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Flores-Flores O, Zevallos-Morales A, Pollard SL, Checkley W, Siddharthan T, Hurst JR, Bernabé-Ortiz A, Runzer-Colmenares FM, Witham MD, Parodi JF. Sarcopenia and sarcopenic obesity among community-dwelling Peruvian adults: A cross-sectional study. PLoS One 2024; 19:e0300224. [PMID: 38593158 PMCID: PMC11003669 DOI: 10.1371/journal.pone.0300224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/25/2024] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION Sarcopenia and sarcopenic obesity (SO) have emerged as significant contributors to negative health outcomes in the past decade. We aimed to estimate the prevalence of probable sarcopenia, sarcopenia, and SO in a community-dwelling population of 1151 adults aged ≥55 years in Lima, Peru. METHODS This cross-sectional study was conducted between 2018 and 2020. Sarcopenia was defined as the presence of low muscle strength (LMS) and low muscle mass (LMM) according to European (EWGSOP2), US (FNIH) and Asian (AWGS2) guidelines. We measured muscle strength by maximum handgrip strength and muscle mass using bioelectrical impedance analyzer. SO was defined as a body mass index ≥ 30 kg/m2 and sarcopenia. RESULTS The study participants had a mean age of 66.2 years (SD 7.1), age range between 60 to 92 years old, of which 621 (53.9%) were men. Among the sample, 41.7% were classified as obese (BMI ≥30.0 kg/m²). The prevalence of probable sarcopenia was estimated to be 22.7% (95%CI: 20.3-25.1) using the EWGSOP2 criteria and 27.8% (95%CI: 25.2-30.4) using the AWGS2 criteria. Sarcopenia prevalence, assessed using skeletal muscle index (SMI), was 5.7% (95%CI: 4.4-7.1) according to EWGSOP2 and 8.3% (95%CI: 6.7-9.9) using AWGS2 criteria. The prevalence of sarcopenia based on the FNIH criteria was 18.1% (95%CI: 15.8-20.3). The prevalence of SO, considering different sarcopenia definitions, ranged from 0.8% (95%CI: 0.3-1.3) to 5.0% (95%CI: 3.8-6.3). CONCLUSION Our findings reveal substantial variation in the prevalence of sarcopenia and SO, underscoring the necessity for context-specific cut-off values. Although the prevalence of SO was relatively low, this result may be underestimated. Furthermore, the consistently high proportion of probable sarcopenia and sarcopenia point to a substantial public health burden.
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Affiliation(s)
- Oscar Flores-Flores
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | - Alejandro Zevallos-Morales
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | - Suzanne L. Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida, United States of America
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | | | - Fernando M. Runzer-Colmenares
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Universidad Científica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
| | - Miles D. Witham
- NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jose F. Parodi
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
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Pollard SL, Siddharthan T, Hossen S, Rykiel NA, Flores-Flores O, Alupo P, Quaderi S, Ascencio I, Barber JA, Chandyo R, Das SK, Gianella G, Kirenga B, Grunstra K, Miranda JJ, Mohan S, Ricciardi F, Sharma AK, Shrestha L, Soares MO, Wosu AC, Hurst JR, Checkley W. Chronic Obstructive Pulmonary Disease Self-Management in Three Low- and Middle-Income Countries: A Pilot Randomized Trial. Am J Respir Crit Care Med 2023; 208:1052-1062. [PMID: 37698443 PMCID: PMC10867931 DOI: 10.1164/rccm.202303-0505oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/11/2023] [Indexed: 09/13/2023] Open
Abstract
Objectives: Chronic obstructive pulmonary disease (COPD) disproportionately affects low- and middle-income countries. Health systems are ill prepared to manage the increase in COPD cases. Methods: We performed a pilot effectiveness-implementation randomized field trial of a community health worker (CHW)-supported, 1-year self-management intervention in individuals with COPD grades B-D. The study took place in low-resource settings of Nepal, Peru, and Uganda. The primary outcome was the St. George's Respiratory Questionnaire (SGRQ) score at 1 year. We evaluated differences in moderate to severe exacerbations, all-cause hospitalizations, and the EuroQol score (EQ-5D-3 L) at 12 months. Measurements and Main Results: We randomly assigned 239 participants (119 control arm, 120 intervention arm) with grades B-D COPD to a multicomponent, CHW-supported intervention or standard of care and COPD education. Twenty-five participants (21%) died or were lost to follow-up in the control arm compared with 11 (9%) in the intervention arm. At 12 months, there was no difference in mean total SGRQ score between the intervention and control arms (34.7 vs. 34.0 points; adjusted mean difference, 1.0; 95% confidence interval, -4.2, 6.1; P = 0.71). The intervention arm had a higher proportion of hospitalizations than the control arm (10% vs. 5.2%; adjusted odds ratio, 2.2; 95% confidence interval, 0.8, 7.5; P = 0.15) at 12 months. Conclusions: A CHW-based intervention to support self-management of acute exacerbations of COPD in three resource-poor settings did not result in differences in SGRQ scores at 1 year. Fidelity was high, and intervention engagement was moderate. Although these results cannot differentiate between a failed intervention or implementation, they nonetheless suggest that we need to revisit our strategy. Clinical trial registered with www.clinicaltrials.gov (NCT03359915).
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Affiliation(s)
- Suzanne L. Pollard
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
| | - Shakir Hossen
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Natalie A. Rykiel
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | - Oscar Flores-Flores
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
- Unidad de Investigación Biomédica, A. B. PRISMA, Lima, Perú
- Facultad de Ciencias de la Salud, Universidad Cientifica del Sur, Lima, Peru
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento, Universidad de San Martin de Porres, Lima, Peru
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | | | | | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | | | - Santa K. Das
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Kelli Grunstra
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - J. Jaime Miranda
- Centro de Excelencia en enfermedades crónicas CRONICAS, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | | | | | | | | | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
| | | | - William Checkley
- Division of Pulmonary and Critical Care
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, and
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Fujita-Conrads R, Williams KN, Underhill LJ, Herrera P, Rahman N, Romani-Huacani E, Flores-Flores O, Checkley W, Pollard SL. Successes and challenges to implementing the Fondo de Inclusión Social Energético LPG access Program in Peru: novel insights from front-end implementers. Energy Sustain Dev 2023; 76:101267. [PMID: 37484495 PMCID: PMC10361398 DOI: 10.1016/j.esd.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Background Household air pollution due to the burning of solid fuels is one of the leading risk factors for disease and mortality worldwide, resulting in an estimated three million deaths annually. Peru's national LPG access program, FISE, aims to reduce the use of biomass fuels and increase access to cleaner fuels for cooking in low-income Peruvian households through public-private partnerships. Perspectives from front-end program implementers are needed to better understand barriers and facilitators to program implementation and to identify strategies to strengthen program reach, uptake, and health impact. Methods We conducted fourteen 30-60-minute, semi-structured interviews with FISE-authorized LPG vendors (also known as agents) in Puno, Peru from November to December of 2019. Questions focused on barriers and facilitators to program enrollment and participation as an LPG agent, and agents' motivations for participating in the program. Results Overall, agents expressed satisfaction with the FISE program and a willingness to continue participating in the program. Distance from main cities and the homes of program participants, knowledge of FISE and LPG stoves among community members, cell service, and lack of communication with FISE authorities were cited as barriers to implementation and LPG distribution. Agents' previous experience selling LPG, as well as their social networks and understanding of the health impacts of household air pollution, aided agents in more effectively navigating the system of FISE rules and regulations and in better serving their clients. Many agents were motivated to participate in FISE because they saw it as a service to their community and were willing to find ways to prioritize the needs of beneficiaries. Conclusion The FISE program provides an example of how a large-scale national program can successfully partner with local private enterprises for program implementation. Building upon the strengths of community-based LPG agents, educating community members on the use and benefits of LPG, incentivizing, and supporting delivery services, and improving communication will be key for increasing program utilization and exclusive use of LPG, and improving health outcomes among Peru's most vulnerable populations.
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Affiliation(s)
- Ryanne Fujita-Conrads
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Lindsay J Underhill
- Division of Cardiology, School of Medicine, Washington University in St. Louis, St. Louis, USA
| | - Phabiola Herrera
- Division of Pulmonary, Critical Care and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Nihaal Rahman
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | | | - Oscar Flores-Flores
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Universidad Científica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Suzanne L Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
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Florman KE, Siddharthan T, Pollard SL, Alupo P, Barber JA, Chandyo RK, Flores-Flores O, Kirenga B, Mendes RG, Miranda JJ, Mohan S, Ricciardi F, Rykiel NA, Sharma AK, Wosu AC, Checkley W, Hurst JR. Unmet Diagnostic and Therapeutic Opportunities for Chronic Obstructive Pulmonary Disease in Low- and Middle-Income Countries. Am J Respir Crit Care Med 2023; 208:442-450. [PMID: 37369142 PMCID: PMC10449073 DOI: 10.1164/rccm.202302-0289oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/27/2023] [Indexed: 06/29/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) is a prevalent and burdensome condition in low- and middle-income countries (LMICs). Challenges to better care include more effective diagnosis and access to affordable interventions. There are no previous reports describing therapeutic needs of populations with COPD in LMICs who were identified through screening. Objectives: To describe unmet therapeutic need in screening-detected COPD in LMIC settings. Methods: We compared interventions recommended by the international Global Initiative for Chronic Obstructive Lung Disease COPD strategy document, with that received in 1,000 people with COPD identified by population screening at three LMIC sites in Nepal, Peru, and Uganda. We calculated costs using data on the availability and affordability of medicines. Measurement and Main Results: The greatest unmet need for nonpharmacological interventions was for education and vaccinations (applicable to all), pulmonary rehabilitation (49%), smoking cessation (30%), and advice on biomass smoke exposure (26%). Ninety-five percent of the cases were previously undiagnosed, and few were receiving therapy (4.5% had short-acting β-agonists). Only three of 47 people (6%) with a previous COPD diagnosis had access to drugs consistent with recommendations. None of those with more severe COPD were accessing appropriate maintenance inhalers. Even when available, maintenance treatments were unaffordable, with 30 days of treatment costing more than a low-skilled worker's daily average wage. Conclusions: We found a significant missed opportunity to reduce the burden of COPD in LMIC settings, with most cases undiagnosed. Although there is unmet need in developing novel therapies, in LMICs where the burden is greatest, better diagnosis combined with access to affordable interventions could translate to immediate benefit.
