Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation.

STUDY OBJECTIVE: The association of in-hospital medical emergency team activation (META) among patients with atrial fibrillation (AF) at risk for obstructive sleep apnea (OSA) is unclear. This study evaluates the performance of the DOISNORE50 sleep questionnaire as an OSA screener for patients with AF and determines the prevalence of META among perioperative patients with underlying AF who have a diagnosis or are at risk for OSA. METHODS: A prospective perioperative cohort of 2,926 patients with the diagnosis of AF was assessed for DOISNORE50 questionnaire screening. Propensity score matching (PSM) was used to match patient physical characteristics, comorbidities, length of stay, and inpatient CPAP usage. META and ICU admissions during the surgical encounter, 30-day hospital readmissions, and 30-day ED visits were evaluated. RESULTS: 1,509 of 2,926 AF patients completed the DOISNORE50 questionnaire and were enrolled in the OSA safety protocol. Following propensity score matching, there was a reduced adjusted odds of META in the screened group of 0.69 (95% CI: 0.48-0.98, p<0.001) in comparison to the non-screened group. The adjusted odds of intensive care unit (ICU) admissions and ED visits within 30-days of discharge were statistically lower for the screened group compared to non-screened group. CONCLUSIONS: Among perioperative AF patients, evidence supports DOISNORE50 screening and implementation of an OSA safety protocol for reduction of META. This study identified a decreased odd of META, ICU admissions, and ED visits among screened group. The High-Risk and Known OSA group showed reduced odds of META following the implementation of an OSA safety protocol.

Adverse Delivery and Neonatal Outcomes Among Women with Severe Maternal Morbidity in Illinois, 2018-2019.

Objective: To examine adverse delivery outcomes from 2018 to 2019 severe maternal morbidity (SMM) cases that were reviewed by facility-level review committees in Illinois (n = 666) and describe the burden of adverse delivery outcomes among demographic subgroups, SMM etiology, and whether the SMM event was potentially preventable. Materials and Methods: This is a descriptive analysis of the SMM review cohort. Consistent with expert recommendations to identify SMM for hospital quality review, SMM was defined as any intensive care or critical care unit admission and/or transfusion of four or more units of packed red blood cells from conception to 42 days postpartum. Adverse delivery outcomes were fetal death, low birthweight, preterm birth, neonatal intensive care unit admission, and 5-minute Apgar score <7. Chi square and Fisher's exact tests compared maternal demographic and delivery characteristics between the SMM sample and 2018-2019 deliveries in Illinois. Logistic regression modeled the associations between primary cause of morbidity, maternal race/ethnicity, adverse delivery outcomes, and opportunities to alter the outcome to assess whether the burden of adverse birth outcomes was distributed evenly across subcategories of the cohort. Results: Overall, 53.9% of women with SMM had at least one adverse delivery outcome. SMM events owing to preeclampsia/eclampsia (adjusted odds ratio [aOR] = 4.41, 95% confidence interval [CI] = 2.37-8.24) and infection/sepsis (aOR = 4.40, 95% CI = 1.79-11.04) were more likely to be accompanied by adverse delivery outcomes compared with hemorrhage-related SMM. Non-Hispanic Black women with SMM were more likely to have an adverse delivery outcome compared with non-Hispanic White women with SMM (aOR = 1.74, 95% CI = 1.01-3.02). Conclusion: A greater proportion of the SMM review cohort experienced adverse delivery outcomes compared with the overall birthing population in the state. Non-Hispanic Black women with SMM were almost twice as likely to have an adverse delivery outcome compared with non-Hispanic White women.

Lung Structure and Risk of Sleep Apnea in SPIROMICS.

