Occupational exposures and the risk of COPD: dusty trades revisited.

BACKGROUND: The contribution of occupational exposures to chronic obstructive pulmonary disease (COPD) and, in particular, their potential interaction with cigarette smoking remains underappreciated. METHODS: Data from the FLOW study of 1202 subjects with COPD (of which 742 had disease classified as stage II or above by Global Obstructive Lung Disease (GOLD) criteria) and 302 referent subjects matched by age, sex and race recruited from a large managed care organisation were analysed. Occupational exposures were assessed using two methods: self-reported exposure to vapours, gas, dust or fumes on the longest held job (VGDF) and a job exposure matrix (JEM) for probability of exposure based on occupation. Multivariate analysis was used to control for age, sex, race and smoking history. The odds ratio (OR) and adjusted population attributable fraction (PAF) associated with occupational exposure were calculated. RESULTS: VGDF exposure was associated with an increased risk of COPD (OR 2.11; 95% CI 1.59 to 2.82) and a PAF of 31% (95% CI 22% to 39%). The risk associated with high probability of workplace exposure by JEM was similar (OR 2.27; 95% CI 1.46 to 3.52), although the PAF was lower (13%; 95% CI 8% to 18%). These estimates were not substantively different when the analysis was limited to COPD GOLD stage II or above. Joint exposure to both smoking and occupational factors markedly increased the risk of COPD (OR 14.1; 95% CI 9.33 to 21.2). CONCLUSIONS: Workplace exposures are strongly associated with an increased risk of COPD. On a population level, prevention of both smoking and occupational exposure, and especially both together, is needed to prevent the global burden of disease.

Occupational exposures and COPD: an ecological analysis of international data.

The occupational contribution to chronic obstructive pulmonary disease (COPD) has yet to be put in a global perspective. In the present study, an ecological approach to this question was used, analysing group-level data from 90 sex-specific strata from 45 sites of the Burden of Obstructive Lung Disease study, the Latin American Project for the Investigation of Obstructive Lung Disease and the European Community Respiratory Health Survey follow-up. These data were used to study the association between occupational exposures and COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II or above. Regression analysis of the sex-specific group-level prevalence rates of COPD at each site against the prevalence of occupational exposure and ever-smoking was performed, taking into account mean smoking pack-yrs and mean age by site, sex, study cohort and sample size. For the entire data set, the prevalence of exposures predicted COPD prevalence (0.8% increase in COPD prevalence per 10% increase in exposure prevalence). By comparison, for every 10% increase in the proportion of the ever-smoking population, the prevalence of COPD GOLD stage II or above increased by 1.3%. Given the observed median population COPD prevalence of 3.4%, the model predicted that a 20% relative reduction in the disease burden (i.e. to a COPD prevalence of 2.7%) could be achieved by a 5.4% reduction in overall smoking rates or an 8.8% reduction in the prevalence of occupational exposures. When the data set was analysed by sex-specific site data, among males, the occupational effect was a 0.8% COPD prevalence increase per 10% change in exposure prevalence; among females, a 1.0% increase in COPD per 10% change in exposure prevalence was observed. Within the limitations of an ecological analysis, these findings support a worldwide association between dusty trades and chronic obstructive pulmonary disease for both females and males, placing this within the context of the dominant role of cigarette smoking in chronic obstructive pulmonary disease causation.

Performance of self-reported occupational exposure compared to a job-exposure matrix approach in asthma and chronic rhinitis.

OBJECTIVES: Self-reported exposure to vapours, gas, dust or fumes (VGDF) has been widely used as an occupational exposure metric in epidemiological studies of chronic lung diseases. Our objective was to characterise the performance of VGDF for repeatability, systematic misclassification, and sensitivity and specificity against exposure likelihood by a job-exposure matrix (JEM). METHODS: We analysed data from two interviews, 24 months apart, of adults with asthma and chronic rhinitis. Using distinct job as the unit of analysis, we tested a single response item (exposure to VGDF) against assignment using a JEM. We further analysed VGDF and the JEM among a subset of 199 subjects who reported the same job at both interviews, using logistic regression analysis to test factors associated with VGDF inconsistency and discordance with the JEM. RESULTS: VGDF was reported for 193 (44%) of 436 distinct jobs held by the 348 subjects studied; moderate to high exposure likelihood by JEM was assigned to 120 jobs (28%). The sensitivity and specificity of VGDF against JEM were 71% and 66%, respectively. Among 199 subjects with the same job at both interviews, 32% had a discordant VGDF status (kappa = 0.35). Those with chronic rhinitis without concomitant asthma compared to asthma alone were more likely to have a VGDF report discordant with the JEM (OR 3.6, 95% CI 1.4 to 9.0; p = 0.01). Rhinitis was also associated with reported VGDF in a job classified by the JEM as low exposure (OR 3.9, 95% CI 1.6 to 9.4; p = 0.003). CONCLUSION: The VGDF item is moderately sensitive measured against JEM as a benchmark. The measure is a useful assessment method for epidemiological studies of occupational exposure risk.