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Affiliation(s)
- Katia E.H. Florman
- Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
| | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | - Ram K. Chandyo
- Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal
| | - Oscar Flores-Flores
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento, Universidad de San Martin de Porres, Lima, Peru
- Facultad de Ciencias de la Salud, Universidad Cientíifica del Sur, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Renata Gonçalves Mendes
- Cardiopulmonary Physiotherapy Laboratory, Federal University of Sao Carlos, Sao Carlos, Brazil
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases and
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London, United Kingdom
| | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Arun K. Sharma
- Child Health Research Project, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal; and
| | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training and
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
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Flores-Flores O, Zevallos-Morales A, Pollard SL, Checkely W, Siddharthan T, Hurst JR, Bernabé-Ortiz A, Runzer-Colmenares FM, Witham M, Parodi JF. Sarcopenia and sarcopenic obesity among community-dwelling Peruvian adults: A cross-sectional study. Res Sq 2023:rs.3.rs-3031470. [PMID: 37398477 PMCID: PMC10312954 DOI: 10.21203/rs.3.rs-3031470/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Background Sarcopenia and sarcopenic obesity (SO) have emerged as significant contributors to negative health outcomes in the past decade. However, there remains a lack of consensus on the criteria and cut-off thresholds for assessing sarcopenia and SO. Moreover, limited data are available on the prevalence of these conditions in Latin American countries. To address this evidence gap, we aimed to estimate the prevalence of probable sarcopenia, sarcopenia, and SO in a community-dwelling population of 1151 adults aged ≥ 55 years in Lima, Peru. Methods Data collection for this cross-sectional study was conducted between 2018 and 2020 in two urban low-resource settings in Lima, Peru. Sarcopenia was defined as the presence of low muscle strength (LMS) and low muscle mass (LMM) according to European (EWGSOP2), US (FNIH) and Asian (AWGS) guidelines. We measured muscle strength by maximum handgrip strength; muscle mass using a whole-body single-frequency bioelectrical impedance analyzer, and physical performance using the Short Physical Performance Battery and 4-meter gait speed. SO was defined as a body mass index ≥ 30 kg/m2 and sarcopenia. Results The study participants had a mean age of 66.2 years (SD 7.1), of which 621 (53.9%) were men, and 41.7% were classified as obese (BMI ≥ 30.0 kg/m2). The prevalence of probable sarcopenia was estimated to be 22.7% (95%CI: 20.3-25.1) using the EWGSOP2 criteria and 27.8% (95%CI:25.2-30.4) using the AWGS criteria. Sarcopenia prevalence, assessed using skeletal muscle index (SMI), was 5.7% (95%CI: 4.4-7.1) according to EWGSOP2 and 8.3% (95%CI: 6.7-9.9) using AWGS criteria. The prevalence of sarcopenia based on the FNIH criteria was 18.1% (95%CI: 15.8-20.3). The prevalence of SO, considering different sarcopenia definitions, ranged from 0.8% (95%CI: 0.3-1.3) to 5.0% (95%CI: 3.8-6.3). Conclusions Our findings reveal substantial variation in the prevalence of sarcopenia and SO when using different guidelines, underscoring the necessity for context-specific cut-off values. Nevertheless, regardless of the chosen guideline, the prevalence of probable sarcopenia and sarcopenia among community-dwelling older adults in Peru remains noteworthy.
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Flores-Flores O, Otero-Oyague D, Rey-Evangelista L, Zevallos-Morales A, Ramos-Bonilla G, Carrión I, Patiño V, Pollard SL, Parodi JF, Hurst JR, Gallo JJ, Reynolds R. Agency and Mental Health Among Peruvian Older Adults During the COVID-19 Lockdown. J Gerontol B Psychol Sci Soc Sci 2023; 78:1109-1117. [PMID: 36869737 PMCID: PMC10214643 DOI: 10.1093/geronb/gbad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES To explore the experiences of older Peruvian adults living in urban areas of Lima under lockdown due to the National COVID-19 Emergency, this study analyzes how older adults (aged 60 and older) exercise agency while also living with the negative impacts of coronavirus disease 2019 (COVID-19) and related control measures. METHODS Between August and December 2020, our research team conducted a telephone-based, qualitative study, in which we undertook semistructured interviews with a purposive sample of low-income older adults living with chronic multimorbidities and limited resources. Forty older adults, 24 women and 16 men, with a mean age of 72 years, participated in the study. For data analysis, we employed thematic analysis with a predominantly inductive approach. RESULTS Older adults demonstrated several forms of agency to regulate emotions, maintain crucial bonds, foster social relationships, and seek economic and food security. Older adults experienced entertainment and support by caring for pets, undertaking farm work, and practicing their religious beliefs. For several participants and their families, quarantine was an opportunity to strengthen family relationships and learn new technologies. Older adults and their families reorganized themselves to assume new roles and perform activities that improved self-worth and confidence, thereby improving their well-being and mental health. DISCUSSION Peruvian older adults exerted agency in different ways to respond to and sustain their mental health during the COVID-19 lockdown. Policymakers should value and recognize the agency of older adults when planning future health responses.
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Affiliation(s)
- Oscar Flores-Flores
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | - Diego Otero-Oyague
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
- Facultad de Psicología, Grupo de Investigación en Psicología Comunitaria (GIPC), Pontificia Universidad Católica del Perú, San Miguel, Peru
| | - Lorena Rey-Evangelista
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | - Alejandro Zevallos-Morales
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | - Gabriela Ramos-Bonilla
- Facultad de Antropología, Grupo de Investigación Edades de la Vida y la Educación (EVE), Pontificia Universidad Católica del Perú, San Miguel, Peru
| | - Ivonne Carrión
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
| | | | - Suzanne L Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jose F Parodi
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Joseph J Gallo
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of General Internal Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland,USA
| | - Rodney Reynolds
- High Point University, Department of Sociology and Anthropology, High Point, North Carolina, USA
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Jackson P, Padalkar R, Katagira W, Mortimer K, Rykiel NA, Robertson NM, Pollard SL, Alupo P, Checkley W, Kirenga B, Siddharthan T. Development and validation of an interstitial lung disease exposure questionnaire for sub-Saharan Africa. ERJ Open Res 2022; 8:00205-2022. [PMID: 36578631 PMCID: PMC9792102 DOI: 10.1183/23120541.00205-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/06/2022] [Indexed: 02/01/2023] Open
Abstract
Background American Thoracic Society/European Respiratory Society guidelines recommend context-specific exposure assessments to diagnose interstitial lung disease (ILD). In sub-Saharan Africa, ILD diagnoses are rare, and locally validated ILD exposure questionnaires are not used. Methods A physician-administered ILD exposure questionnaire was developed using a four-step mixed-methods modified Delphi approach. First, ILD questionnaires from high-income countries and data from Pneumotox were reviewed, compiled and face-validated. Second, a local pilot group of ILD experts ranked item relevance using a Likert scale and suggested additions. Third, the questionnaire format and pilot rankings were addressed in a focus group discussion that was analysed using grounded theory. Finally, following focus group discussion modifications, the resulting items (with three duplicate item groups for evaluation of internal consistency) were ranked for importance by members of the Pan-African Thoracic Society (PATS). Results Face validation resulted in 82 items in four categories: "Smoking and Drugs", "Environmental Exposures", "Occupations" and "Medications". Pilot group (n=10) ranking revealed 27 outliers and 30 novel suggestions. Focus group (n=12) discussion resulted in 10 item deletions, 14 additions and 22 re-wordings; themes included desire for extensive questionnaires and stigma sensitivity. Final validation involved 58 PATS members (mean±sd age 46±10.6 years, 76% male, from 17 countries) ranking 84 items derived from previous steps and three duplicate question groups. The questionnaire was internally consistent (Cronbach's α >0.80) and ultimately included 73 items. Conclusion This mixed-methods study included experts from 17 countries in sub-Saharan Africa and successfully developed a 73-item ILD exposure questionnaire for sub-Saharan Africa. African pulmonary experts valued region-specific additions and ranked several items from existing ILD questionnaires as unimportant.
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Affiliation(s)
- Peter Jackson
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA,Corresponding author: Peter Jackson ()
| | - Roma Padalkar
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | | | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | | | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA,Division of Pulmonary and Critical Care, University of Miami, Miami, FL, USA
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Mohan S, Cárdenas MK, Ricciardi F, Siddharthan T, Pollard SL, Rykiel NA, Checkley W, Hurst JR, Soares MO. Cost-Accuracy Analysis of Chronic Obstructive Pulmonary Disease Screening in Low- and Middle-Income Countries. Am J Respir Crit Care Med 2022; 206:353-356. [PMID: 35442182 PMCID: PMC9890258 DOI: 10.1164/rccm.202201-0071le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - John R. Hurst
- University College LondonLondon, United Kingdom,Corresponding author (e-mail: )
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9
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Siddharthan T, Pollard SL, Quaderi SA, Rykiel NA, Wosu AC, Alupo P, Barber JA, Cárdenas MK, Chandyo RK, Flores-Flores O, Kirenga B, Miranda JJ, Mohan S, Ricciardi F, Sharma AK, Das SK, Shrestha L, Soares MO, Checkley W, Hurst JR. Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings. JAMA 2022; 327:151-160. [PMID: 35015039 PMCID: PMC8753498 DOI: 10.1001/jama.2021.23065] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Most of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs), with significant economic effects. OBJECTIVE To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age- and sex-stratified sample of the population 40 years or older. EXPOSURES Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [<250 L/min for females and <350 L/min for males]), the COPD in LMICs Assessment questionnaire (COLA-6; range, 0-5; high risk indicated by a score of 4 or more), and the Lung Function Questionnaire (LFQ; range, 0-25; high risk indicated by a score of 18 or less) were assessed against a reference standard diagnosis of COPD using quality-assured postbronchodilator spirometry. CAPTURE and COLA-6 include a measure of PEF. MAIN OUTCOMES AND MEASURES The primary outcome was discriminative accuracy of the tools in identifying COPD as measured by area under receiver operating characteristic curves (AUCs) with 95% CIs. Secondary outcomes included sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS Among 10 709 adults who consented to participate in the study (mean age, 56.3 years (SD, 11.7); 50% female), 35% had ever smoked, and 30% were currently exposed to biomass smoke. The unweighted prevalence of COPD at the 3 sites was 18.2% (642/3534 participants) in Nepal, 2.7% (97/3550) in Peru, and 7.4% (264/3580) in Uganda. Among 1000 COPD cases, 49.3% had clinically important disease (Global Initiative for Chronic Obstructive Lung Disease classification B-D), 16.4% had severe or very severe airflow obstruction (forced expiratory volume in 1 second <50% predicted), and 95.3% of cases were previously undiagnosed. The AUC for the screening instruments ranged from 0.717 (95% CI, 0.677-0.774) for LFQ in Peru to 0.791 (95% CI, 0.770-0.809) for COLA-6 in Nepal. The sensitivity ranged from 34.8% (95% CI, 25.3%-45.2%) for COLA-6 in Nepal to 64.2% (95% CI, 60.3%-67.9%) for CAPTURE in Nepal. The mean time to administer the instruments was 7.6 minutes (SD 1.11), and data completeness was 99.5%. CONCLUSIONS AND RELEVANCE This study demonstrated that screening instruments for COPD were feasible to administer in 3 low- and middle-income settings. Further research is needed to assess instrument performance in other low- and middle-income settings and to determine whether implementation is associated with improved clinical outcomes.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Suzanne L. Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Now with the National Institutes of Health, Bethesda, Maryland
| | | | - Natalie A. Rykiel
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Adaeze C. Wosu
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Julie A. Barber
- Department of Statistical Science, University College London, London, United Kingdom
| | - Maria Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ram K. Chandyo
- Department of Community Medicine, Kathmandu Medical College, Nepal
| | - Oscar Flores-Flores
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Biomedical Research Unit, A.BPRISMA, Lima, Peru
- Centro de Investigación del Envejecimiento (CIEN), Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London, United Kingdom
| | - Arun K. Sharma
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Santa Kumar Das
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Laxman Shrestha
- Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Marta O. Soares
- Centre for Health Economics, University of York, York, United Kingdom
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
