormonal derangements and their potential pathophysiological implications in PAH.

Social deprivation and prognosis in Scottish patients with pulmonary arterial hypertension

Several demographic and clinical factors have prognostic significance in idiopathic pulmonary arterial hypertension (IPAH). Studies in China and the USA have suggested an association between low socioeconomic status and reduced survival. The impact of social deprivation on IPAH survival in the UK is not known.

280 patients with IPAH and hereditary PAH (HPAH) attending the Scottish Pulmonary Vascular Unit (Glasgow, UK) were assigned to social deprivation quintiles using the Scottish Index of Multiple Deprivation database. The association between survival and social deprivation quintile was assessed using Cox proportional hazards regression analysis.

The distribution of IPAH/HPAH patients was more socially deprived than would be expected based on Scottish citizenry as a whole (Chi-squared 16.16, p=0.003), suggesting referral and access to care is not impeded by socioeconomic status. Univariate analysis demonstrated no significant association between social deprivation and survival (p=0.81), and this association failed to reach significance with inclusion of time, sex and age as covariates in the model (p=0.23). There were no statistically significant correlations between social deprivation and baseline clinical variables of prognostic importance except for age, sex and quality of life.

Social deprivation is not a significant referral barrier or prognostic factor for IPAH and HPAH in Scotland.

Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement

BACKGROUND

Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated.

OBJECTIVES

The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research.

METHODS

Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research.

RESULTS

Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies.

CONCLUSIONS

At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.

Ethnicity in Pulmonary Arterial Hypertension: Possibilities for Novel Phenotypes in the Age of Personalized Medicine

In the past decade and a half, the introduction of new therapeutic agents has revolutionized the management of pulmonary arterial hypertension (PAH). These new treatment options have improved the quality of life and survival in PAH. With an armamentarium of options available, the identification of unique phenotypes can help practitioners choose tailored treatment regimens. Experts in other cardiovascular diseases, such as congestive heart failure and hypertension, have recommended race-specific treatments in their fields based on data highlighting variations in response to therapies. With this perspective, we review evidence supporting the hypothesis that ethnicity or race plays an important role in the management of PAH. Preliminary research suggests that races/ethnicities have differences in the presentation and outcome of PAH and could respond to PAH-specific medications with varying efficacy. Genetic, physiological, and anatomic differences exist between races, particularly regarding the structure and function of the right ventricle. Unfortunately, clinical trials have not adequately included minorities, and registry data often omit inclusion of this demographic information. Further studies are needed to characterize the role that ethnicity plays in the prevalence, presentation, outcomes, and optimal treatment of PAH.

The influence of individual socioeconomic status on the clinical outcomes in ischemic stroke patients with different neighborhood status in Shanghai, China

Objective: Socioeconomic status (SES) is being recognized as an important factor in both social and medical problems. The aim of present study is to examine the relationship between SES and ischemic stroke and investigate whether SES is a predictor of clinical outcomes among patients with different neighborhood status from Shanghai, China. Methods: A total of 471 first-ever ischemic stroke patients aged 18-80 years were enrolled in this retrospective study. The personal SES of each patient was evaluated using a summed score derived from his or her educational level, household income, occupation, and medical reimbursement rate. Clinical adverse events and all-cause mortality were analyzed to determine whether SES was a prognostic factor, its prognostic impact was then assessed based on different neighborhood status using multivariable Cox proportional hazard models after adjusting for other covariates. Results: The individual SES showed a significant positive correlation with neighborhood status (r = 0.370; P < 0.001). The incidence of clinical adverse events and mortality were significantly higher in low SES patients compared with middle and high SES patients (P = 0.001 and P = 0.037, respectively). After adjusting other risk factors and neighborhood status, Kaplan-Meier analysis showed clinical adverse events and deaths were still higher in the low SES patients (all P < 0.05). Multivariate Cox regression analysis demonstrated that both personal SES and neighborhood status are independent prognostic factors for ischemic stroke (all P < 0.05). Besides, among patients with low and middle neighborhood status, lower individual SES was significantly associated with clinical adverse events and mortality (all P < 0.05). Conclusion: Both individual SES and neighborhood status are significantly associated with the prognosis after ischemic stroke. A lower personal SES as well as poorer neighborhood status may significantly increase risk for adverse clinical outcomes among ischemic stroke patients.