Plasma receptor for advanced glycation end products and clinical outcomes in acute lung injury.

OBJECTIVES: To determine whether baseline plasma levels of the receptor for advanced glycation end products (RAGE), a novel marker of alveolar type I cell injury, are associated with the severity and outcomes of acute lung injury, and whether plasma RAGE levels are affected by lower tidal volume ventilation. DESIGN, SETTING AND PARTICIPANTS: Measurement of plasma RAGE levels from 676 subjects enrolled in a large randomised controlled trial of lower tidal volume ventilation in acute lung injury. MEASUREMENTS AND MAIN RESULTS: Higher baseline plasma RAGE was associated with increased severity of lung injury. In addition, higher baseline RAGE was associated with increased mortality (OR for death 1.38 (95% CI 1.13 to 1.68) per 1 log increment in RAGE; p = 0.002) and fewer ventilator free and organ failure free days in patients randomised to higher tidal volumes. These associations persisted in multivariable models that adjusted for age, gender, severity of illness and the presence of sepsis or trauma. Plasma RAGE was not associated with outcomes in the lower tidal volume group (p = 0.09 for interaction in unadjusted analysis). In both tidal volume groups, plasma RAGE levels declined over the first 3 days; however, the decline was 15% greater in the lower tidal volume group (p = 0.02; 95% CI 2.4% to 25.0%). CONCLUSIONS: Baseline plasma RAGE levels are strongly associated with clinical outcomes in patients with acute lung injury ventilated with higher tidal volumes. Lower tidal volume ventilation may be beneficial in part by decreasing injury to the alveolar epithelium.

Measurement of environmental tobacco smoke exposure among adults with asthma.

Because the morbidity and mortality from adult asthma have been increasing, the identification of modifiable environmental exposures that exacerbate asthma has become a priority. Limited evidence suggests that exposure to environmental tobacco smoke (ETS) may adversely affect adults with asthma. To study the effects of ETS better, we developed a survey instrument to measure ETS exposure in a cohort of adults with asthma living in northern California, where public indoor smoking is limited. To validate this survey instrument, we used a passive badge monitor that measures actual exposure to ambient nicotine, a direct and specific measure of ETS. In this validation study, we recruited 50 subjects from an ongoing longitudinal asthma cohort study who had a positive screening question for ETS exposure or potential exposure. Each subject wore a passive nicotine badge monitor for 7 days. After the personal monitoring period, we readministered the ETS exposure survey instrument. Based on the survey, self-reported total ETS exposure duration ranged from 0 to 70 hr during the previous 7 days. Based on the upper-range boundary, bars or nightclubs (55 hr) and the home (50 hr) were the sites associated with greatest maximal self-reported exposure. As measured by the personal nicotine badge monitors, the overall median 7-day nicotine concentration was 0.03 microg/m(3) (25th-75th interquartile range 0-3.69 microg/m(3)). Measured nicotine concentrations were highest among persons who reported home exposure (median 0.61 microg/m(3)), followed by work exposure (0.03 microg/m(3)), other (outdoor) exposure (0.025 microg/m(3)), and no exposure (0 microg/m(3); p = 0.03). The Spearman rank correlation coefficient between self-reported ETS exposure duration and directly measured personal nicotine concentration during the same 7-day period was 0.47, supporting the survey's validity (p = 0.0006). Compared to persons with no measured exposure, lower-level [odds ratio (OR) 1.9; 95% confidence interval (CI), 0.4-8.8] and higher-level ETS exposures (OR 6.8; 95% CI, 1.4-32.3) were associated with increased risk of respiratory symptoms. A brief, validated survey instrument can be used to assess ETS exposure among adults with asthma, even with low levels of exposure. This instrument could be a valuable tool for studying the effect of ETS exposure on adult asthma health outcomes.