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Siddharthan T, Robertson NM, Rykiel NA, Underhill LJ, Rahman N, Kafle S, Mohan S, Padalkar R, McKeown S, Flores-Flores O, Quaderi SA, Alupo P, Kalyesubula R, Kirenga B, Luo J, Cárdenas MK, Gianella G, Miranda JJ, Checkley W, Hurst JR, Pollard SL. Availability, affordability and access to essential medications for asthma and chronic obstructive pulmonary disease in three low- and middle-income country settings. PLOS Glob Public Health 2022; 2:e0001309. [PMID: 36962898 PMCID: PMC10021856 DOI: 10.1371/journal.pgph.0001309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Despite the rising burden of chronic respiratory disease globally, and although many respiratory medications are included in the World Health Organization Essential Medications List (WHO-EML), there is limited information concerning the availability and affordability of treatment drugs for respiratory conditions in low- and middle-income countries (LMICs). METHODS All public and private pharmacies in catchment areas of the Global Excellence in COPD outcomes (GECo) study sites in Bhaktapur, Nepal, Lima, Peru, and Nakaseke, Uganda, were approached in 2017-2019 to assess pricing and availability of medications for the management of asthma and COPD. RESULTS We surveyed all 63 pharmacies in respective study areas in Nepal (95.2% private), 104 pharmacies in Peru (94.2% private) and 53 pharmacies in Uganda (98.1% private). The availability of any medication for respiratory disease was higher in private (93.3%) compared to public (73.3%) pharmacies. Salbutamol (WHO-EML) monotherapy in any formulation was the most commonly available respiratory medication among the three sites (93.7% Nepal, 86.5% Peru and 79.2% Uganda) while beclomethasone (WHO-EML) was only available in Peru (33.7%) and Nepal (22%). LABA-LAMA combination therapy was only available in Nepal (14.3% of pharmacies surveyed). The monthly treatment cost of respiratory medications was lowest in Nepal according to several cost metrics: the overall monthly cost, the median price ratio comparing medication costs to international reference prices at time of survey in dollars, and in terms of days' wages of the lowest-paid government worker. For the treatment of intermittent asthma, defined as 100 mcg Salbutamol/Albuterol inhaler, days' wages ranged from 0.47 days in Nepal and Peru to 3.33 days in Uganda. CONCLUSION The availability and pricing of respiratory medications varied across LMIC settings, with medications for acute care of respiratory diseases being more widely available than those for long-term management.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, University of Miami, Miami, Florida, United States of America
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Nicole M Robertson
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
- University of Kentucky School of Medicine, Louisville, Kentucky, United States of America
| | - Natalie A Rykiel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Lindsay J Underhill
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Nihaal Rahman
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sujan Kafle
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Sakshi Mohan
- Centre for Health Economics, University of York, York, United Kingdom
| | - Roma Padalkar
- Rowan University School of Osteopathic Medicine, Glassboro, New Jersey, United States of America
| | - Sarah McKeown
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Oscar Flores-Flores
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
| | | | - Patricia Alupo
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | | | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Jing Luo
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Maria Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Gonzalo Gianella
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John R Hurst
- Respiratory Medicine, University College London, London, United Kingdom
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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11
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Siddharthan T, Pollard SL, Jackson P, Robertson NM, Wosu AC, Rahman N, Padalkar R, Sekitoleko I, Namazzi E, Alupo P, Hurst JR, Kalyesubula R, Dowdy D, Wise R, Barnes PJ, Checkley W, Kirenga B. Effectiveness of low-dose theophylline for the management of biomass-associated COPD (LODOT-BCOPD): study protocol for a randomized controlled trial. Trials 2021; 22:213. [PMID: 33726828 PMCID: PMC7962083 DOI: 10.1186/s13063-021-05163-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND COPD is a leading cause of death globally, with the majority of morbidity and mortality occurring in low- and middle-income country (LMIC) settings. While tobacco-smoke exposure is the most important risk factor for COPD in high-income settings, household air pollution from biomass smoke combustion is a leading risk factor for COPD in LMICs. Despite the high burden of biomass smoke-related COPD, few studies have evaluated the efficacy of pharmacotherapy in this context. Currently recommended inhaler-based therapy for COPD is neither available nor affordable in most resource-limited settings. Low-dose theophylline is an oral, once-a-day therapy, long used in high-income countries (HICs), which has been proposed for the management of COPD in LMICs in the absence of inhaled steroids and/or bronchodilators. The Low-dose Theophylline for the Management of Biomass-Associated COPD (LODOT-BCOPD) trial investigates the clinical efficacy and cost-effectiveness of low-dose theophylline for the management of biomass-related COPD in a low-income setting. METHODS LODOT-BCOPD is a randomized, double-blind, placebo-controlled trial to test the efficacy of low-dose theophylline in improving respiratory symptoms in 110 participants with moderate to severe COPD in Central Uganda. The inclusion criteria are as follows: (1) age 40 to 80 years, (2) full-time resident of the study area, (3) daily biomass exposure, (4) post-bronchodilator FEV1/FVC below the 5th percentile of the Global Lung Initiative mixed ethnic reference population, and (5) GOLD Grade B-D COPD. Participants will be randomly assigned to receive once daily low-dose theophylline (200 mg ER, Unicontin-E) or placebo for 52 weeks. All participants will receive education about self-management of COPD and rescue salbutamol inhalers. We will measure health status using the St. George's Respiratory Questionnaire (SGRQ) and quality of life using the EuroQol-5D (EQ-5D) at baseline and every 6 months. In addition, we will assess household air pollution levels, serum inflammatory biomarkers (fibrinogen, hs-CRP), and theophylline levels at baseline, 1 month, and 6 months. The primary outcome is change in SGRQ score at 12 months. Lastly, we will assess the cost-effectiveness of the intervention by calculating quality-adjusted life years (QALYs) from the EQ-5D. TRIAL REGISTRATION ClinicalTrials.gov NCT03984188 . Registered on June 12, 2019 TRIAL ACRONYM: Low-dose Theophylline for the Management of Biomass-Associated COPD (LODOT-BCOPD).
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA. .,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA.
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Peter Jackson
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, USA
| | - Nicole M Robertson
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Adaeze C Wosu
- Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Nihaal Rahman
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Roma Padalkar
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Isaac Sekitoleko
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Esther Namazzi
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Patricia Alupo
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Robert Kalyesubula
- Department of Physiology, Makerere College of Health Sciences, Kampala, Uganda.,African Community Center for Social Sustainability, Nakaseke, Uganda
| | - David Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Robert Wise
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Peter J Barnes
- National Health and Lung Institute, Imperial College, London, UK
| | - William Checkley
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Bruce Kirenga
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
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12
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Siddharthan T, Wosu AC, Pollard SL, Hossen S, Alupo P, Shade T, Kalyesubula R, Quaderi S, Wise RA, Hurst JR, Kirenga B, Checkley W. A Novel Case-Finding Instrument for Chronic Obstructive Pulmonary Disease in Low- and Middle-Income Country Settings. Int J Chron Obstruct Pulmon Dis 2020; 15:2769-2777. [PMID: 33173289 PMCID: PMC7648534 DOI: 10.2147/copd.s268076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022] Open
Abstract
Background Low- and middle-income countries (LMICs) account for >90% of deaths and illness episodes related to COPD; however, this condition is commonly underdiagnosed in these settings. Case-finding instruments for COPD may improve diagnosis and identify individuals that need treatment, but few have been validated in resource-limited settings. Methods We conducted a population-based cross-sectional study in Uganda to assess the diagnostic accuracy of a respiratory symptom, exposure and functional questionnaire in combination with peak expiratory flow for COPD diagnosis using post-bronchodilator FEV1/FVC z-score below the 5th percentile as the gold standard. We included locally relevant exposure questions and statistical learning techniques to identify the most important risk factors for COPD. We used 80% of the data to develop the case-finding instrument and validated it in the remaining 20%. We evaluated for calibration and discrimination using standard approaches. The final score, COLA (COPD in LMICs Assessment), included seven questions, age and pre-bronchodilator peak expiratory flow. Results We analyzed data from 1,173 participants (average age 47 years, 46.9% male, 4.5% with COPD) with acceptable and reproducible spirometry. The seven questions yielded a cross-validated area-under-the-curve [AUC] of 0.68 (95% CI 0.61-0.75) with higher scores conferring greater odds of COPD. The inclusion of peak expiratory flow and age improved prediction in a validation sample (AUC=0.83, 95% CI 0.78-0.88) with a positive predictive value of 50% and a negative predictive value of 96%. The final instrument (COLA) included seven questions, age and pre-bronchodilator peak expiratory flow. Conclusion COLA predicted COPD in urban and rural settings in Uganda has high calibration and discrimination, and could serve as a simple, low-cost screening tool in resource-limited settings.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Adaeze C Wosu
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Patricia Alupo
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Timothy Shade
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Kalyesubula
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Robert A Wise
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Bruce Kirenga
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - On behalf of LiNK Cohort Study Investigators
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Makerere Lung Institute, Makerere University, Kampala, Uganda
- UCL Respiratory, University College London, London, UK
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13
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Namburar S, Checkley W, Flores-Flores O, Romero KM, Fraser KT, Hansel NN, Pollard SL. Risk Factors for Physical Inactivity Among Children With and Without Asthma Living in Peri-Urban Communities of Lima, Peru. J Phys Act Health 2020; 17:816-822. [PMID: 32663801 DOI: 10.1123/jpah.2019-0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 03/30/2020] [Accepted: 05/15/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The authors sought to examine physical activity patterns among children with and without asthma in 2 peri-urban communities in Lima, Peru, to identify socioeconomic and demographic risk factors for physical inactivity and examine the relationship between asthma and physical activity. METHODS The authors measured mean steps per day in 114 children (49 with asthma and 65 without) using pedometers worn over a 1-week period. They also used the 3-day physical activity recall to determine the most common activities carried out by children. RESULTS The authors found that 84.2% of the children did not meet the daily international physical activity recommendations. Girls took significantly fewer mean steps per day as compared with boys (2258 fewer steps, 95% confidence interval, 1042-3474), but no other factors, including asthma status, showed significant differences in the mean daily steps. Mean daily steps were positively associated with higher socioeconomic status among girls, and current asthma had a larger inverse effect on daily steps in boys when compared with girls. CONCLUSION Physical activity levels were below recommended guidelines in all children. There is a need for policy and neighborhood-level interventions to address low physical activity levels among Peruvian youth. Special focus should be given to increasing the physical activity levels in girls.
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14
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Nagourney EM, Robertson NM, Rykiel N, Siddharthan T, Alupo P, Encarnacion M, Kirenga BJ, Kalyesubula R, Quaderi SA, Hurst JR, Checkley W, Pollard SL. Illness representations of chronic obstructive pulmonary disease (COPD) to inform health education strategies and research design-learning from rural Uganda. Health Educ Res 2020; 35:258-269. [PMID: 32702133 PMCID: PMC7787214 DOI: 10.1093/her/cyaa016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
More than 90% of chronic obstructive pulmonary disease (COPD)-related deaths occur in low- and middle-income countries; however, few studies have examined the illness experiences of individuals living with and providing treatment for COPD in these settings. This study characterizes illness representations for COPD in Nakaseke, Uganda from the perspectives of health care providers, village health teams and community members (CMs) with COPD. We conducted 40 in-depth, semi-structured interviews (16 health care providers, 12 village health teams and 12 CMs, aged 25-80 years). Interviews were analyzed using inductive coding, and the Illness Representations Model guided our analysis. Stakeholder groups showed concordance in identifying causal mechanisms of COPD, but showed disagreement in reasons for care seeking behaviors and treatment preferences. CMs did not use a distinct label to differentiate COPD from other respiratory illnesses, and described both the physical and social consequences of COPD. Local representations can inform development of adapted educational and self-management tools for COPD.