Socioeconomic status affects pulmonary hypertension disease severity at time of first evaluation

A low socioeconomic status (SES) has been linked to disproportionate access to health care in many diseases, leading to worse disease severity at initial presentation. There is a paucity of these data in the pulmonary hypertension (PHTN) population. We studied the association of SES, as measured by zip code-based median annual household income, with World Health Organization functional class (WHO-FC) at time of first evaluation in PHTN patients. All patients evaluated at our center with a right heart catheterization revealing a mean pulmonary artery pressure of ≥25 mmHg within 12 months of initial evaluation were considered for the study. Demographics, WHO-FC, and zip codes were obtained from retrospective chart analysis. The 2010 US census was used to obtain zip code-based annual median income. The income groups were divided into quartiles. Patients were categorized by their WHO-FC and zip code-derived median income. Similar analyses were conducted for pulmonary arterial hypertension (PAH) patients. Survival was estimated with the Kaplan-Meier method. Data were analyzed in SAS, and P < 0.05 was considered significant. There were 228 PHTN patients (70 [30.7%] male, 158 [69.3%] female). As median income decreased, the FC at presentation increased, signifying higher disease severity (Spearman correlation: r = -0.161, P < 0.0515). This association between median income groups and WHO-FC at initial evaluation was significant (χ(2) test: P < 0.0168). There were 116 PAH patients (32 [27.6%] male, 84 [72.4%] female). There was again a negative relationship between income and initial FC (Spearman correlation: r = -0.0307, P < 0.0007). A lower SES was associated with worse disease, as measured by WHO-FC.

Treatment of pulmonary arterial hypertension in congenital heart disease in Singapore versus the Netherlands: age exceeds ethnicity in influencing clinical outcome

Background

Advanced treatment of pulmonary arterial hypertension (PAH) in congenital heart disease (CHD) is increasingly applied worldwide following the—mainly Western world based—international PAH-CHD guidelines. However, studies comparing clinical presentation and outcome after the initiation of PAH-specific treatment are lacking. We aimed to analyse this in a Singaporean and Dutch cohort of PAH-CHD patients.

Methods

Adult CHD patients starting PAH-specific therapy, enrolled in two nationwide registries, were analysed. Patients received phosphodiesterase-type-5 inhibitors, endothelin receptor antagonists, or a combination. Change in six-minute walk test (6MWT) during follow-up was analysed using linear mixed model analysis. Determinants for mortality were assessed using Cox proportional hazard analyses.

Results

A total of 74 patients, 45 Dutch (mean age 47 ± 14 years) and 29 Singaporean (mean age 41 ± 14 years) were analysed. Despite a lower 6MWT (312 versus 395 metres, p = 0.01) and peak VO₂ (35 versus 49 % of predicted, p = 0.01) at baseline in Singaporean patients, the treatment effect was similar in the two populations. Age at initiation of therapy (per 5 year lower age, β = + 4.5, p = 0.017) was the strongest predictor of improvement in exercise capacity, corrected for ethnicity, baseline 6MWT, sex and CHD defect.

Conclusions

Patients from Singapore had a worse clinical performance at baseline compared with the PAH-CHD patients from the Netherlands. No relation between ethnicity and improvement in 6MWT after PAH-specific therapy was found. Age at initiation of PAH-specific therapy was the strongest predictor of treatment efficacy and mortality, emphasising the need for early initiation of treatment in these patients.