Necrotizing lymphadenitis associated with systemic lupus erythematosus.

OBJECTIVE: Systemic lupus erythematosus (SLE) may have protean manifestations, including necrotizing lymphadenitis. After describing an illustrative case, we discuss the incidence, clinical features, and pathologic findings of SLE-associated necrotizing lymphadenitis. METHODS: A case of SLE associated with necrotizing lymphadenitis is reported. The patient's clinical presentation, course, and response to therapy is detailed. The literature on lupus lymphadenitis is reviewed. RESULTS: A young man who presented with a febrile illness characterized by multifocal necrotizing lymphadenitis is described. Glomerulonephritis, meningo-encephalitis, pericarditis, and hemolytic anemia evolved. The diagnosis of SLE was based on the clinical features, positive antinuclear antibody (ANA), and characteristic renal biopsy. High dose corticosteroids and cyclophosphamide induced a complete remission. In recent series from the literature the prevalence of lymphadenopathy was 12% to 59% of patients with SLE. The most common nodal groups involved were cervical (43%), mesenteric (21%), axillary (18%), and inguinal (17%). Lymph node pathology was characterized by paracortical foci of necrosis and infiltration by histiocytes, lymphocytes, plasma cells, and immunoblasts. The hematoxylin body, an amorphic aggregate of basophilic material, was pathognomonic of lupus lymphadenitis. The necrotizing lymphadenitis of SLE is pathologically similar to Kikuchi-Fujumoto disease (KFD), a distinctive, self-limited form of necrotizing lymphadenitis. The pathologic and clinical literature support a close link between SLE and KFD. CONCLUSIONS: SLE can be complicated by necrotizing lymphadenitis, with distinctive pathologic features. Lupus lymphadenitis and KFD share some common clinical and pathologic features, supporting a relationship between the disorders.

The Marks Asthma Quality of Life Questionnaire: further validation and examination of responsiveness to change.

We performed analyses to examine the structure, validity, and responsiveness to change of the Marks Asthma Quality of Life Questionnaire (AQLQ), originally validated in Australia in a self-administered format, among 539 U.S. subjects with asthma. Subjects were interviewed twice by telephone over an 18-month period. Based on factor analyses, the subscale structure of the AQLQ was modified slightly to eliminate item overlap among subscale scores. Cross-sectionally, total AQLQ scores were significantly correlated in expected directions with baseline asthma severity scores (r = 0.58), SF-36 physical (r = -0.66) and mental (r = -0.40) health status scores, and pulmonary function (FEV1% predicted, r = -0.14). Longitudinally, changes in AQLQ total and subscale scores were significantly (P<0.01) associated with changes in asthma severity and both physical and mental status. The AQLQ, administered by telephone, appears to be useful for assessing changes in the impact of adult asthma.

The pulmonary manifestations of AIDS-related non-Hodgkin's lymphoma.

STUDY OBJECTIVE: To describe the clinical, radiographic, and autopsy features of AIDS-related non-Hodgkin's Iymphoma (NHL) with pulmonary involvement. DESIGN: Retrospective series of patients with HIV infection and NHL with pathologically documented lung or pleural involvement. SETTING: A university and a county hospital in San Francisco. PATIENTS: Thirty-eight patients with HIV infection and NHL involving the lungs or pleura. RESULTS: Most patients had respiratory symptoms (87%) and signs (84%). The majority of patients had advanced HIV infection, with a mean CD4 count of 67 (+/- 65). The most common laboratory abnormalities were elevated lactate dehydrogenase value (89%), elevated erythrocyte sedimentation rate (94%), hematologic abnormalities (95%), and widened alveolar-arterial gradient (89%). Thoracic CT revealed pulmonary nodules (50%), lobar infiltrates (27%), and lung mass (19%) as the most common parenchymal abnormalities. Pleural effusion (68%) and thoracic lymphadenopathy (54%) were unexpectedly common. Autopsy confirmed the high prevalence of pulmonary nodules (30%), airspace disease (35%), and lung mass (25%). Pleural effusions (65%) and thoracic lymphadenopathy (60%) were also common at autopsy. The respiratory system was the most common extranodal site (71%) in patients with AIDS-related NHL undergoing autopsy. Of the bronchoscopic procedures performed, transbronchial biopsy had the highest diagnostic yield (58%) for lymphoma. BAL and bronchial brushing were never diagnostic. Pleural fluid cytologic study and open lung biopsy specimens also had high diagnostic yields (75% each). CONCLUSIONS: The lung is a common extranodal site in AIDS-related NHL. NHL with pulmonary involvement occurs primarily in patients with advanced HIV infection. Most patients have nodules, infiltrates, or masses by thoracic imaging and autopsy. Thoracic lymphadenopathy is much more common than previously believed. Transbronchial biopsy, pleural fluid cytologic study, and open lung biopsy are the most useful diagnostic procedures.