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Affiliation(s)
- Emily M Nagourney
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Nicole M Robertson
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Natalie Rykiel
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Trishul Siddharthan
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Patricia Alupo
- College of Health Sciences Lung Institute, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Marysol Encarnacion
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Bruce J Kirenga
- College of Health Sciences Lung Institute, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
- Department of Medicine, College of Health Sciences, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Robert Kalyesubula
- Department of Physiology, College of Health Sciences, Makerere University, Upper Mulago Hill Road, Kampala, Uganda
| | - Shumonta A Quaderi
- UCL Respiratory, University College London, Gower Street, London, WC1E 6BT, UK
| | - John R Hurst
- UCL Respiratory, University College London, Gower Street, London, WC1E 6BT, UK
| | - William Checkley
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
| | - Suzanne L Pollard
- Department fo International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21205, USA
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15
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Flores-Flores O, Zevallos-Morales A, Carrión I, Pawer D, Rey L, Checkley W, Hurst JR, Siddharthan T, Parodi JF, Gallo JJ, Pollard SL. "We can't carry the weight of the whole world ": illness experiences among Peruvian older adults with symptoms of depression and anxiety. Int J Ment Health Syst 2020; 14:49. [PMID: 32670400 PMCID: PMC7350592 DOI: 10.1186/s13033-020-00381-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/03/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Despite the high levels of depression and anxiety symptoms in old age, the use of mental health services in this population is low. Help-seeking behaviors are shaped by how an individual perceives and experiences their illness. The objective of this study was to characterize the illness experiences of Peruvian older adults with depression and anxiety symptoms in order to lay the foundation for tailored community-based mental health interventions. METHODS In this qualitative study, we conducted in-depth interviews with a purposively selected sample of older adults (≥ 60 years) from peri-urban areas of Lima, Peru. We included individuals with only depressive symptoms (Patient Health Questionnaire-9 ≥ 10), only anxiety symptoms (Beck Anxiety Inventory ≥ 16), with depressive and anxiety symptoms, and older adults who mentioned they had received mental health treatment/care. The interview guide included the following topics: perceptions and experiences about depression and anxiety; perceptions about the relationship between physical chronic diseases and mental health; experiences with mental health professionals and treatments, and coping mechanisms. Data collection was conducted between October 2018 and February 2019. RESULTS We interviewed 38 participants (23 women, 15 men) with a mean age of 67.9 years. Participants' ideas and perceptions of depression and anxiety showed considerable overlap. Participants attributed depression and anxiety mainly to familial and financial problems, loneliness, loss of independence and past traumatic experiences. Coping strategies used by older adults included 'self-reflection and adaptation' to circumstances, 'do your part', and seeking 'emotional support' mainly from non-professionals (relatives, friends, acquaintances, and religion). CONCLUSIONS Illness experiences of depression and anxiety set the pathway for tailored community-based mental health interventions for older adults. Overlapping narratives and perceptions of depression and anxiety suggest that these conditions should be addressed together. Mental health interventions should incorporate addressing areas related to depression and anxiety such as prevention of loss of independence, trauma, and loneliness. Good acceptability of receiving emotional support for non-professionals might offer an opportunity to incorporate them when delivering mental health care to older adults.
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Affiliation(s)
- Oscar Flores-Flores
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Universidad de San Martin de Porres, Lima, Peru
- Asociación Benéfica PRISMA, Lima, Peru
| | | | - Ivonne Carrión
- Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
| | - Dalia Pawer
- Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
| | - Lorena Rey
- Pontificia Universidad Católica del Perú, Lima, Peru
| | - W. Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD USA
| | - J. R. Hurst
- UCL Respiratory, University College London, London, UK
| | - T. Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Jose F. Parodi
- Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Universidad de San Martin de Porres, Lima, Peru
| | - Joseph J. Gallo
- Department of Mental Health, Bloomberg School of Public Health, Baltimore, MD USA
- Department of General Internal Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Suzanne L. Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD USA
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16
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Romani ED, Siddharthan T, Lovatón N, Alvítez-Luna CC, Flores-Flores O, Pollard SL. Implementation of an intervention to improve the adoption of asthma self-management practices in Peru: Asthma Implementation Research (AIRE) randomized trial study protocol. Trials 2020; 21:377. [PMID: 32366314 PMCID: PMC7199375 DOI: 10.1186/s13063-020-4207-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/25/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Asthma is the most common chronic disease among children worldwide, with 80% of asthma-related deaths occurring in low- and middle-income countries (LMICs). While evidence-based guidelines exist for asthma treatment and management, adoption of guideline-based practices is low in high-income country and LMIC settings alike. While asthma prevalence among children and adolescents in Lima, Peru is in the range of 13%–19.6%, our data suggest that < 5% of children in low-resource communities are currently taking guideline-based therapies. There is an urgent need for effective, locally tailored solutions to address the asthma treatment gap in low-income communities in Peru. Methods This study aims to develop and test a locally adapted intervention package to improve adoption of self-management practices and utilization of preventive health services for asthma among children in Lima Norte. The intervention package was designed using a systematic, theory-based framework (Capability, Opportunity, Motivation – Behavior Framework) and is rooted in a multi-phased formative research approach. The main study design is an individually randomized implementation-effectiveness hybrid trial enrolling 110 children aged 5–17 years with asthma and their caregivers. Families allocated to the treatment group receive the supported self-management intervention package, while families allocated to the control group receive the standard of care plus asthma education. We will follow participants monthly for six months and evaluate asthma control (Asthma Control Test), healthcare utilization, and medication adherence (Adherence to Refills and Medications Scale). Disease-specific quality of life for children (Pediatric Asthma Quality of Life Questionnaire) and caregivers (Pediatric Asthma Caregiver’s Quality of Life Questionnaire) will be evaluated at baseline, 3 months, and 6 months. We will also evaluate acceptability, feasibility, and fidelity of the intervention using mixed methods approaches. Discussion The long-term goal of this study is to disseminate locally appropriate asthma management strategies in LMIC settings. This study will contribute to the body of knowledge surrounding approaches for developing and evaluating intervention strategies for asthma using systematic, theory-based approaches grounded in local context. Such strategies have the potential to inform the development and adaptation of appropriate and scalable solutions for asthma management in LMIC settings. Trial registration ClinicalTrials.gov, NCT03986177. Registered on 14 June 2019.
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Affiliation(s)
- Elisa D Romani
- Biomedical Research Unit, Asociación Benéfica PRISMA, Carlos González 251, San Miguel, Lima, Peru.,Center for Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Trishul Siddharthan
- Center for Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Ste 516, Baltimore, MD, USA
| | - Nair Lovatón
- Pediatric Pulmonology Unit, Cayetano Heredia Hospital, Av. Honorio Delgado 262, San Martín de Porres, Baltimore, Peru
| | - Carol C Alvítez-Luna
- Pediatric Pulmonology Unit, Cayetano Heredia Hospital, Av. Honorio Delgado 262, San Martín de Porres, Baltimore, Peru
| | - Oscar Flores-Flores
- Biomedical Research Unit, Asociación Benéfica PRISMA, Carlos González 251, San Miguel, Lima, Peru.,Center for Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Universidad de San Martin de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru.,Universidad Cientifica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
| | - Suzanne L Pollard
- Center for Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA. .,Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Ste 516, Baltimore, MD, USA. .,Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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17
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Tarazona-Meza CE, Hanson C, Pollard SL, Romero Rivero KM, Galvez Davila RM, Talegawkar S, Rojas C, Rice JL, Checkley W, Hansel NN. Dietary patterns and asthma among Peruvian children and adolescents. BMC Pulm Med 2020; 20:63. [PMID: 32171269 PMCID: PMC7071620 DOI: 10.1186/s12890-020-1087-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/17/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Asthma is one of the conditions that contributes to the global burden of respiratory diseases and has been previously associated with diet intake. The goal of this study was to determine the relationship between diet, assessed by a developed score, and asthma in Peruvian children. METHODS This study was a cross sectional analysis nested within an unmatched case-control study of children in two peri-urban communities of Lima, Peru. We evaluated 767 children and adolescents (573 with asthma, 194 controls) between 9 and 19 years. Diet was assessed using a food frequency questionnaire (FFQ), with food groups classified as "healthy" or "unhealthy". Asthma control, Lung function and atopy were assessed by Asthma Control Test, Spirometry and InmunoCAP 250 test, respectively. RESULTS Mean age of participants was 13.8 years (SD 2.6). Mean diet score was 5 (SD 1.23; range 2-8). Healthy Diet Score was associated with asthma status [OR 0.83, 95% CI (0.72, 0.95), p = 0.009] in adjusted analysis. Thus, participants with higher HDS, had lower odds of asthma. In sensitivity analyses, when adjusting for atopy, results did not change significantly. [OR 0.85, 95% CI (0.72, 0.99); p = 0.04]. No association between the HDS and asthma control, FEV1, nor FeNO were observed. Atopy did not modify the association between diet and asthma outcomes. CONCLUSIONS In our study cohort, better diet quality was associated with lower odds of asthma, but was not associated with asthma control. Diet modification may be a potential intervention to impact the increasing prevalence of this disease.
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Affiliation(s)
- Carla E Tarazona-Meza
- Center for Non-Communicable Diseases Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Biomedical Research Unit, Asociacion Benefica PRISMA, Carlos Gonzales 251, San Miguel, Lima, Peru
| | - Corrine Hanson
- Division of Medical Nutrition Education, University of Nebraska Medical Center, 984035 Nebraska Medical Center, Omaha, NE, 68198-4035, USA
| | - Suzanne L Pollard
- Center for Non-Communicable Diseases Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Johns Hopkins Bayview, 1830 E, Monument, 5th Floor, Baltimore, MD, 21205, USA
| | - Karina M Romero Rivero
- Biomedical Research Unit, Asociacion Benefica PRISMA, Carlos Gonzales 251, San Miguel, Lima, Peru.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Johns Hopkins Bayview, 1830 E, Monument, 5th Floor, Baltimore, MD, 21205, USA
| | - Rocio M Galvez Davila
- Biomedical Research Unit, Asociacion Benefica PRISMA, Carlos Gonzales 251, San Miguel, Lima, Peru
| | - Sameera Talegawkar
- Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire Ave, NW. 7th Floor, Washington, DC, 20052, USA
| | - Carlos Rojas
- Monitoring and Evaluation Office, UNICEF Peru, Parque Meliton Porras No. 350, Miraflores, Lima, Peru
| | - Jessica L Rice
- Division of Pediatric Pulmonology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Center for Non-Communicable Diseases Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Johns Hopkins Bayview, 1830 E, Monument, 5th Floor, Baltimore, MD, 21205, USA
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Johns Hopkins Bayview, 1830 E, Monument, 5th Floor, Baltimore, MD, 21205, USA.
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18
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Quinn AK, Neta G, Sturke R, Olopade CO, Pollard SL, Sherr K, Rosenthal JP. Adapting and Operationalizing the RE-AIM Framework for Implementation Science in Environmental Health: Clean Fuel Cooking Programs in Low Resource Countries. Front Public Health 2019; 7:389. [PMID: 31921753 PMCID: PMC6932973 DOI: 10.3389/fpubh.2019.00389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 12/02/2019] [Indexed: 12/27/2022] Open
Abstract
Introduction: The use of models and frameworks to design and evaluate strategies to improve delivery of evidence-based interventions is a foundational element of implementation science. To date, however, evaluative implementation science frameworks such as Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) have not been widely employed to examine environmental health interventions. We take advantage of a unique opportunity to utilize and iteratively adapt the RE-AIM framework to guide NIH-funded case studies of the implementation of clean cooking fuel programs in eleven low- and middle-income countries. Methods: We used existing literature and expert consultation to translate and iteratively adapt the RE-AIM framework across several stages of the NIH Clean Cooking Implementation Science case study project. Checklists and templates to guide investigators were developed at each stage. Results: The RE-AIM framework facilitated identification of important emerging issues across this set of case studies, in particular highlighting the fact that data associated with certain important outcomes related to health and welfare are chronically lacking in clean fuel programs. Monitoring of these outcomes should be prioritized in future implementation efforts. As RE-AIM was not originally designed to evaluate household energy interventions, employing the framework required adaptation. Specific adaptations include the broadening of Effectiveness to encompass indicators of success toward any stated programmatic goal, and expansion of Adoption to include household-level uptake of technology. Conclusions: The RE-AIM implementation science framework proved to be a useful organizing schema for 11 case studies of clean fuel cooking programs, in particular highlighting areas requiring emphasis in future research and evaluation efforts. The iterative approach used here to adapt an implementation science framework to a specific programmatic goal may be of value to other multi-country program efforts, such as those led by international development agencies. The checklists and templates developed for this project are publicly available for others to use and/or further modify.