Rationale: The SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS) is a prospective cohort study that enrolled 2981 participants with the goal of identifying new chronic obstructive pulmonary disease (COPD) subgroups and intermediate markers of disease progression. Individuals with COPD and obstructive sleep apnea (OSA) experience impaired quality of life and more frequent exacerbations. COPD severity also associates with computed tomography scan-based emphysema and alterations in airway dimensions. Objectives: The objective was to determine whether the combination of lung function and structure influences the risk of OSA among current and former smokers. Methods: Using 2 OSA risk scores, the Berlin Sleep Questionnaire (BSQ), and the DOISNORE50 (Diseases, Observed apnea, Insomnia, Snoring, Neck circumference > 18 inches, Obesity with body mass index [BMI] > 32, R = are you male, Excessive daytime sleepiness, 50 = age ≥ 50) (DIS), 1767 current and former smokers were evaluated for an association of lung structure and function with OSA risk. Measurements and Main Results: The study cohort's mean age was 63 years, BMI was 28 kg/m2, and forced expiratory volume in 1 second (FEV1) was 74.8% predicted. The majority were male (55%), White (77%), former smokers (59%), and had COPD (63%). A high-risk OSA score was reported in 36% and 61% using DIS and BSQ respectively. There was a 9% increased odds of a high-risk DIS score (odds ratio [OR]=1.09, 95% confidence interval [CI]:1.03-1.14) and nominally increased odds of a high-risk BSQ score for every 10% decrease in FEV1 %predicted (OR=1.04, 95%CI: 0.998-1.09). Lung function-OSA risk associations persisted after additionally adjusting for lung structure measurements (%emphysema, %air trapping, parametric response mapping for functional small airways disease, , mean segmental wall area, tracheal %wall area, dysanapsis) for DIS (OR=1.12, 95%CI:1.03-1.22) and BSQ (OR=1.09, 95%CI:1.01-1.18). Conclusions: Lower lung function independently associates with having high risk for OSA in current and former smokers. Lung structural elements, especially dysanapsis, functional small airways disease, and tracheal %wall area strengthened the effects on OSA risk.

Federally Funded Randomized Controlled Trials Increase Analysis and Reporting of Study Outcomes by Sex, Race, and Ethnicity.

Background: We previously examined National Institutes of Health (NIH)-funded randomized controlled trials (RCTs) published in 2004, 2009, and 2015 and found low compliance with NIH policies on inclusion, analysis, and reporting results for female and minoritized subgroups, with no improvement over time. We conducted a fourth wave of data collection using RCTs published in 2021, comparing current results with previous years. Materials and Methods: The authors used PubMed to find 657 RCTs published in print in 14 leading US medical journals in 2021. Of those, 93 (14.2%) were eligible for analysis. We reviewed all parts of eligible studies and any published commentary. Fisher's exact statistics compared proportions of studies analyzing or reporting results for subgroups in 2021 compared with RCTs studied in previous waves. Posthoc analysis compared eligible RCTs about the Covid-19 pandemic to eligible RCTs on other topics. Results: Twenty-five of 93 studies (26.9%) analyzed or reported outcomes by race or ethnicity, an increase over previous years (p < 0.01). Among 79 RCTs with participants of both sexes, the median proportion of female participants was 43%. Moreover, 34 (43.0%) reported an outcome by sex, included sex as a covariate in statistical analysis, or reported results by sex, also an increase over previous waves (p < 0.01). Eleven eligible studies (11.8%) were on a SARS-CoV-2 topic; there was no difference between SARS-CoV-2 RCTs and RCTs on other topics. Conclusions: Analysis and reporting by sex, race, and ethnicity for NIH-funded RCTs published in 2021 significantly increased from previous waves, despite no corresponding increase in enrollment.

MK2 nonenzymatically promotes nuclear translocation of caspase-3 and resultant apoptosis.