SOCIAL ENGAGEMENT AND USE OF HYPERTENSIVE MEDICATION AMONG ADULTS IN CHINA

This study’s objectives were, first, to examine the association between social engagement and the odds of taking hypertensive medications and treatment among adults in China; and second, to explore the lifestyle and psychological mechanisms underlying this association. Data were from the WHO Study on Global AGEing and Adult Health (WHO-SAGE), a national survey of 11,046 participants aged 18 to 69 conducted in China in 2010. The key outcome was a dichotomous indicator of whether the respondent was taking hypertensive medication or other treatment. A series of logistic regression models were fitted to examine the research questions. Higher levels of social engagement were found to be associated with a lower odds of taking hypertensive medication or treatment, and the association was stronger for women than for men. Lifestyle factors (i.e. smoking and BMI) and perceived overall life satisfaction were significant covariates. Life satisfaction helped explain some of the social engagement benefit for both men and women and BMI only appeared to be a mediator for men. Being married was not significantly associated with lower odds of taking hypertensive medication or treatment in either men or women. Social engagement seems to be protective against hypertension for adult men and women in China, although causation could not be determined in this cross-sectional study. Psychosocial mechanisms are probably at work, but these vary by gender.

Interleukin-6 and tumor necrosis factor-α are associated with quality of life-related symptoms in pulmonary arterial hypertension

RATIONALE

Inflammation is associated with symptoms in many chronic illnesses; however, this link has not been established in pulmonary arterial hypertension.

OBJECTIVES

The objective of this study was to investigate the association between inflammatory markers and quality of life-related symptoms in patients with pulmonary arterial hypertension. We hypothesized that higher circulating IL-6 and tumor necrosis factor-α levels would be associated with worse quality of life-related symptoms.

METHODS

We performed a secondary analysis using baseline and 3-month assessments of 62 subjects in a clinical trial of aspirin and simvastatin to determine the association between plasma IL-6 and tumor necrosis factor-α levels and the Medical Outcomes Study Short Form-36 subscales (pain, vitality, mental health).

MEASUREMENTS AND MAIN RESULTS

The mean age was 49.7±13.4 years; 87% were female. Higher IL-6 levels were significantly associated with lower Medical Outcomes Study Short Form-36 subscale scores, indicating worse bodily pain, vitality, and mental health (all P<0.01). Higher tumor necrosis factor-α levels were significantly associated with increased bodily pain, but better mental health scores.

CONCLUSIONS

IL-6 and tumor necrosis factor-α levels are associated with certain quality of life domains in patients with pulmonary arterial hypertension. Clinical trial registered with www.clinicaltrials.gov (NCT00384865).

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition

BACKGROUND

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS

We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS

Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION

Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING

Bill & Melinda Gates Foundation.

The basic social medical insurance is associated with clinical outcomes in the patients with ST-elevation myocardial infarction: a retrospective study from Shanghai, China

OBJECTIVE

Several social economic factors play important roles in treatments of ST-elevation myocardial infarction (STEMI) and finally influence the clinical outcomes. The basic social medical insurance (BSMI) is an important economic factor in China's medical system. However, the impact of BSMI on clinical outcomes in STEMI patients has not been explored yet. The aim of this study is to investigate whether BSMI is a predictor of clinical outcomes in the patients with STEMI in Shanghai, China.

MATERIAL AND METHODS

In this retrospective study, 681 STEMI patients from different areas in Shanghai were classified into four groups: new rural cooperative medical scheme (NCMS) group, urban resident basic medical insurance scheme (URBMI) group, urban employee basic medical insurance scheme (UEBMI) group and UNINSURED group, major adverse events (cardiac death, nonfatal reinfarction, clinically driven target lesion revascularization/target vessel revascularization, stroke, heart failure) were regarded as study endpoints to determine whether BSMI was a prognostic factor.

RESULTS

During a mean follow-up of 36 months, the incidence of major adverse events was significantly higher in NCMS patients (64; 38.8%) compared with the other groups: URBMI (47; 24.6%); UEBMI (28; 15.6%); UNISURED (40; 27.6%). Similarly, cardiac mortality was also higher in NCMS group (19; 11.5%). A Kaplan-Meier survival analysis revealed significantly lower event-free survival rate for major adverse events (p < 0.001) and cardiac mortality (p = 0.01) in NCMS group. Multivariate Cox regression analysis revealed that BSMI was an important prognostic factor in STEMI patients.