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Affiliation(s)
- Ashlinn K. Quinn
- Fogarty International Center, U.S. National Institutes of Health, Bethesda, MD, United States
| | - Gila Neta
- National Cancer Institute, U.S. National Institutes of Health, Bethesda, MD, United States
| | - Rachel Sturke
- Fogarty International Center, U.S. National Institutes of Health, Bethesda, MD, United States
| | | | - Suzanne L. Pollard
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Joshua P. Rosenthal
- Fogarty International Center, U.S. National Institutes of Health, Bethesda, MD, United States
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19
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Tarazona-Meza CE, Nicholson A, Romero KM, Pollard SL, Gálvez-Davila RM, Hansel NN, Checkley W. Household food insecurity is associated with asthma control in Peruvian children living in a resource-poor setting. J Asthma 2019; 57:1308-1315. [PMID: 31418600 DOI: 10.1080/02770903.2019.1648506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Rationale: Prior evidence suggests that there may be an association between asthma and food insecurity. We sought to describe the prevalence of food insecurity access, defined as having sufficient resources for appropriate foods in Lima, Peru, and evaluate its association with asthma status and control.Methods: We analyzed data from 553 children with asthma and 268 healthy controls aged nine to 19 years living in two peri-urban communities in Lima, Peru, in 2013. We used the Household Food Insecurity Access Scale to assess food insecurity. We defined uncontrolled asthma as an asthma control test score ≤19. We used multivariable logistic regressions to determine the relationship between asthma outcomes and food insecurity adjusting for age, sex, socioeconomic status, body mass index, and setting.Results: Average age was 14.2 years (SD 2.7). There was a high prevalence of household food insecurity in our study: 330 participants (40.2%) were food insecure, and average food insecurity access score was 2.7 points (SD 4.2). While being food insecure was not associated with asthma status (OR = 1.23, 95% CI 0.85 to 1.79; p = 0.28), it was associated with a higher odds of having uncontrolled asthma (OR = 2.01, 95% CI 1.13 to 3.59; p = 0.02). Each one-unit increase in food insecurity score (higher scores indicating more insecurity) was associated with 8% higher odds of having uncontrolled asthma (OR = 1.08, 95% CI 1.02 to 1.14; p < 0.01).Conclusions: Worse asthma control was associated with food insecurity. Future studies are needed to better understand the role of food security in determining the success of treatment strategies.
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Affiliation(s)
- Carla E Tarazona-Meza
- Center for Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Biomedical Research Unit, A.B. PRISMA, Lima, Peru
| | - Andrew Nicholson
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karina M Romero
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Suzanne L Pollard
- Center for Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Center for Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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20
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Grigsby MR, Siddharthan T, Pollard SL, Chowdhury M, Rubinstein A, Miranda JJ, Bernabe-Ortiz A, Alam D, Kirenga B, Jones R, van Gemert F, Checkley W. Low Body Mass Index Is Associated with Higher Odds of COPD and Lower Lung Function in Low- and Middle-Income Countries. COPD 2019; 16:58-65. [PMID: 31032662 DOI: 10.1080/15412555.2019.1589443] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The relationship of body mass index (BMI) with lung function and COPD has been previously described in several high-income settings. However, few studies have examined this relationship in resource-limited settings where being underweight is more common. We evaluated the association between BMI and lung function outcomes across 14 diverse low- and middle-income countries. We included data from 12,396 participants aged 35-95 years and used multivariable regressions to assess the relationship between BMI with either COPD and lung function while adjusting for known risk factors. An inflection point was observed at a BMI of 19.8 kg/m2. Participants with BMI < 19.8 kg/m2 had a 2.28 greater odds (95% CI 1.83-2.86) of having COPD and had a 0.21 (0.13-0.30) lower FEV1 and 0.34 (0.27-0.41) lower FEV1/FVC z-score compared to those with BMI ≥ 19.8 kg/m2. The association with lung function remained even after excluding participants with COPD. Individuals with lower BMI were more likely to have COPD and had lower lung function compared to those in higher BMI. The association with lung function remained positive even after excluding participants with COPD, suggesting that being underweight may also play a role in having worse lung function.
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Affiliation(s)
- Matthew R Grigsby
- a Division of Pulmonary and Critical Care, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA.,b Center for Global Non-Communicable Disease Research and Training, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA
| | - Trishul Siddharthan
- a Division of Pulmonary and Critical Care, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA.,b Center for Global Non-Communicable Disease Research and Training, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA
| | - Suzanne L Pollard
- a Division of Pulmonary and Critical Care, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA.,b Center for Global Non-Communicable Disease Research and Training, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA
| | | | - Adolfo Rubinstein
- d Institute for Clinical Effectiveness and Health Policy , Buenos Aires , Argentina
| | - J Jaime Miranda
- e CRONICAS Centre of Excellence in Chronic Diseases , Universidad Peruana Cayetano Heredia , Lima , Peru.,f Departamento de Medicina, Facultad de Medicina , Universidad Peruana Cayetano Heredia , Lima , Peru
| | - Antonio Bernabe-Ortiz
- e CRONICAS Centre of Excellence in Chronic Diseases , Universidad Peruana Cayetano Heredia , Lima , Peru
| | - Dewan Alam
- g School of Kinesiology and Health Science, Faculty of Health , York University , Toronto , Ontario , Canada
| | - Bruce Kirenga
- h Makerere Lung Institute , Makerere University , Kampala , Uganda
| | - Rupert Jones
- i Plymouth University , Plymouth , United Kingdom
| | - Frederick van Gemert
- j University of Groningen, University Medical Centre Groningen , Harlingen , Netherlands
| | - William Checkley
- a Division of Pulmonary and Critical Care, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA.,b Center for Global Non-Communicable Disease Research and Training, School of Medicine , Johns Hopkins University , Baltimore , Maryland , USA
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21
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Robertson NM, Nagourney EM, Pollard SL, Siddharthan T, Kalyesubula R, Surkan PJ, Hurst JR, Checkley W, Kirenga BJ. Urban-Rural Disparities in Chronic Obstructive Pulmonary Disease Management and Access in Uganda. Chronic Obstr Pulm Dis 2019; 6:17-28. [PMID: 30775421 PMCID: PMC6373590 DOI: 10.15326/jcopdf.6.1.2018.0143] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/16/2018] [Indexed: 11/21/2022]
Abstract
Introduction: Almost 90% of chronic obstructive pulmonary disease (COPD) deaths occur in low- and middle-income countries (LMICs), where there are large rural populations and access to health care for COPD is poor. The purpose of this study was to compare urban-rural provider experiences regarding systemic facilitators and barriers to COPD management and treatment access. Methods: We conducted a qualitative study using direct observations and in-depth semi-structured interviews with 16 and 10 health care providers in urban Kampala and rural Nakaseke, Uganda, respectively. We analyzed interviews by performing inductive coding using generated topical codes. Results: In both urban and rural districts, exposure to evidence-based practices for COPD diagnosis and treatment was limited. The biomedical definition of COPD is not well distinguished in rural communities and was commonly confused with asthma and other respiratory diseases. Urban and rural participants alike described low availability of medications, limited access to diagnostic tools, poor awareness of the disease, and lack of financial means for medical care as common barriers to seeking and receiving care for COPD. While there was greater access to COPD treatment in urban areas, rural populations faced more pronounced barriers in access to diagnostic equipment, following standard treatment guidelines, and training medical personnel in non-communicable disease (NCD) management and treatment. Conclusion: Our results suggest that health system challenges for the treatment of COPD may disproportionately affect rural areas in Uganda. Implementation of diagnostic and treatment guidelines and training health professionals in COPD, with a special emphasis on rural communities, will assist in addressing these barriers.
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Affiliation(s)
- Nicole M Robertson
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Emily M Nagourney
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Robert Kalyesubula
- Department of Physiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Pamela J Surkan
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - John R Hurst
- UCL Respiratory, University College London, United Kingdom
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Bruce J Kirenga
- Department of Medicine and Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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22
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Pereira AA, Pollard SL, Locke R, Romero K, Lima JJ, Hansel NN, Checkley W. Association between exhaled carbon monoxide and asthma outcomes in Peruvian children. Respir Med 2018; 145:212-216. [PMID: 30509712 DOI: 10.1016/j.rmed.2018.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Asthma prevalence continues to increase in low and middle-income countries, presenting challenges in assessing asthma control in resource-poor settings. Previous studies suggest that exhaled carbon monoxide (eCO) is higher with asthma severity and lower with treatment. We hypothesized that eCO levels may be elevated in children with asthma, particularly in children with partially controlled or uncontrolled asthma in a low-resource setting in Lima, Peru. METHODS We compared average eCO levels between 248 children with asthma and 221 healthy controls as well as the odds of asthma by eCO quartiles (0-1, 2, 3, and ≥4 ppm) using multivariable linear and logistic regression. eCO quartiles were also used to compare the odds of partially controlled or uncontrolled asthma (score ≤19 on the Asthma Control Test) in a multivariable logistic regression model. FINDINGS Average adjusted eCO level was 0.56 ppm (95% CI 0.07-1.05) higher in children with asthma. The adjusted odds of asthma were 1.22 (95% CI 0.75-1.97), 1.46 (0.81-2.63), and 1.76 (0.96-3.23) in the second, third, and fourth eCO quartiles compared to the first eCO quartile, respectively. Among children with asthma, the adjusted odds of partially controlled or uncontrolled asthma in those in the second, third, and fourth eCO quartiles, compared to the first, were 1.61 (95% CI 0.74-3.48), 3.66 (95% CI 1.51-8.87), and 2.50 (95% CI 1.06-5.90), respectively. INTERPRETATION eCO may serve as an inexpensive biomarker for asthma control, particularly in low-resource settings.
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Affiliation(s)
- Amanda A Pereira
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Suzanne L Pollard
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Robert Locke
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Karina Romero
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, USA
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - William Checkley
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Biomedical Research Unit, A.B. PRISMA, Lima, Peru.
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Siddharthan T, Pollard SL, Quaderi SA, Mirelman AJ, Cárdenas MK, Kirenga B, Rykiel NA, Miranda JJ, Shrestha L, Chandyo RK, Cattamanchi A, Michie S, Barber J, Checkley W, Hurst JR. Effectiveness-implementation of COPD case finding and self-management action plans in low- and middle-income countries: global excellence in COPD outcomes (GECo) study protocol. Trials 2018; 19:571. [PMID: 30340648 PMCID: PMC6194571 DOI: 10.1186/s13063-018-2909-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/08/2018] [Indexed: 12/03/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is the end result of a susceptible individual being exposed to sufficiently deleterious environmental stimuli. More than 90% of COPD-related deaths occur in low- and middle-income countries (LMICs). LMICs face unique challenges in managing COPD; for example, deficient primary care systems present challenges for proper diagnosis and management. Formal diagnosis of COPD requires quality-assured spirometry, which is often limited to urban health centres. Similarly, standard treatment options for COPD remain limited where few providers are trained to manage COPD. The Global Excellence in COPD Outcomes (GECo) studies aim to assess the performance of a COPD case-finding questionnaire with and without peak expiratory flow (PEF) to diagnose COPD, and inform the effectiveness and implementation of COPD self-management Action Plans in LMIC settings. The ultimate goal is to develop simple, low-cost models of care that can be implemented in LMICs. This study will be carried out in Nepal, Peru and Uganda, three distinct LMIC settings. Methods/design We aim to assess the diagnostic accuracy of a simple questionnaire with and without PEF to case-find COPD (GECo1), and examine the effectiveness, cost-effectiveness and implementation of a community-health-worker-supported self-management Action Plan strategy for managing exacerbations of COPD (GECo2). To achieve the first aim, we will enrol a randomly selected sample of up to 10,500 adults aged ≥ 40 years across our three sites, with the goal to enrol 240 participants with moderate-to-severe COPD in to GECo2. We will apply two case-finding questionnaires (Lung Function Questionnaire and CAPTURE) with and without PEF and compare performance against spirometry. We will report ROC areas, sensitivity and specificity. Individuals who are identified as having COPD grades B–D will be invited to enrol in an effectiveness-implementation hybrid randomised trial of a multi-faceted COPD self-management Action Plan intervention delivered by CHWs. The intervention group will receive (1) COPD education, (2) facilitated-self management Action Plans for COPD exacerbations and (3) monthly visits by community health workers. The control group will receive COPD education and standard of care treatment provided by local health providers. Beginning at baseline, we will measure quality of life with the EuroQol-5D (EQ-5D) and St. George’s Respiratory Questionnaire (SGRQ) every 3 months over a period of 1 year. The primary endpoint is SGRQ at 12 months. Quality-adjusted life years (QALYs) using the Short-Form 36 version 2 will also be calculated. We will additionally assess the acceptability and feasibility of implementing COPD Action Plans in each setting among providers and individuals with COPD. Discussion This study should provide evidence to inform the use of pragmatic models of COPD diagnosis and management in LMIC settings. Trial registration NCT03359915 (GECo1). Registered on 2 December 2017 and NCT03365713 (GECo2). Registered on 7 December 2017. Trial acronym: Global Excellence in COPD Outcomes (GECo1; GECo2). Electronic supplementary material The online version of this article (10.1186/s13063-018-2909-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, OH, USA.,Center for Global Non-Communicable Diseases, School of Medicine, Johns Hopkins University, Baltimore, OH, USA
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, OH, USA.,Center for Global Non-Communicable Diseases, School of Medicine, Johns Hopkins University, Baltimore, OH, USA
| | | | | | - Maria Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Bruce Kirenga
- Makerere Lung Institute, Makerere University, Kampala, Uganda
| | - Natalie A Rykiel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, OH, USA.,Center for Global Non-Communicable Diseases, School of Medicine, Johns Hopkins University, Baltimore, OH, USA
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.,Departamento de Medicina, Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Laxman Shrestha
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, OH, USA.,Center for Global Non-Communicable Diseases, School of Medicine, Johns Hopkins University, Baltimore, OH, USA
| | - John R Hurst
- UCL Respiratory, University College London, London, UK.