The association between occupation and asthma in general medical practice.

BACKGROUND: In general practice settings, the proportion of adult asthma attributable to occupational factors is not known. OBJECTIVE: The goal of this study was to estimate the proportion of adult asthma cases that can be attributed to occupational factors initiating new disease onset and exacerbating preexisting disease. METHODS: We performed a cross-sectional analysis of interview data for 150 adults with asthma recruited from a random sample of family practice specialists. We ascertained the asthma and work histories of the subjects and estimated the proportion with likely work-initiated asthma and work-related asthma recrudescence. RESULTS: Seventy-four subjects (49%) reported adult-onset asthma while employed; an additional 25 (17%) reported recrudescence of previously quiescent childhood-onset asthma during employment. Of those with new-onset asthma while employed, 15 (10% of the study group; 95% confidence interval, 5 to 15%) were employed in occupations at increased risk of occupational asthma initiation on the basis of an independent job scoring matrix. Of those with asthma recrudescence in adulthood, seven (5% of the study group; 95% confidence interval, 2 to 8%) were employed in occupations at increased risk of exposures aggravating asthma. CONCLUSIONS: Among adults with asthma treated in general practice settings, > 1 in 10 patients has a work history strongly suggestive of a potential relationship between exposure and disease.

Alternative therapies among adults with a reported diagnosis of asthma or rhinosinusitis : data from a population-based survey.

BACKGROUND: Asthma and rhinosinusitis are common medical conditions among adults. Alternative treatments could have important impacts on health status among those individuals with these conditions, but specific prevalence data for these treatments are limited. OBJECTIVE: To estimate the prevalence of specific alternative treatment modalities, including herbal agents, ingestion of caffeinated beverages, homeopathy, acupuncture, and massage therapies. DESIGN: Random population telephone sample. SETTING: Northern California. PARTICIPANTS: Three hundred adults aged 18 to 50 years with self-report of a physician diagnosis of asthma (n = 125) or rhinosinusitis without concomitant asthma (n = 175). MEASUREMENTS: Structured telephone interviews covering demographics and clinical variables, including the following alternative treatments used in the previous 12 months: herbal agents; caffeine-containing products; homeopathy; acupuncture; aromatherapy; reflexology; and massage. RESULTS: Any alternative practice was reported by 127 subjects (42%; 95% confidence interval [CI], 36 to 48%). Of these, 33 subjects (26%; 95% CI, 21 to 31%) were not current prescription medication users. Herbal use was reported by 72 subjects (24%), caffeine treatment by 54 subjects (18%), and other alternative treatments by 66 subjects (22%). Taking into account demographic variables, subjects with asthma were more likely than those with rhinitis alone to report caffeine self-treatment for their condition (odds ratio, 2.5; 95% CI, 1.4 to 4.8%), but herbal use and other alternative treatments did not differ significantly by condition group. CONCLUSION: Alternative treatments are frequent among adults with asthma or rhinosinusitis and should be taken into account by health-care providers and public health and policy analysts.

Cigarette smoking, alcohol consumption, and risk of ARDS: a 15-year cohort study in a managed care setting.