CONCLUSION

These results demonstrate that BSMI is closely associated with the major adverse events-free survival rate at 36-month follow-up in the STEMI patients under the current policies in Shanghai, China.

Baicalin attenuates transforming growth factor-β1-induced human pulmonary artery smooth muscle cell proliferation and phenotypic switch by inhibiting hypoxia inducible factor-1α and aryl hydrocarbon receptor expression

Objectives

Baicalin, a natural flavone, has antithrombotic, antihyperlipidemic and antiinflammortory activity. It can also inhibit cancer cell proliferation and reduce brain cell apoptosis. This study aimed to elucidate the effect of baicalin on the excessive proliferation of human pulmonary arterial smooth muscle cells (HPASMCs) induced by transforming growth factor-β1 (TGF-β1) and to investigate the roles of hypoxia inducible factor-1α (HIF-1α) and aryl hydrocarbon receptor (AhR) in mediating this TGF-β1-induced excessive proliferation of HPASMCs.

Methods

TGF-β1-induced proliferation of HPASMCs was assayed using the CCK8 method. The cellular phenotype was identified by immunocytochemical staining. Expression of HIF-1α and AhR mRNA was determined by real-time quantitative PCR.

Key findings

TGF-β1 promoted significantly HPASMC proliferation (P &lt; 0.05) and induced a phenotypic switch from the contractile to synthetic type. Baicalin inhibited this TGF-β1-induced phenotypic switch and consequently the excessive growth of HPASMCs in a time-dependent and dose-dependent manner (P &lt; 0.05). Furthermore, baicalin attenuated the abnormal proliferation of HPASMCs through suppression of the HIF-1α and AhR pathways.

Conclusions

Our study shows that baicalin has the potential to be used as a novel drug in the treatment of pulmonary arterial hypertension pathology by antagonizing HIF-1α and AhR expression and subsequently decreasing HPASMC proliferation and the phenotypic switch.

Socioeconomic status and asthma control in African American youth in SAGE II

OBJECTIVE

African Americans are disproportionately burdened by asthma. We assessed the individual and joint contribution of socioeconomic status (SES) on asthma morbidity among African American youth.

METHODS

We examined 686 African Americans (8-21 years) with asthma. To account for the joint effects of SES, a composite index was derived from maternal educational attainment, household income, and insurance status. Ordinal logistic regression was used to estimate the individual and joint effect of SES on asthma control. Models were adjusted for age, sex, controller medication use, in utero smoke exposure, family history of asthma, family history of rhinitis, breastfeeding, daycare attendance, and mold exposure.

RESULTS

Participants were classified as Poorly Controlled Asthma (40.8%), Partially Controlled Asthma (29.7%), or Controlled Asthma (30.2%). Of the individual SES indicators, low income was the strongest predictor of poor asthma control. Children with low income had worse asthma control than those with higher income (OR 1.39; 95% CI 0.92-2.12). The SES index ranged from 4-9. SES was associated with 17% increased odds of poor asthma control with each decrease in the index (95% CI 1.05-1.32). The SES index was associated with asthma-related symptoms, nocturnal awakenings, limited activity, and missed school days.

CONCLUSIONS

The negative effects of SES were observed along the entire socioeconomic gradient, and the adverse asthma outcomes observed in African American youth were not limited to the very poor. We also found that the SES index may be a more consistent and useful predictor of poor asthma outcomes than each indicator alone.

Development and initial psychometric properties of the Pulmonary Arterial Hypertension Symptom Scale (PAHSS)

AIMS

The aim of this study is to report the development and psychometric properties of the Pulmonary Arterial Hypertension Symptom Scale (PAHSS).

BACKGROUND

Patients with pulmonary arterial hypertension (PAH) experience multiple symptoms such as dyspnea, fatigue and chest pain, yet there is no comprehensive, validated symptom assessment tool to date.

METHODS

This study used a cross sectional design. Participants completed: socio-demographic and medical data form, the PAHSS, the Medical Outcomes Study Short Form-36 and the Profile of Mood States short form.