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24
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Pollard SL, Williams KN, O'Brien CJ, Winiker A, Puzzolo E, Kephart JL, Fandiño-Del-Rio M, Tarazona-Meza C, Grigsby M, Chiang M, Checkley W. An evaluation of the Fondo de Inclusión Social Energético program to promote access to liquefied petroleum gas in Peru. Energy Sustain Dev 2018; 46:82-93. [PMID: 30364502 PMCID: PMC6197055 DOI: 10.1016/j.esd.2018.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Over 80% of rural households in Peru use solid fuels as their primary source of domestic energy, which contributes to several health problems. In 2016, 6.7 million Peruvians were living in rural areas. The Fondo de Inclusión Social Energético (FISE) LPG Promotion Program, which began in 2012 and is housed under the Ministry of Energy and Mining, is a government-sponsored initiative aimed at reducing use of solid fuels by increasing access to clean fuel for cooking to poor Peruvian households. METHODS We conducted a mixed methods study incorporating data from publicly available records and reports, a community survey of 375 households in Puno (the province with the largest number of FISE beneficiary households), and in-depth interviews with community members and key stakeholders. We used the Reach, Effectiveness - Adoption, Implementation, Maintenance (RE-AIM) framework to guide our data collection and analysis efforts. In a sample of 95 households, we also measured 48-hour area concentrations and personal exposures to fine particulate matter (PM2.5). RESULTS The FISE LPG promotion program has achieved high geographical reach; the program is currently serving households in 100% of districts in Peru. Households with access to electricity may be participating at a higher level than households without electricity because the program is implemented primarily by electricity distributors. In a sample of 95 households, FISE beneficiaries experienced a reduction in kitchen concentrations of PM2.5; however, there were no differences in personal exposures, and both kitchen and personal exposures were above the WHO intermediate target for indoor air quality. Among the 375 households surveyed, stove stacking with biomass fuels was reported in more than 95% of both beneficiary and non-beneficiary households, with fewer than 5% reporting exclusive use. In-depth interviews suggest that the complexity of enrollment process and access to LPG distribution points may be key barriers to participating in FISE. CONCLUSION The FISE LPG Program has achieved high reach and its targeted subsidy and surcharge-based financing structure represent a potentially feasible and sustainable model for other government programs. However, the prevalence of stove stacking among FISE beneficiaries remains high. There is a need for improved communication channels between program implementers and beneficiaries. FISE should also consider expanding the mobile LPG network and community delivery service to reduce physical barriers and indirect costs of LPG acquisition. Finally, increasing the value of LPG vouchers to completely cover one or two tanks a month, or alternatively, introducing behavior change strategies to reduce monthly LPG usage, may facilitate the transition to exclusive LPG use.
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Affiliation(s)
- Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Carolyn J O'Brien
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Abigail Winiker
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Elisa Puzzolo
- Department of Public Health and Policy, the University of Liverpool, United Kingdom
- The Global LPG Partnership, New York, USA
| | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Magdalena Fandiño-Del-Rio
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | - Matthew Grigsby
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
| | | | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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25
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Morgan BW, Siddharthan T, Grigsby MR, Pollard SL, Kalyesubula R, Wise RA, Kirenga B, Checkley W. Asthma and Allergic Disorders in Uganda: A Population-Based Study Across Urban and Rural Settings. J Allergy Clin Immunol Pract 2018; 6:1580-1587.e2. [PMID: 29361510 DOI: 10.1016/j.jaip.2017.11.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Allergic diseases are increasing in sub-Saharan Africa, but few studies have characterized the burden among adults. OBJECTIVE We conducted a study to evaluate the prevalence and risk factors of allergic disorders in urban and rural Uganda. METHODS We present a cross-sectional analysis of enrollment data from a population-based cohort study of adults aged ≥35 years in urban and rural Uganda. Sociodemographic and both lifetime and 12-month respiratory symptoms data were collected and spirometry was conducted following standard guidelines. RESULTS In 1,308 adults (median age 43.8 years and 52.3% female), we found an age-adjusted prevalence of 6.8% for asthma (9.8% urban, 4.3% rural; P < .001), 11.9% for allergic rhinitis (16.4% urban, 7.8% rural; P < .001), and 8.2% for eczema (9.9% urban, 7.8% rural; P = .15). Urbanization was the primary driver of asthma, accounting for 61.4% of cases (95% confidence interval [CI] 22.0% to 83.4%), and was the strongest risk factor for any allergic illness (odds ratio [OR] = 1.87, 95% CI 1.39-2.51). Parental asthma was not associated with allergic illness. Asthma was associated with a lower forced expiratory volume in 1 second (FEV1) by 0.56 z scores (95% CI 0.33-0.80). We found a dose-response association between lower quintiles of the FEV1/forced vital capacity ratio and both hospitalization (OR = 1.77, 95% CI 1.21-2.59) and impairment in daily activities (1.65, 1.20-2.27). CONCLUSIONS Asthma and allergic rhinitis were twice as prevalent in urban settings. Asthma was associated with greater impairment and worse lung function outcomes. We identified a high prevalence of allergic disorders in Uganda, which can be expected to increase due to urbanization and resultant exposures throughout early development.
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Affiliation(s)
- Brooks W Morgan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Matthew R Grigsby
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Robert Kalyesubula
- Department of Medicine and Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert A Wise
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Bruce Kirenga
- Department of Medicine and Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Md; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
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Nicholson A, Pollard SL, Lima JJ, Romero KM, Tarazona-Meza C, Malpartida-Guzmán G, Mougey E, Hansel NN, Checkley W. Serum folate concentrations, asthma, atopy, and asthma control in Peruvian children. Respir Med 2017; 133:29-35. [PMID: 29173446 DOI: 10.1016/j.rmed.2017.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/20/2017] [Accepted: 10/31/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The relationship between folate status and asthma-related outcomes has not been carefully examined in low- and middle-income countries where folate deficiency is common. METHODS Ancillary analysis of an unmatched case-control study in which we analyzed serum folate concentrations in 412 children with asthma and 342 controls living in peri-urban communities in Lima, Peru. We examined baseline associations between folate and asthma, atopy, total serum IgE, pulmonary function, and fractional exhaled nitric oxide. We then followed children with asthma longitudinally for 6-9 months and assessed associations between folate and odds of uncontrolled asthma (defined as Asthma Control Test score ≤ 19) and of ≥1 emergency visits during follow-up. RESULTS A 10 ng/mL decrease in serum folate was associated with 45% higher adjusted odds of asthma (OR = 1.45, 95% CI 1.05-2.02). The folate-asthma relationship differed by atopic status: a 10 ng/mL decrease in serum folate was associated with a 2.4-fold higher odds of asthma among children without atopy (2.38, 1.20-4.72) and 23% higher odds of asthma in children with atopy (1.23, 0.85-1.80). Among children with asthma, a 10 ng/mL decrease in serum folate was associated with 62% higher odds of uncontrolled asthma (1.62, 1.02-2.56) and 73% higher odds of ≥1 emergency visits during follow-up (1.73, 1.05-2.85). CONCLUSIONS Serum folate concentrations were inversely associated with asthma, but this effect was stronger in children without atopy. Among children with asthma, lower serum folate concentrations were associated with higher risk of uncontrolled asthma.
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Affiliation(s)
- Andrew Nicholson
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Suzanne L Pollard
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
| | - Karina M Romero
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Biomedical Research Unit, A.B. PRISMA, Lima, Peru
| | | | | | - Edward Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - William Checkley
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.
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Pollard SL, Lima JJ, Romero K, Tarazona-Meza C, Mougey E, Tomaino K, Malpartida-Guzmán G, Hansel NN, Checkley W. Associations between serum 25(OH)D concentrations and prevalent asthma among children living in communities with differing levels of urbanization: a cross-sectional study. Asthma Res Pract 2017; 3:5. [PMID: 28588900 PMCID: PMC5457560 DOI: 10.1186/s40733-017-0033-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/23/2017] [Indexed: 02/04/2023] Open
Abstract
Background Prior evidence suggests that vitamin D deficiency may increase the risk of asthma and atopy and impair pulmonary function in children. Methods In this cross-sectional analysis nested in a case-control study, we analyzed serum 25(OH)D concentrations in 413 children with asthma and 471 children without asthma living in two geographically adjacent study communities (Pampas and Villa El Salvador). We measured total and antigen-specific IgE levels, pulmonary function, asthma control, and exhaled nitric oxide. Results Mean 25(OH)D concentrations were 25.2 ng/mL (SD 10.1) in children with asthma and 26.1 ng/mL (SD 13.7) in children without asthma (p = 0.28). Vitamin D deficiency (25(OH)D < 20 ng/ml) was more common in Pampas than in Villa El Salvador (52.7% vs. 10.5%; p < 0.001). In the overall study population, a 10 ng/ml decrease in serum 25(OH)D concentrations was not significantly associated with odds of asthma (OR 1.09, 95% CI: 0.94 to 1.25). However, vitamin D deficiency was associated with a 1.6-fold increase in odds of asthma in the overall cohort (95% CI: 1.14 to 2.25). After stratifying by site, a 10 ng/mL decrease in serum 25(OH)D concentrations was associated with 18% higher odds of having asthma in Pampas (OR = 1.18, 95% CI 1.02 to 1.38), whereas there was no significant association between 25(OH)D concentrations and asthma in Villa El Salvador (OR = 0.95, 95% CI 0.87 to 1.05). Combined data from these geographically adjacent populations suggests a possible threshold for the relationship between 25(OH)D levels and asthma at approximately 27.5 ng/ml. Serum 25(OH)D concentrations were not clearly associated with asthma control, total serum IgE, atopy, or airway inflammation. Conclusion Serum 25(OH)D concentrations were inversely associated with asthma in one study community with a high prevalence of deficiency. Studies are needed to investigate a possible threshold 25(OH)D concentration after which higher vitamin D levels show no further benefit for asthma. Electronic supplementary material The online version of this article (doi:10.1186/s40733-017-0033-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave, Suite 9121, Baltimore, USA.,Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL USA
| | - Karina Romero
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave, Suite 9121, Baltimore, USA
| | | | - Edward Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL USA
| | - Katherine Tomaino
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave, Suite 9121, Baltimore, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave, Suite 9121, Baltimore, USA.,Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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28
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Pollard SL, Lima JJ, Mougey E, Romero K, Tarazona-Meza C, Tomaino K, Guzmán GM, Hansel NN, Checkley W. Free 25(OH)D concentrations are associated with atopy and lung function in children with asthma. Ann Allergy Asthma Immunol 2017; 119:37-41. [PMID: 28533007 DOI: 10.1016/j.anai.2017.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 04/20/2017] [Accepted: 04/25/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evidence suggests free mono-hydroxyvitamin D (25[OH]D) concentrations are more strongly linked to certain outcomes than total concentrations; however, no studies have examined the relation between free 25(OH)D and respiratory or allergic disease. OBJECTIVE To examine associations between total and free 25(OH)D concentrations and asthma outcomes. METHODS We quantified total and free 25(OH)D concentrations in 137 Peruvian children with asthma and 152 children without asthma and examined associations with asthma outcomes. RESULTS Mean age ± SD was 13 ± 2.5 years, and 50.2% were boys. Mean total and measured free 25(OH)D concentrations were 29 ± 9.5 ng/mL and 5.0 ± 1.3 pg/mL, respectively. Lower free but not total 25(OH)D concentrations were significantly associated with atopy in all children (total, odds ratio [OR] 1.3 per 10-ng/mL decrease, 95% confidence interval [CI] 0.95-1.7, P = .12; vs free, OR 1.3 per 1-pg/mL decrease, 95% CI 1.0-1.6, P = .02) and children with asthma (total, OR 1.1 per 10-ng/mL decrease, 95% CI 0.75-1.7, P = .57; vs free, OR 1.6 per 1-pg/mL decrease, 95% CI 1.0-2.5, P = .04). Free but not total 25(OH)D levels were significantly associated with pre-bronchodilator forced expiratory volume in 1 second (total, 0.11 L, -0.12 to 0.34, P = .34; vs free, 0.20 L, 0.021-0.39, P = .03) and forced vital capacity (total, 0.13 L, -0.12 to 0.37, P = .31; vs free, 0.22 L, 0.026-0.42, P = .03) Z-scores in children with asthma. CONCLUSION Atopy, forced expiratory volume in 1 second, and forced vital capacity were more strongly linked to free than to total 25(OH)D concentrations, suggesting the free form might be more relevant in modulating allergic disease risk and pulmonary function in children with asthma.