STUDY OBJECTIVE: To examine the association of cigarette smoking and alcohol consumption with hospital presentation of ARDS in a well-defined, multiethnic population. DESIGN: Retrospective cohort study. SETTING: Health maintenance organization in Northern California. PARTICIPANTS: A total of 121,012 health plan subscribers (54.2% women), aged 25 to 89 years. OUTCOME MEASURE: Hospital presentation of ARDS (validated by medical chart review) from baseline in 1979 to 1985 through the end of 1993 (median, 9.9 years). RESULTS: There were 56 cases of ARDS (33 in men, 23 in women). The case fatality rate was 39% in both genders. ARDS was independently related to increasing age (rate ratio of 10 years, 1.38; 95% confidence interval [CI], 1.12 to 1.71), to current smoking of < 20 cigarettes/d (rate ratio vs never cigarette smokers, 2.85; 95% CI, 1. 23 to 6.60), and to current cigarette smoking of > or = 20 cigarettes/d (rate ratio vs never smokers, 4.59; 95% CI, 2.13 to 9.88). No association was observed between alcohol consumption and ARDS. CONCLUSIONS: The results of this study suggest a relationship (with evidence of dose-response effect) between cigarette smoking and ARDS. Assuming a causal relationship, approximately 50% of ARDS cases were attributable to cigarette smoking.

Pulmonary function improves after expandable metal stent placement for benign airway obstruction.

STUDY OBJECTIVE: To determine whether expandable metal stent placement for benign airway lesions improves pulmonary function. DESIGN: Case series. SETTING: University medical center. PATIENTS: Nine patients who underwent balloon-mediated expandable metal stent deployment for airway obstruction due to benign etiologies. RESULTS: All nine patients had expandable stents deployed for benign airway lesions using fiberoptic bronchoscopy and fluoroscopic guidance. Pulmonary function improved after stent placement. The mean FVC increased by 388 mL (95% confidence interval [CI], 30 to 740 mL), the mean peak expiratory flow (PEF) increased by 1,288 mL (95% CI, 730 to 1,840 mL), the mean FEV1 increased by 550 mL (95% CI, 240 to 860 mL), and the mean forced expiratory flow between 25% and 50% of vital capacity (FEF25-75%) increased by 600 mL (95% CI, 110 to 1,090 mL). Corresponding relative measurements included increases in FVC (12%), PEF (95%), FEV1 (38%), and FEF25-75% (87%). The complete characterization of a benign airway obstruction generally required a multimodal approach. CONCLUSIONS: Expandable metal stent placement appears to be an effective therapy for benign airway obstruction.

Impact of donor and recipient characteristics on the development of acute and chronic graft-versus-host disease following pediatric bone marrow transplantation.

Current knowledge of risk factors for graft-versus-host disease (GVHD) in pediatric bone marrow transplantation is derived from studies focusing primarily on adults. We reviewed 100 pediatric HLA-matched allogeneic marrow transplants to identify donor and recipient factors (age, sex, age mismatch, sex mismatch) associated with increased incidence of acute or chronic GVHD. The incidence of acute (32%) and chronic (29%) GVHD were very low. In univariate analyses, recipient age (P = 0.003), donor age (P = 0.002), donor sex (P = 0.089) and age mismatch (P = 0.018) are related to acute GVHD. Prior acute GVHD (P = 0.0001), recipient age (P = 0.057), donor age (P = 0.016), donor sex (P = 0.01) and sex mismatch (P = 0.024) are associated with chronic GVHD. In multivariate analyses, older donor age (P = 0.003) and female donor sex (P = 0.046) independently predict acute GVHD. Only acute GVHD (P = 0.0001) was independently related to chronic GVHD. When acute GVHD was excluded, older donor age (P = 0.032) and sex mismatch (P = 0.005) predict chronic GVHD. Thus, the incidence of acute and chronic GVHD were very low in our pediatric population, especially in the youngest patients. Older donor age and female donor sex are associated with a higher incidence of acute GVHD. Prior acute GVHD, older donor age and sex mismatch are associated with a higher incidence of chronic GVHD.

Exposure to environmental tobacco smoke: association with personal characteristics and self reported health conditions.