RESULTS

The PAHSS contains 17 symptoms measured on a 0 to 10 scale. Principal components analysis demonstrated a three factor solution for the PAHSS: pulmonary, diffuse, and cardiac. Coefficient alphas were good. Statistically significant Pearson coefficients were found between the PAHSS and the Medical Outcomes Study Short Form-36 and the Profile of Mood States short form.

CONCLUSION

Findings show that the PAHSS is a promising scale to assess symptom severity.

Presence and outcomes of kidney disease in patients with pulmonary hypertension

BACKGROUND AND OBJECTIVES

Pulmonary hypertension is associated with higher mortality rates. The associations of nondialysis-dependent CKD and all-cause mortality in patients with pulmonary hypertension were studied.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study population included those patients who underwent right heart catheterization for confirmation of pulmonary hypertension between 1996 and January 2011. Pulmonary hypertension was defined as the presence of mean pulmonary artery pressure ≥ 25 mmHg at rest measured by right heart catheterization. CKD was defined as the presence of two measurements of eGFR<60 ml/min per 1.73 m(2) 90 days apart. The risk factors associated with CKD as well as the association between CKD and death in those patients with pulmonary hypertension using logistic regression and Cox proportional hazard models were examined.

RESULTS

Of 1088 patients with pulmonary hypertension, 388 (36%) patients had CKD: 340 patients had stage 3 CKD, and 48 (4%) patients had stage 4 CKD. In the multivariable analysis, older age, higher hemoglobin, and higher mean right atrial pressures were independently associated with CKD. During a median follow-up of 3.2 years (interquartile range=1.5-5.6 years), 559 patients died. After adjusting for relevant covariates, presence of stage 3 CKD (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.66) and stage 4 CKD (hazard ratio, 2.69; 95% confidence interval, 1.88 to 3.86) was associated with all-cause mortality in those patients with pulmonary hypertension. When eGFR was examined as a continuous measure, a 5 ml/min per 1.73 m(2) lower eGFR was associated with a 5% (95% confidence interval, 1.03 to 1.07) higher hazard for death. This higher risk with CKD was similar irrespective of demographics, left ventricular function, and pulmonary capillary wedge pressure.

CONCLUSION

In a clinical population referred for right heart catheterization, presence of CKD was associated with higher all-cause mortality in those patients with pulmonary hypertension. Mechanisms that may underlie these associations warrant additional studies.

Socioeconomic status and childhood asthma in urban minority youths. The GALA II and SAGE II studies

RATIONALE

The burden of asthma is highest among socioeconomically disadvantaged populations; however, its impact is differentially distributed among racial and ethnic groups.

OBJECTIVES

To assess the collective effect of maternal educational attainment, annual household income, and insurance type on childhood asthma among minority, urban youth.

METHODS

We included Mexican American (n = 485), other Latino (n = 217), and African American (n = 1,141) children (aged 8-21 yr) with and without asthma from the San Francisco Bay Area. An index was derived from maternal educational attainment, annual household income, and insurance type to assess the collective effect of socioeconomic status on predicting asthma. Logistic regression stratified by racial and ethnic group was used to estimate adjusted odds ratios (aOR) and their 95% confidence intervals (CI). We further examined whether acculturation explained the socioeconomic-asthma association in our Latino population.

MEASUREMENTS AND MAIN RESULTS

In the adjusted analyses, African American children had 23% greater odds of asthma with each decrease in the socioeconomic index (aOR, 1.23; 95% CI, 1.09-1.38). Conversely, Mexican American children have 17% reduced odds of asthma with each decrease in the socioeconomic index (aOR, 0.83; 95% CI, 0.72-0.96) and this relationship was not fully explained by acculturation. This association was not observed in the other Latino group.

CONCLUSIONS

Socioeconomic status plays an important role in predicting asthma, but has different effects depending on race and ethnicity. Further steps are necessary to better understand the risk factors through which socioeconomic status could operate in these populations to prevent asthma.