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Affiliation(s)
- Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, Florida
| | - Edward Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, Florida
| | - Karina Romero
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Katherine Tomaino
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
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29
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Checkley W, Deza MP, Klawitter J, Romero KM, Klawitter J, Pollard SL, Wise RA, Christians U, Hansel NN. Identifying biomarkers for asthma diagnosis using targeted metabolomics approaches. Respir Med 2016; 121:59-66. [PMID: 27888993 DOI: 10.1016/j.rmed.2016.10.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/21/2016] [Accepted: 10/17/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND The diagnosis of asthma in children is challenging and relies on a combination of clinical factors and biomarkers including methacholine challenge, lung function, bronchodilator responsiveness, and presence of airway inflammation. No single test is diagnostic. We sought to identify a pattern of inflammatory biomarkers that was unique to asthma using a targeted metabolomics approach combined with data science methods. METHODS We conducted a nested case-control study of 100 children living in a peri-urban community in Lima, Peru. We defined cases as children with current asthma, and controls as children with no prior history of asthma and normal lung function. We further categorized enrollment following a factorial design to enroll equal numbers of children as either overweight or not. We obtained a fasting venous blood sample to characterize a comprehensive panel of targeted markers using a metabolomics approach based on high performance liquid chromatography-mass spectrometry. RESULTS A statistical comparison of targeted metabolites between children with asthma (n = 50) and healthy controls (n = 49) revealed distinct patterns in relative concentrations of several metabolites: children with asthma had approximately 40-50% lower relative concentrations of ascorbic acid, 2-isopropylmalic acid, shikimate-3-phosphate, and 6-phospho-d-gluconate when compared to children without asthma, and 70% lower relative concentrations of reduced glutathione (all p < 0.001 after Bonferroni correction). Moreover, a combination of 2-isopropylmalic acid and betaine strongly discriminated between children with asthma (2-isopropylmalic acid ≤ 13 077 normalized counts/second) and controls (2-isopropylmalic acid > 13 077 normalized counts/second and betaine ≤ 16 47 121 normalized counts/second). CONCLUSIONS By using a metabolomics approach applied to serum, we were able to discriminate between children with and without asthma by revealing different metabolic patterns. These results suggest that serum metabolomics may represent a diagnostic tool for asthma and may be helpful for distinguishing asthma phenotypes.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA.
| | - Maria P Deza
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jost Klawitter
- iC42 Clinical Research and Development, University of Colorado, Aurora, CO, USA
| | - Karina M Romero
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA; Biomedical Research Unit, A.B. PRISMA, Lima, Peru
| | - Jelena Klawitter
- iC42 Clinical Research and Development, University of Colorado, Aurora, CO, USA
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Robert A Wise
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Uwe Christians
- iC42 Clinical Research and Development, University of Colorado, Aurora, CO, USA
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
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30
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Checkley W, Pollard SL, Siddharthan T, Babu GR, Thakur M, Miele CH, Van Schayck OC. Managing threats to respiratory health in urban slums. Lancet Respir Med 2016; 4:852-854. [PMID: 27760724 DOI: 10.1016/s2213-2600(16)30245-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 07/20/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Giridhara R Babu
- Public Health Foundation of India, Indian Institute of Public Health-Hyderabad, Bangalore campus, Bangalore, India
| | - Megha Thakur
- Public Health Foundation of India, Indian Institute of Public Health-Hyderabad, Bangalore campus, Bangalore, India
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Onno Cp Van Schayck
- Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, Netherlands
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Checkley W, Robinson CL, Baumann LM, Hansel NN, Romero KM, Pollard SL, Wise RA, Gilman RH, Mougey E, Lima JJ. 25-hydroxy vitamin D levels are associated with childhood asthma in a population-based study in Peru. Clin Exp Allergy 2015; 45:273-82. [PMID: 24666565 DOI: 10.1111/cea.12311] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Vitamin D deficiency may be associated with an increased risk of asthma. OBJECTIVE We studied the association between 25-hydroxy (25-OH) vitamin D deficiency and asthma prevalence in two Peruvian populations close to the equator but with disparate degrees of urbanization. METHODS We conducted a population-based study in 1441 children in two communities in Peru, of which 1134 (79%) provided a blood sample for 25-OH vitamin D analysis. RESULTS In these 1134 children, mean age was 14.8 years; 52% were boys; asthma and atopy prevalence was 12% in Lima vs. 3% in Tumbes (P < 0.001) and 59% in Lima vs. 41% in Tumbes (P < 0.001), respectively; and, mean 25-OH vitamin D level was 20.8 ng/mL in Lima vs. 30.1 ng/mL in Tumbes (P < 0.001). Prevalence of 25-OH vitamin D deficiency (< 20 ng/mL) was 47% in Lima vs. 7% in Tumbes (P < 0.001). In multi-variable logistic regression, we found that lower 25-OH vitamin D levels were associated with an increased odds of asthma (OR = 1.7 per each 10 ng/mL decrease in 25-OH vitamin D levels, 95% CI 1.2-2.6; P < 0.01). In stratified analyses, the association between lower 25-OH vitamin D levels and asthma was limited to children with atopy (OR = 2.2, 95% CI 1.3-3.6) and not in those without atopy (OR = 0.9, 95% CI 0.5-2.0). We did not find associations between 25-OH vitamin D levels and other clinical biomarkers for asthma, including exhaled nitric oxide, total serum IgE and pulmonary function. CONCLUSION AND CLINICAL RELEVANCE Both asthma and 25-OH vitamin D deficiency were common among children living in Lima (latitude = 12.0 °S) but not among those in Tumbes (3.6 °S). The relationship between 25-OH vitamin D deficiency and asthma was similar in both sites and was limited among children with atopy. Future supplementation trials may need to consider stratification by atopy at the time of design.
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Affiliation(s)
- W Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Program in Global Disease Epidemiology and Control, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Tomaino K, Romero KM, Robinson CL, Baumann LM, Hansel NN, Pollard SL, Gilman RH, Mougey E, Lima JJ, Checkley W. Association Between Serum 25-Hydroxy Vitamin D Levels and Blood Pressure Among Adolescents in Two Resource-Limited Settings in Peru. Am J Hypertens 2015; 28:1017-23. [PMID: 25600222 DOI: 10.1093/ajh/hpu264] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/06/2014] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Serum 25-hydroxyvitamin D (25OHD) deficiency (<50 nmol/l or 20 ng/ml) has been associated with increased blood pressure (BP) in observational studies. A paucity of data on this relationship is available in Latin American or child populations. This study investigates the association between 25OHD levels and BP in adolescents at risk for vitamin D deficiency in 2 Peruvian settings. METHODS In a population-based study of 1,441 Peruvian adolescents aged 13-15 years, 1,074 (75%) provided a serum blood sample for 25OHD analysis and BP measurements. Relationships between 25OHD and BP metrics were assessed using multiple linear regressions, adjusted for anthropometrics and sociodemographic factors. RESULTS 25OHD deficiency was associated with an elevated diastolic BP (DBP) (1.09 mm Hg increase, 95% confidence interval: 0.04 to 2.14; P = 0.04) compared to nondeficient adolescents. Systolic BP (SBP) trended to increase with vitamin D deficiency (1.30 mm Hg increase, 95% confidence interval: -0.13 to 2.72; P = 0.08). Mean arterial pressure (MAP) was also greater in adolescents with 25OHD (1.16 mm Hg increase, 95% confidence interval: 0.10 to 2.22; P = 0.03). SBP was found to demonstrate a U-shaped relationship with 25OHD, while DBP and MAP demonstrated inverse J-shaped relationships with serum 25OHD status. The association between 25OHD deficiency and BP was not different across study sites (all P ≥ 0.19). DISCUSSION Adolescents deficient in 25OHD demonstrated increased DBP and MAP and a trend toward increased SBP, when compared to nondeficient subjects. 25OHD deficiency early in life was associated with elevated BP metrics, which may predispose risk of hypertension later in adulthood.
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Affiliation(s)
- Katherine Tomaino
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Colin L Robinson
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lauren M Baumann
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Suzanne L Pollard
- Program in Global Disease Epidemiology and Control, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert H Gilman
- Program in Global Disease Epidemiology and Control, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Edward Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children Clinic, Jacksonville, Florida, USA
| | - John J Lima
- Center for Pharmacogenomics and Translational Research, Nemours Children Clinic, Jacksonville, Florida, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; Program in Global Disease Epidemiology and Control, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA;
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Pollard SL, Lima JJ, Checkley W. Vitamin D and COPD: who benefits from supplementation? Lancet Respir Med 2014; 3:89-91. [PMID: 25476070 DOI: 10.1016/s2213-2600(14)70295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Avenue, Suite 9121, Baltimore, MD 21205, USA; Program in Global Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - John J Lima
- Nemours Children's Clinic, Jacksonville, FL, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Avenue, Suite 9121, Baltimore, MD 21205, USA; Program in Global Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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Caravedo MA, Painschab MS, Davila-Roman VG, De Ferrari A, Gilman RH, Vasquez-Villar AD, Pollard SL, Miranda JJ, Checkley W. Lack of association between chronic exposure to biomass fuel smoke and markers of right ventricular pressure overload at high altitude. Am Heart J 2014; 168:731-8. [PMID: 25440802 DOI: 10.1016/j.ahj.2014.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 06/15/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic exposure to biomass fuel smoke has been implicated in the development of pulmonary hypertension and right ventricular pressure/volume overload through activation of inflammation, increase in vascular resistance, and endothelial dysfunction. We sought to compare N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) and echocardiography-derived pulmonary artery systolic pressure (PASP) levels in a high-altitude population-based study in Peru with and without chronic exposure to biomass fuel smoke. METHODS NT-pro-BNP levels were measured in 519 adults (275 with and 244 without chronic exposure to biomass fuel smoke). Participants answered sociodemographics and clinical history questionnaires, underwent a clinical examination and blood testing for cardiopulmonary biomarkers. PASP was measured in a subgroup of 153 (31%) subjects. RESULTS The study group consisted of 280 men (54%) and 239 women (46%). Average age was 56 years and average body mass index was 27 kg/m(2). In multivariable analysis, there was no association between chronic exposure to biomass fuel smoke and NT-pro-BNP (P = .31) or PASP (P = .31). In the subgroup in which both NT-pro-BNP levels and PASP were measured, there was strong evidence of an association between these two variables (ρ = 0.24, 95% CI 0.09-0.39; P = .003). We found that age, high sensitivity C-reactive protein, being male, and systolic blood pressure were positively associated with NT-pro-BNP levels whereas body mass index, low-density/high-density lipoprotein ratio, and Homeostasis Model of Assessment-Insulin Resistance were negatively associated (all P ≤ .02). CONCLUSIONS In this population-based study in a high-altitude setting, neither NT-pro-BNP levels nor echocardiography-derived PASP were associated with chronic exposure to biomass fuel smoke.