We have previously identified mitogen-activated protein kinase-activated protein kinase 2 (MK2) is required for caspase-3 nuclear translocation in the execution of apoptosis; however, little is known of the underlying mechanisms. Therefore, we sought to determine the role of kinase and nonkinase functions of MK2 in promoting nuclear translocation of caspase-3. We identified two non-small cell lung cancer cell lines for use in these experiments based on low MK2 expression. Wild-type, enzymatic and cellular localization mutant MK2 constructs were expressed using adenoviral infection. Cell death was evaluated by flow cytometry. In addition, cell lysates were harvested for protein analyses. Phosphorylation of caspase-3 was determined using two-dimensional gel electrophoresis followed by immunoblotting and in vitro kinase assay. Association between MK2 and caspase-3 was evaluated using proximity-based biotin ligation assays and co-immunoprecipitation. Overexpression of MK2 resulted in nuclear translocation of caspase-3 and caspase-3-mediated apoptosis. MK2 directly phosphorylates caspase-3; however, phosphorylation status of caspase-3 or MK2-dependent phosphorylation of caspase-3 did not alter caspase-3 activity. The enzymatic function of MK2 was dispensable in nuclear translocation of caspase-3. MK2 and caspase-3 associated together and a nonenzymatic function of MK2, chaperoned nuclear trafficking, is required for caspase-3-mediated apoptosis. Taken together, our results demonstrate a nonenzymatic role for MK2 in the nuclear translocation of caspase-3. Furthermore, MK2 may function as a molecular switch in regulating the transition between the cytosolic and nuclear functions of caspase-3.

Tumor MK2 transcript levels are associated with improved response to chemotherapy and patient survival in non-small cell lung cancer.

Non-small cell lung cancers (NSCLCs) demonstrate intrinsic resistance to cell death, even after chemotherapy. Previous work suggested defective nuclear translocation of active caspase-3 in observed resistance to cell death. We have identified mitogen-activated protein kinase-activated protein kinase 2 (MK2; encoded by the gene MAPKAPK2) is required for caspase-3 nuclear translocation in the execution of apoptosis in endothelial cells. The objective was to determine MK2 expression in NSCLCs and the association between MK2 and clinical outcomes in patients with NSCLC. Clinical and MK2 mRNA data were extracted from two demographically distinct NSCLC clinical cohorts, North American (The Cancer Genome Atlas, TCGA) and East Asian (EA). Tumor responses following first round of chemotherapy were dichotomized as clinical response (complete response, partial response, and stable disease) or progression of disease. Multivariable survival analyses were performed using Cox proportional hazard ratios and Kaplan-Meier curves. NSCLC exhibited lower MK2 expression than SCLC cell lines. In patients, lower tumor MK2 transcript levels were observed in those presenting with late-stage NSCLC. Higher MK2 expression was associated with clinical response following initial chemotherapy and independently associated with improved 2-yr survival in two distinct cohorts, 0.52 (0.28-0.98) and 0.1 (0.01-0.81), TCGA and EA, respectively, even after adjusting for common oncogenic driver mutations. Survival benefit of higher MK2 expression was unique to lung adenocarcinoma when comparing across various cancers. This study implicates MK2 in apoptosis resistance in NSCLC and suggests prognostic value of MK2 transcript levels in patients with lung adenocarcinoma.

Comparing State-Level and Facility-Based Review to Assess Quality of Severe Maternal Morbidity Reviews.

OBJECTIVE: To compare results from facility-level and state-level severe maternal morbidity (SMM) reviews in Illinois. DESIGN: We report descriptive characteristics about SMM cases and compare the results of both review processes, including the primary cause, assessment of preventability, and factors that contributed to the severity of the SMM cases. SETTING: All birthing hospitals in Illinois. PARTICIPANTS: A total of 81 SMM cases were reviewed by a facility-level committee and the state-level review committee. SMM was defined as any intensive care or critical care unit admission and/or transfusion of 4 or more units of packed red blood cells from conception to 42 days postpartum. RESULTS: Among the cases reviewed by both committees, hemorrhage was the primary cause of morbidity, with 26 (32.1%) and 38 (46.9%) hemorrhage cases identified by the facility-level and state-level committees, respectively. Both committees identified infection/sepsis (n = 12) and preeclampsia/eclampsia (n = 12) as the next most common causes of SMM. State-level review found more cases potentially preventable (n = 29, 35.8% vs n = 18, 22.2%) and more cases not preventable but improvement in care needed (n = 31, 38.3% vs n = 27, 33.3%). State-level review found more provider and system opportunities to alter the SMM outcome and fewer patient opportunities than facility-level review. CONCLUSION: State-level review found more SMM cases potentially preventable and identified more opportunities to improve care than facility-level review. State-level review has the potential to strengthen facility-level reviews by identifying opportunities to improve the review process and develop recommendations and tools to aid facility-level reviews.