STUDY OBJECTIVE: To examine the association between exposure to environmental tobacco smoke (ETS) and demographic, lifestyle, occupational characteristics and self reported health conditions. DESIGN: Cross sectional study, using data from multiphasic health checkups between 1979 and 1985. SETTING: Large health plan in Northern California, USA. PARTICIPANTS: 16 524 men aged 15-89 years and 26 197 women aged 15-105 years who never smoked. RESULTS: Sixty eight per cent of men and 64 per cent of women reported any current ETS exposure (at home, in small spaces other than home or in large indoor areas). The exposure time from all three sources of ETS exposure correlated negatively with age. Men and women reporting high level ETS exposure were more likely to be black and never married or separated/divorced, to have no college or partial college education, to consume three alcoholic drink/day or more and to report exposure to several occupational hazards. Consistent independent relations across sexes were found between any current exposure to ETS and a positive history of hay fever/asthma (odds ratio (OR)=1.22 in men, 1.14 in women), hearing loss (OR=1.30 in men, 1.27 in women), severe headache (OR=1.22 in men, 1.17 in women), and cold/flu symptoms (OR=1.52 in men, 1.57 in women). Any current ETS exposure was also associated with chronic cough (OR=1.22) in men and with heart disease (OR=1.10) in women. Self reported stroke was inversely associated with any current ETS exposure in men (OR=0.27). No associations were noted for cancer or tumour and for migraine. CONCLUSION: ETS exposure correlated with several personal characteristics potentially associated with adverse health outcomes. Although the study design precluded causal inference, ETS exposure was associated with several self reported acute and chronic medical conditions.

Gas stove use and respiratory health among adults with asthma in NHANES III.

BACKGROUND: Gas stoves release respiratory irritants, such as nitrogen dioxide and other combustion by-products. Adults with asthma may be susceptible to the effects of gas stove exposure because of their underlying airway hyperresponsiveness, but this association has been difficult to establish. AIMS: To examine the association between gas stove use and respiratory health. METHODS: The analysis used data from the US Third National Health and Nutrition Examination Survey among 445 adults with asthma (representing 4.8 million persons with the condition). RESULTS: Nearly half of the adults with asthma had a gas stove in their home (47.1%). There was no association between gas stove use and FEV1 (mean change 146 ml; 95% CI -50 to 342 ml), FVC (0 ml; 95% CI -151 to 152 ml), or FEF25%-75% (357 ml; 95% CI -7 to 722 ml). There was also no relation between gas stove use and the risk of self reported cough (OR 0.8; 95% CI 0.4 to 1.7), wheeze (OR 1.5; 95% CI 0.7 to 3.2), or other respiratory symptoms. Controlling for sociodemographic, smoking, housing, and geographic factors did not appreciably affect these results. CONCLUSIONS: Among adults with asthma, there was no apparent impact of gas stove use on pulmonary function or respiratory symptoms. These results should be reassuring to adults with asthma and their health care providers.

The association between occupational factors and adverse health outcomes in chronic obstructive pulmonary disease.

BACKGROUND AND AIMS: Despite recognition that occupational exposures may make a substantive contribution to the aetiology of COPD, little is known about the potential role of work related factors in COPD related health outcomes. METHODS: Prospective cohort study using structured telephone interviews among a random sample of adults aged 55-75 reporting a COPD condition (emphysema, chronic bronchitis, or COPD). Using multivariate models adjusting for smoking and demographic factors, the separate and combined associations were estimated between occupational exposure to vapours, gas, dust, or fumes (VGDF) and leaving work due to lung disease (respiratory related work disability) with health outcomes and utilisation ascertained at one year follow up. RESULTS: Of 234 subjects, 128 (55%) reported exposure to VGDF on their longest held jobs, 58 (25%) reported respiratory related work disability, and 38 (16%) subjects reported both. Combined exposure to VGDF and respiratory related work disability (rather than either factor alone) was associated with the greatest risk at follow up of frequent (everyday) restricted activity days attributed to a breathing or lung condition (OR 3.8; 95% CI 1.4 to 10.1), emergency department (ED) visit (OR 3.9; 95% CI 1.4 to 10.5), and hospitalisation (OR 7.6; 95% CI 1.8 to 32). CONCLUSIONS: Among persons with COPD, past occupational exposures and work disability attributed to lung disease, particularly in combination, appear to be risk factors for adverse health related outcomes.

Asthma and smoking status in a population-based study of California adults.