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Pollard SL, Zachary DA, Wingert K, Booker SS, Surkan PJ. Family and Community Influences on Diabetes-Related Dietary Change in a Low-Income Urban Neighborhood. Diabetes Educ 2014; 40:462-469. [DOI: 10.1177/0145721714527520] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The purpose of this study is to explore the influence of the social environment, including family and community relationships, on diabetes-related dietary change behaviors in a low-income, predominantly African American community with limited access to healthy foods. Methods Study methods included interviews and focus groups with adults with diabetes and family members of individuals with diabetes in a low-income African American community. In this analysis, interview participants included 11 participants with diabetes, one with prediabetes, and 8 family members or close friends with diabetes. Information from 4 participants with diabetes and 6 with family members with diabetes was included from 6 focus groups. Transcripts were analyzed via thematic iterative coding influenced by social cognitive theory to understand the influence of family and community relationships on dietary change. Results Participants’ social environments strongly influenced diet-related behavioral change. Family members without diabetes provided reinforcements for dietary change for those with diabetes by preparing healthy food and monitoring intake, as well as by adopting dietary changes made by those with diabetes. Family and community members served as sources of observational learning about the potential impacts of diabetes and enhanced behavioral capability for dietary change among people with diabetes by providing dietary advice and strategies for making healthy choices. Conclusions This study demonstrates the ways in which family and community members can influence dietary change in people with diabetes. Interventions targeting diabetes management should incorporate families and communities as sources of information, learning, and support.
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Affiliation(s)
- Suzanne L. Pollard
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Pollard)
- Program in Social Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA (Ms Zachary)
- Program in Social and Behavioral Interventions, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Wingert, Dr Surkan)
- Nutrition Education, School, and Community Nutrition Programs Branch, Maryland State Department of Education, Baltimore, MD, USA (Ms Booker)
| | - Drew A. Zachary
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Pollard)
- Program in Social Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA (Ms Zachary)
- Program in Social and Behavioral Interventions, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Wingert, Dr Surkan)
- Nutrition Education, School, and Community Nutrition Programs Branch, Maryland State Department of Education, Baltimore, MD, USA (Ms Booker)
| | - Katherine Wingert
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Pollard)
- Program in Social Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA (Ms Zachary)
- Program in Social and Behavioral Interventions, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Wingert, Dr Surkan)
- Nutrition Education, School, and Community Nutrition Programs Branch, Maryland State Department of Education, Baltimore, MD, USA (Ms Booker)
| | - Sara S. Booker
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Pollard)
- Program in Social Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA (Ms Zachary)
- Program in Social and Behavioral Interventions, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Wingert, Dr Surkan)
- Nutrition Education, School, and Community Nutrition Programs Branch, Maryland State Department of Education, Baltimore, MD, USA (Ms Booker)
| | - Pamela J. Surkan
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Pollard)
- Program in Social Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA (Ms Zachary)
- Program in Social and Behavioral Interventions, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA (Ms Wingert, Dr Surkan)
- Nutrition Education, School, and Community Nutrition Programs Branch, Maryland State Department of Education, Baltimore, MD, USA (Ms Booker)
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Pollard SL, Williams DL, Breysse PN, Baron PA, Grajeda LM, Gilman RH, Miranda JJ, Checkley W. A cross-sectional study of determinants of indoor environmental exposures in households with and without chronic exposure to biomass fuel smoke. Environ Health 2014; 13:21. [PMID: 24655424 PMCID: PMC3978088 DOI: 10.1186/1476-069x-13-21] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 03/14/2014] [Indexed: 05/19/2023]
Abstract
BACKGROUND Burning biomass fuels indoors for cooking is associated with high concentrations of particulate matter (PM) and carbon monoxide (CO). More efficient biomass-burning stoves and chimneys for ventilation have been proposed as solutions to reduce indoor pollution. We sought to quantify indoor PM and CO exposures in urban and rural households and determine factors associated with higher exposures. A secondary objective was to identify chronic vs. acute changes in cardiopulmonary biomarkers associated with exposure to biomass smoke. METHODS We conducted a census survey followed by a cross-sectional study of indoor environmental exposures and cardiopulmonary biomarkers in the main household cook in Puno, Peru. We measured 24-hour indoor PM and CO concentrations in 86 households. We also measured PM2.5 and PM10 concentrations gravimetrically for 24 hours in urban households and during cook times in rural households, and generated a calibration equation using PM2.5 measurements. RESULTS In a census of 4903 households, 93% vs. 16% of rural vs. urban households used an open-fire stove; 22% of rural households had a homemade chimney; and <3% of rural households participated in a national program encouraging installation of a chimney. Median 24-hour indoor PM2.5 and CO concentrations were 130 vs. 22 μg/m3 and 5.8 vs. 0.4 ppm (all p<0.001) in rural vs. urban households. Having a chimney did not significantly reduce median concentrations in 24-hour indoor PM2.5 (119 vs. 137 μg/m3; p=0.40) or CO (4.6 vs. 7.2 ppm; p=0.23) among rural households with and without chimneys. Having a chimney did not significantly reduce median cook-time PM2.5 (360 vs. 298 μg/m3, p=0.45) or cook-time CO concentrations (15.2 vs. 9.4 ppm, p=0.23). Having a thatched roof (p=0.007) and hours spent cooking (p=0.02) were associated with higher 24-hour average PM concentrations. Rural participants had higher median exhaled CO (10 vs. 6 ppm; p=0.01) and exhaled carboxyhemoglobin (1.6% vs. 1.0%; p=0.04) than urban participants. CONCLUSIONS Indoor air concentrations associated with biomass smoke were six-fold greater in rural vs. urban households. Having a homemade chimney did not reduce environmental exposures significantly. Measures of exhaled CO provide useful cardiopulmonary biomarkers for chronic exposure to biomass smoke.
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Affiliation(s)
- Suzanne L Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave, Suite 9121, Baltimore, MD, USA
- Program in Global Disease Epidemiology and Control, Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - D’Ann L Williams
- Department of Environmental Health Sciences, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patrick N Breysse
- Department of Environmental Health Sciences, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patrick A Baron
- Department of Environmental Health Sciences, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura M Grajeda
- Program in Global Disease Epidemiology and Control, Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert H Gilman
- Program in Global Disease Epidemiology and Control, Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Departamento de Medicina, Escuela de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1800 Orleans Ave, Suite 9121, Baltimore, MD, USA
- Program in Global Disease Epidemiology and Control, Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
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Painschab MS, Davila-Roman VG, Gilman RH, Vasquez-Villar AD, Pollard SL, Wise RA, Miranda JJ, Checkley W. Chronic exposure to biomass fuel is associated with increased carotid artery intima-media thickness and a higher prevalence of atherosclerotic plaque. Heart 2013; 99:984-91. [PMID: 23619984 DOI: 10.1136/heartjnl-2012-303440] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Biomass fuels are used for cooking in the majority of rural households worldwide. While their use is associated with an increased risk of lung diseases and all-cause mortality, the effects on cardiovascular disease (CVD) are not well characterised. Exposure to biomass fuel smoke has been associated with lung-mediated inflammation and oxidative stress, which may increase the risk of atherosclerosis as evaluated by carotid intima-media thickness (CIMT), carotid atherosclerotic plaque prevalence and blood pressure. METHODS A cross-sectional study was performed in 266 adults aged ≥35 years in Puno, Peru (3825 m above sea level). We stratified participants by their long-term history of exposure to clean fuel (n=112) or biomass fuel (n=154) and measured 24 h indoor particulate matter (PM2.5) in a random subset (n=84). Participants completed questionnaires and underwent a clinical assessment, laboratory analyses and carotid artery ultrasound. The main outcome measures were CIMT, carotid plaque and blood pressure. RESULTS The groups were similar in age and gender. The biomass fuel group had greater unadjusted mean CIMT (0.66 vs 0.60 mm; p<0.001), carotid plaque prevalence (26% vs 14%; p=0.03), systolic blood pressure (118 vs 111 mm Hg; p<0.001) and median household PM2.5 (280 vs 14 µg/m(3); p<0.001). In multivariable regression, the biomass fuel group had greater mean CIMT (mean difference=0.03 mm, 95% CI 0.01 to 0.06; p=0.02), a higher prevalence of carotid plaques (OR=2.6, 95% CI 1.1 to 6.0; p=0.03) and higher systolic blood pressure (mean difference=9.2 mm Hg, 95% CI 5.4 to 13.0; p<0.001). CONCLUSIONS Chronic exposure to biomass fuel was associated with increased CIMT, increased prevalence of atherosclerotic plaques and higher blood pressure. These findings identify biomass fuel use as a risk factor for CVD, which may have important global health implications.
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Abstract
The arrangement of Hox genes into physical clusters is fundamental to the patterning of animal body plans. Other homeobox genes are often described as dispersed, with only occasional examples of linkage reported, such as the amphioxus ParaHox and Drosophila 93D/E clusters. This clustering is unlikely to be the derived condition, as the genes of the ParaHox and 93D/E clusters are phylogenetically widespread. To assess whether clustering is retained in mammals, and to infer its history, we considered the distribution of ANTP superclass homeobox genes in human and mouse genomes. We postulate four ancient arrays of ANTP superclass genes in animal genomes, denoted 'extended Hox' (Hox, Evx and Mox), NKL (including NK1, NK3, NK4, Lbx, Tlx, Emx, Vax, Hmx, NK6, Msx), ParaHox (Cdx, Xlox, Gsx) and EHGbox (En, HB9, Gbx). Each of these duplicated in the ancestry of the human genome to yield four Hox, four NKL, four ParaHox and at least two EHGbox clusters or arrays. Two of the human NKL clusters (four in mouse) have subsequently been split by chromosome rearrangement, as has one human EHGbox array. We date all cluster duplications to early chordate evolution and infer that three clusters (Hox, NKL, EHGbox) resided on the same chromosome before duplication.
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Affiliation(s)
- S L Pollard
- School of Animal and Microbial Sciences, The University of Reading, Whiteknights, PO Box 228, Reading RG6 6AJ, UK
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Abstract
Mice with the inherited disorder "motor end-plate disease" suffered from a progressive neuromuscular weakness and muscular wasting. The weakness resulted from a failure of evoked transmitter release from the motor nerve terminals. The failure in transmission was all-or-nothing in nature. The numbers of muscle fibres in skeletal muscle and myelinated axons in several major nerve trunks were no different from normal. The loss in muscle bulk was caused by the neuromuscular defect and not from a loss of motor units or muscle fibres. The inherited murine disorder "jolting" was allelic with "motor end-plate disease". Affected "jolting" mice suffered no detectable morphological abnormality in skeletal muscle or peripheral nerve. The physiological properties of skeletal muscle and the characteristics of neuromuscular transmission were indistinguishable from normal.
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