Sleep-Disordered Breathing Destabilizes Ventricular Repolarization.

Rationale: Sleep-disordered breathing (SDB) increases the risk of cardiac arrhythmias, sudden death, and all-cause mortality. Objectives: To characterize the associations between SDB, intermittent hypoxemia, and the QT variability index (QTVI), a measure of ventricular repolarization lability associated with a higher risk for cardiac arrhythmias, sudden death, and cardiovascular mortality. Methods: Polysomnograms from three cohorts were used: a matched sample of 122 participants with and without severe SDB, a matched sample of 52 participants with and without incident SDB, and a cohort of 19 healthy adults exposed to intermittent hypoxia and ambient air on two separate days. Electrocardiographic measures were calculated from one-lead electrocardiograms. Measurements and Main Results: Compared to those without SDB, participants with severe SDB had larger QTVI (-1.19 vs. -1.43, P=0.027), heart rate (68.34 vs. 64.92 beats/minute; P=0.028), and hypoxemia burden during sleep as assessed by the total sleep time with oxygen saturation less than 90% (TST90; 11.39% vs. 1.32%, P<0.001). TST90, but not the frequency of arousals, was a predictor of QTVI. Heart rate and QTVI during sleep were predictive of all-cause mortality. In the cohort with incident SDB, the mean QTVI increased from -1.23 to -0.86 over 5 years (P=0.017). Finally, in the cohort of healthy adults, exposure to intermittent hypoxia for four hours increased QTVI (-1.85 vs. -1.64; P=0.016). Conclusions: Prevalent and incident SDB are associated with ventricular repolarization instability, which predisposes to ventricular arrhythmias and sudden cardiac death. Intermittent hypoxemia can destabilize ventricular repolarization and may mediate the increased mortality in SDB.

Ambient Air Pollution Exposure and Sleep Quality in COPD.

Rationale: Ambient air pollution exposure is associated with respiratory morbidity among individuals with chronic obstructive pulmonary disease (COPD), particularly among those with concomitant obesity. Although people with COPD report high incidence of poor sleep quality, no studies have evaluated the association between air pollution exposure, obesity, and sleep disturbances in COPD. Methods: We analyzed data collected from current and former smokers with COPD enrolled in the Subpopulations and Intermediate Outcome Measures in COPD -Air Pollution ancillary study (SPIROMICS AIR). Socio-demographics and anthropometric measurements were collected, and 1-year mean historical ambient particulate matter (PM2.5) and ozone concentrations at participants' residences were estimated by cohort-specific spatiotemporal modeling. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), and regression models were constructed to determine the association of 1-year PM2.5 (1Yr-PM2.5) and 1-year ozone (1Yr-ozone) with the PSQI score, and whether obesity modified the association. Results: In 1308 participants (age: 65.8±7.8 years, 42% women), results of regression analyses suggest that each 10µg/m3 increase in 1Yr-PM2.5 was associated with a 2.1-point increase in PSQI (P=0.03). Obesity modified the association between 1Yr-PM2.5 and PSQI (P=0.03). In obese and overweight participants, a 10µg/m3 increase in 1Yr-PM2.5 was associated with a higher PSQI (4.0 points, P<0.01, and 3.4 points, P<0.01, respectively); but no association in lean-normal weight participants (P=0.51). There was no association between 1 Yr-ozone and PSQI. Conclusions: Overweight and obese individuals with COPD appear to be susceptible to the effects of ambient PM2.5 on sleep quality. In COPD, weight and ambient PM2.5 may be modifiable risk factors to improve sleep quality.