OBJECTIVE: Because they experience respiratory symptoms, adults with asthma might be expected to avoid cigarette smoking. However, previous studies have not adequately addressed whether adults with asthma have a lower prevalence of smoking than the general population. The authors sought to determine whether adult asthmatics are less likely to smoke cigarettes than members of the general population. METHODS: The authors used data from a random sample of 2,902 California adults ages 18 years or older,with oversampling of African Americans, Asian/Pacific Islanders, adults with disabilities, and adults aged 45 to 70 years. Sampling weights were used in all analyses. In this cross-sectional study, 217 participants (7.5%) reported a physician diagnosis of asthma. RESULTS: The prevalence of "ever smoking" was similar among adults with asthma (48.3%) and those without asthma (43.0%) (risk difference 5.3%; 95% CI -1.6%, 12.2%). There was also no difference in the prevalence of "current smoking" among adults with asthma (20.2%) compared with the non-asthmatic subjects (18.8%) (risk difference 1.4%; 95% CI -4.2%, 6.9%). After controlling for age, gender, race, and education, there was no evidence that adults with asthma were less likely to ever smoke. Although the confidence intervals did not exclude "no association," asthma was actually associated with an increased risk of ever smoking (OR 1.3; 95% CI 1.0, 1.8). There was also no association between asthma and the risk of current smoking after controlling for covariates (OR 1.1; 95% CI 0.8, 1.6). Moreover, there were no differences in "age of smoking initiation," "duration of smoking," or "intensity of smoking" after adjusting for demographic characteristics. Redefining the referent group to exclude respondents with other chronic lung diseases did not appreciably change study conclusions. CONCLUSION: Adults with asthma do not appear to selectively avoid cigarette smoking. Specific smoking prevention and cessation efforts should be targeted to adults with asthma.

Systemic nicotine exposure in tobacco harvesters.

Several epidemics of nicotine intoxication have been described among tobacco harvesters; however, little is known about nicotine absorption under typical working conditions. To assess systemic nicotine absorption during a regular working shift, the authors performed an observational field study. Included in the study were 10 healthy, nonsmoking, female tobacco harvesters and a control group of 5 healthy, nonsmoking, female hospital workers. Nicotine and cotinine were measured in sequential samples of blood and urine during a regular workshift. Blood nicotine levels rose from a nadir value of 0.79 +/- 0.12 ng/ml to a peak value of 3.45 +/- 0.84 ng/ml (p < .05 [Tukey's modified t test]) in the exposed group. In the control group, levels were stable at 0.1 +/- 0.1 ng/ml (p < .01). Moreover, the mean blood nicotine level measured 3 mo following the end of exposure in 6 of 10 exposed subjects was 0.24 +/- 0.12 ng/ml (p < .01). Corresponding higher values of urine nicotine and urine cotinine were observed in the exposed versus control group (comparative p values were < .01 and < .05, respectively). Overall, tobacco harvesters absorbed approximately 0.8 mg of nicotine daily. Given that nicotine can induce adverse health effects, the authors believe that prevention of nicotine absorption in tobacco harvesters should be sought and that workers should be informed about occupational risks.

The association between asthma, asthma, therapeutic classes and hepatic enzyme elevation among adult HMO members.

The results of this case-control study conducted at a large HMO support the notion that severe asthma may be associated with transient hepatic enzyme elevation. Conversely, we found no evidence of associations between asthma therapeutic classes and hepatic enzyme elevation.

Socioeconomic status, race and COPD health outcomes.

BACKGROUND: Although chronic obstructive pulmonary disease (COPD) is a common cause of death and disability, little is known about the effects of socioeconomic status (SES) and race-ethnicity on health outcomes. METHODS: The aim of this study is to determine the independent impacts of SES and race-ethnicity on COPD severity status, functional limitations and acute exacerbations of COPD among patients with access to healthcare. Data were used from the Function, Living, Outcomes and Work cohort study of 1202 Kaiser Permanente Northern California Medical Care Plan members with COPD. RESULTS: Lower educational attainment and household income were consistently related to greater disease severity, poorer lung function and greater physical functional limitations in cross-sectional analysis. Black race was associated with greater COPD severity, but these differences were no longer apparent after controlling for SES variables and other covariates (comorbidities, smoking, body mass index and occupational exposures). Lower education and lower income were independently related to a greater prospective risk of acute COPD exacerbation (HR 1.5; 95% CI 1.01 to 2.1; and HR 2.1; 95% CI 1.4 to 3.4, respectively). CONCLUSION: Low SES is a risk factor for a broad array of adverse COPD health outcomes. Clinicians and disease management programs should consider SES as a key patient-level marker of risk for poor outcomes.