Prolonged, physiologically relevant nicotine concentrations in the airways of smokers.

Nicotine from cigarette smoke is a biologically active molecule that has pleiotropic effects in the airway, which could play a role in smoking-induced lung disease. However, whether nicotine and its metabolites reach sustained, physiologically relevant concentrations on airway surfaces of smokers is not well defined. To address these issues, concentrations of nicotine, cotinine, and hydroxycotinine were measured by mass spectrometry (MS) in supernatants of induced sputum obtained from participants in the subpopulations and intermediate outcome measures in COPD study (SPIROMICS), an ongoing observational study that included never smokers, former smokers, and current smokers with and without chronic obstructive pulmonary disease (COPD). A total of 980 sputum supernatants were analyzed from 77 healthy never smokers, 494 former smokers (233 with COPD), and 396 active smokers (151 with COPD). Sputum nicotine, cotinine, and hydroxycotinine concentrations corresponded to self-reported smoking status and were strongly correlated to urine measures. A cutoff of ∼8-10 ng/mL of sputum cotinine distinguished never smokers from active smokers. Accounting for sample dilution during processing, active smokers had airway nicotine concentrations in the 70-850 ng/mL (∼0.5-5 µM) range, and concentrations remained elevated even in current smokers who had not smoked within 24 h. This study demonstrates that airway nicotine and its metabolites are readily measured in sputum supernatants and can serve as biological markers of smoke exposure. In current smokers, nicotine is present at physiologically relevant concentrations for prolonged periods, supporting a contribution to cigarette-induced airway disease.

Risk of COPD exacerbation is increased by poor sleep quality and modified by social adversity.

STUDY OBJECTIVES: Sleep is an important dimension in the care of chronic obstructive pulmonary disease (COPD), but its relevance to exacerbations is unclear. We wanted to assess whether sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) is associated with an increased risk of COPD exacerbations and does this differ by socio-environmental exposures. METHODS: We included 1647 current and former smokers with spirometrically confirmed COPD from the SPIROMICS cohort. We assessed incidence rate ratios for exacerbation using zero-inflated negative binomial regression adjusting for demographics, medical comorbidities, and multiple metrics of disease severity, including respiratory medications, airflow obstruction, and symptom burden. Our final model adjusted for socio-environmental exposures using the Area Deprivation Index, a composite measure of contemporary neighborhood quality, and Adversity-Opportunity Index, a composite measure of individual-level historic and current socioeconomic indicators. We used a pre-determined threshold of 20% missingness to undertake multiple imputation by chained equations. As sensitivity analyses, we repeated models in those with complete data and after controlling for prior exacerbations. As an exploratory analysis, we considered an interaction between socio-environmental condition and sleep quality. RESULTS: After adjustment for all co-variates, increasing PSQI scores (range 0-21) were associated with a 5% increased risk for exacerbation per point (p = .001) in the imputed dataset. Sensitivity analyses using complete cases and after controlling for prior exacerbation history were similar. Exploratory analysis suggested less effect among those who lived in poor-quality neighborhoods (p-for-interaction = .035). CONCLUSIONS: Poor sleep quality may contribute to future exacerbations among patients with COPD. This represents one target for improving disease control. CLINICAL TRIAL REGISTRATION: Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS). ClinicalTrials.gov Identifier# NCT01969344. Registry URL: https://clinicaltrials.gov/ct2/show/.

FDA Approval Summary: Osimertinib for Adjuvant Treatment of Surgically Resected Non-Small Cell Lung Cancer, a Collaborative Project Orbis Review.

On December 18, 2020, the FDA approved osimertinib as adjuvant therapy in patients with non-small cell lung cancer (NSCLC) whose tumors have EGFR exon 19 deletions or exon 21 (L858R) mutations, as detected by an FDA-approved test. The approval was based on the ADAURA study, in which 682 patients with NSCLC were randomized to receive osimertinib (n = 339) or placebo (n = 343). Disease-free survival (DFS) in the overall population (stage IB-IIIA) was improved for patients who received osimertinib, with an HR of 0.20; 95% confidence interval (CI), 0.15-0.27; P < 0.0001. Median DFS was not reached for the osimertinib arm compared with 27.5 months (95% CI, 22.0-35.0) for patients receiving placebo. Overall survival data were not mature at the time of the approval. This application was reviewed under FDA's Project Orbis, in collaboration with Australia Therapeutic Goods Administration, Brazil ANVISA, Health Canada, Singapore Health Sciences Authority, Switzerland Swissmedic, and the United Kingdom Medicines and Healthcare products Regulatory Agency. This is the first targeted therapy adjuvant approval for NSCLC and has practice-changing implications.

Racial and Ethnic Disparities in Pregnancy-Related Mortality in Illinois, 2002-2015.

Background: Little is known about racial or ethnic differences in the potential preventability of pregnancy-related deaths, or the provider, systems, or patient factors associated with those deaths. Materials and Methods: This is a retrospective cohort study of pregnancy-related deaths among black, Hispanic, and white women between 2002 and 2015 in Illinois using Illinois Department of Public Health maternal mortality data. We compared the distribution of women's characteristics and calculated race- and ethnicity-specific pregnancy-related mortality ratios (PRMRs) per 100,000 live births. We describe the proportion of deaths that were determined to be potentially preventable by race and ethnicity and critical factors associated with pregnancy-related deaths by cause. Results: There were 130, 33, and 109 pregnancy-related deaths of black, Hispanic, and white women, respectively, in Illinois during the study period. Overall, black women's PRMR was nearly four times that of white women (32.6 vs. 8.9 per 100,000 live births). The PRMR for Hispanic women under 30 years was lower than for white women, but that advantage disappeared after age 30. Emboli and vascular accidents were the most common underlying cause of death overall. Over a third of deaths were potentially preventable. Provider factors, particularly delays in diagnosis and treatment and inappropriate treatment, were cited in 56.1%, 71.4%, and 50.0% of black, Hispanic, and white women's preventable deaths, respectively. Conclusion: Surprisingly, racial disparities in maternal mortality were not associated with statistically significant differences in the cause of death or class of contributing critical factors in this small, single-state analysis; further study in aggregate or pooled data with deeper qualitative assessment of individual cases is, therefore, required to understand how to narrow racial disparities in maternal outcome. If aggregate or pooled analysis showed systematic racial or ethnic differences in committee findings, it would be important to assess whether those differences were due to committee bias or other factors.

Omega-3 fatty acid intake and prevalent respiratory symptoms among U.S. adults with COPD.

BACKGROUND: Omega-3 fatty acids, including alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and derivatives, play a key role in the resolution of inflammation. Higher intake has been linked to decreased morbidity in several diseases, though effects on respiratory diseases like COPD are understudied. METHODS: The National Health and Nutrition Examination Survey (NHANES), with a focus on dietary assessment, provides a unique opportunity to explore relationships between omega-3 intake and morbidity in respiratory diseases marked by inflammation in the United States (US) population. We investigated relationships between ALA or EPA + DHA intake and respiratory symptoms among US adults with COPD, as well as variation in relationships based on personal characteristics or exposures. RESULTS: Of 878 participants, mean age was 60.6 years, 48% were current smokers, and 68% completed high school. Omega-3 intake was, 1.71 ± 0.89 g (ALA), and 0.11 ± 0.21 g (EPA + DHA). Logistic regression models, adjusting for age, gender, race, body mass index, FEV1, education, smoking status, pack-years, total caloric intake, and omega-6 (linoleic acid, LA) intake demonstrated no primary associations between omega-3 intake and respiratory symptoms. Interaction terms were used to determine potential modification of relationships by personal characteristics (race, gender, education) or exposures (LA intake, smoking status), demonstrating that at lower levels of LA intake, increasing ALA intake was associated with reduced odds of chronic cough (pint = 0.015) and wheeze (pint = 0.037). EPA + DHA, but not ALA, was associated with reduced symptoms only among current smokers who did not complete high school. CONCLUSIONS: Individual factors should be taken into consideration when studying the association of fatty acid intake on respiratory diseases, as differential responses may reveal susceptible subgroups.

Omega-3 and Omega-6 Intake Modifies Asthma Severity and Response to Indoor Air Pollution in Children.

Rationale: Higher indoor particulate matter (PM) concentrations are linked with increased asthma morbidity. Dietary intake of fatty acids, also linked with asthma outcomes, may influence this relationship. Objectives: To determine the relationship between omega-3 and omega-6 fatty acid intake and pediatric asthma morbidity, and the association between fatty acid intake and strength of indoor, PM-related asthma symptoms, albuterol use, and systemic inflammation. Methods: Analyses included 135 children with asthma enrolled in the AsthmaDIET Study. At baseline, 3 months, and 6 months, data included: week-long average home indoor concentration of PM ≤2.5 µm in aerodynamic diameter and PM ≤10 µm in aerodynamic diameter, dietary intake of omega-3 and omega-6 fatty acids, daily symptoms, and peripheral blood leukocytes. Asthma severity and lung function were assessed at baseline. Multivariable regression models, adjusted for known confounders, were used to determine associations between each fatty acid and outcomes of interest, with interaction terms (fatty acids × PM) in longitudinal analyses. Measurements and Main Results: Higher omega-6 intake associated with increased odds of increased asthma severity (P = 0.02), and lower FEV1/FVC ratio (P = 0.01). Higher omega-3 intake associated with reduced effect of indoor PM ≤2.5 µm in aerodynamic diameter on symptoms (P < 0.01), whereas higher omega-6 intake associated with amplified effect of indoor PM ≤2.5 µm in aerodynamic diameter on symptoms and circulating neutrophil percentage (P < 0.01). Conclusions: Omega-3 and omega-6 intake are associated with pediatric asthma morbidity and may modify the asthmatic response to indoor PM.

Racial and Ethnic Disparities in Severe Maternal Morbidity in the United States.

Severe maternal morbidity (SMM) is 50 to 100 times more common than maternal death, and has increased disproportionately among ethnic/racial minority women in the United States. However, specific knowledge about how the types and timing of severe maternal morbidities deferentially affect ethnic/racial minority women is poorly understood. This study examines racial/ethnic disparities in severe maternal morbidity during antepartum (AP), intrapartum (IP), and postpartum (PP) hospital admissions in the United States (US) for 2002-2014. We identified AP, IP, and PP hospitalizations in the National Inpatient Sample. Distribution of sociodemographic, behavioral and hospital characteristics, insurance, comorbidities, and SMM occurrence was summarized using descriptive statistics. Through Joinpoint regression, temporal SMM trends of hospitalizations were examined and stratified by race. Multivariate logistic regression assessed the association between race and SMM. We found black women have the highest proportion of SMM across all pregnancy intervals with a 70% greater risk of SMM during AP after adjusting for all cofactors. In the PP period, Hispanic women's risk of SMM is 19% less when compared to white women. Racial/ethnic disparities in SMM vary in timing and SMM type. Systematic investigation is needed to understand risks to black women and the protective factors associated with Hispanic women in the PP. Addressing racial disparities in maternal morbidity and mortality requires national policies and initiatives tailored to black women that address the specific types and timings of life-threatening obstetric complications.