The carbon footprint of as-needed budesonide-formoterol in mild asthma: a post hoc analysis.

INTRODUCTION: The use of pressurised metered-dose inhalers (pMDIs) and asthma exacerbations necessitating healthcare reviews contribute substantially to the global carbon footprint of healthcare. It is possible that a reduction in carbon footprint could be achieved by switching patients with mild asthma from salbutamol pMDI reliever therapy to inhaled corticosteroid-formoterol dry powder inhaler (DPI) reliever therapy, as recommended by the Global Initiative for Asthma (GINA). METHODS: This post hoc analysis included all 668 adult participants in the Novel START trial, who were randomised 1:1:1 to treatment with: as-needed budesonide-formoterol DPI, as-needed salbutamol pMDI, or maintenance budesonide DPI plus as-needed salbutamol pMDI. The primary outcome was carbon footprint of asthma management, expressed as kilograms of carbon dioxide equivalent emissions (kgCO2e), per person year. Secondary outcomes explored the effect of baseline symptom control and adherence (maintenance budesonide DPI arm only) on carbon footprint. RESULTS: As-needed budesonide-formoterol DPI was associated with 95.8% and 93.6% lower carbon footprint compared with as-needed salbutamol pMDI (least squares mean 1.1 versus 26.2 kgCO2e; difference -25.0, 95% CI -29.7 to -20.4; p<0.001) and maintenance budesonide DPI plus as-needed salbutamol pMDI (least squares mean 1.1 versus 17.3 kgCO2e; difference -16.2, 95% CI -20.9 to -11.6; p<0.001), respectively. There was no statistically significant evidence that treatment differences in carbon footprint depended on baseline symptom control or adherence in the maintenance budesonide DPI arm. CONCLUSIONS: The as-needed budesonide-formoterol DPI treatment option was associated with a markedly lower carbon footprint than as-needed salbutamol pMDI and maintenance budesonide DPI plus as-needed salbutamol pMDI.

Distinct trajectories of lung function from childhood to mid-adulthood.

RATIONALE: Life course trajectories of lung function development and decline influence the risk for lung disease but are poorly documented. OBJECTIVE: To document lung function trajectories from childhood to mid-adult life. METHODS: We modelled forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC at ages 9, 11, 13, 15, 18, 21, 26, 32, 38 and 45 years from a population-based cohort using latent profile analysis to identify distinct subgroups of participants with similar lung function trajectories. Regression analyses were used to assess associations between the trajectories, early life factors and postbronchodilator airflow obstruction at age 45. RESULTS: Among 865 participants with ≥6 measures of lung function, we identified 10 distinct FEV1 trajectories. Most were approximately parallel except for a childhood airway hyper-responsiveness-related persistently low trajectory (3% of study population); two accelerated-decline trajectories, one of which (8%) was associated with smoking and higher adult body mass index (BMI) and a catch-up trajectory (8%). Findings for FEV1/FVC trajectories were similar. Nine trajectories were identified for FVC: most were also approximately parallel except for a higher BMI-related accelerated-decline trajectory. The three FEV1 trajectories leading to the lowest FEV1 values comprised 19% of the cohort but contributed 55% of airflow obstruction at age 45. CONCLUSIONS: Lung function trajectories to mid-adult life are largely established before adolescence, with a few exceptions: a childhood airway hyper-responsiveness-related persistently low trajectory, which starts low and gets worse with age, and accelerated adult decline trajectories associated with smoking and obesity. Adverse trajectories are associated with a high risk of airflow obstruction in mid-adult life.

Global mortality and readmission rates following COPD exacerbation-related hospitalisation: a meta-analysis of 65 945 individual patients.

Background: Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design. Methods: A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement. Results: Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event. Conclusions: This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD.

Lung function and cardiovascular risk at age 45 in a cohort of the general population.

BACKGROUND: Impaired lung function is associated with cardiovascular mortality, but the origins of this association are poorly understood. We investigated associations between lung function and cardiovascular risk scores in a general population cohort of men and women aged 45 years. METHODS: Participants are members of an unselected birth cohort followed to adulthood. Lung function determined at ages 32 and 45 by spirometry, body plethysmography, gas diffusion, and airway conductance were the main predictors. Future cardiovascular risk was estimated at age 45 using a multivariable cardiovascular risk algorithm - PREDICT. Risk scores were log-transformed and used as the dependent variable in linear regression analyses. We investigated cross-sectional associations with lung function at age 45 and longitudinal associations using changes in lung function between ages 32-45 as the predictors. RESULTS: 863 of 1037 original cohort participants had data for analysis. Low lung volumes (FEV1, FVC, VA, TLC, and FRC) were associated with greater cardiovascular risk scores in the cross-sectional analyses at age 45 and the longitudinal analyses. These associations were stronger in women than in men, were independent of smoking history, and present in never smokers, even after adjusting for body mass index. Associations were not found for measures of airway function (FEV1/FVC ratio and sGaw) or gas transfer (TLco/VA). CONCLUSIONS: Low lung volumes at age 45 and accelerated pulmonary function decline are associated with a higher estimated cardiovascular risk scores in mid-adulthood. This association is stronger in women and is not explained by smoking or obesity.

Attitudes towards the mixing of COVID-19 vaccinated and unvaccinated patients in multi-bed hospital rooms.

AIM: To explore patient and staff views about the mixing of COVID-19 vaccinated and unvaccinated patients in multi-bed hospital rooms. METHODS: We conducted a mixed methods study with paper surveys and structured interviews. Self-administered surveys were undertaken with inpatients on the general medicine, general surgery, orthopaedic and respiratory wards in Dunedin Public Hospital. Face-to-face interviews were conducted with ward staff including consultants, registrars, charge nurses, registered nurses and nurse managers. The study was undertaken in February 2022, at the start of the first New Zealand wave of the Omicron variant. RESULTS: Of 118 eligible patients, 63 agreed to participate. Sixty (95%) of these patients were vaccinated for COVID-19. Most patients (59%) thought that vaccinated and unvaccinated people should be accommodated in separate hospital rooms. Vaccinated patients felt more comfortable sharing a multi-bed room with others of the same COVID-19 vaccination status as themselves than with unvaccinated patients. Participants who thought that they were at higher risk of severe illness from COVID-19 were more likely to support separation of patients based on vaccination status. Fifteen ward staff were interviewed: most would prefer the hospital to separate patients by vaccination status but were aware this would present practical and ethical problems and thought that current arrangements were adequate. CONCLUSION: While most vaccinated patients and staff wanted patients to be separated according to their COVID-19 vaccination status, the current precautionary measures for COVID-19 were viewed by most staff members as adequate.

Childhood and Adolescent Television Viewing and Metabolic Syndrome in Mid-Adulthood.

BACKGROUND: Excessive sedentary behaviors, such as television viewing or other screen time, may have adverse metabolic effects. We hypothesized that television viewing time in childhood would be associated with the risk of metabolic syndrome at 45 years of age. METHODS: We studied a population-based birth cohort born in Dunedin, New Zealand in 1972 and 1973. Parent- and self-reported weekday television viewing times were recorded at ages 5, 7, 9, 11, 13, 15, and 32 years. The primary outcome was metabolic syndrome at age 45 years, defined as 3 or more of: high glycated hemoglobin; high waist circumference; high blood triglyceride; low high-density lipoprotein cholesterol; and high blood pressure. Reported television viewing time and metabolic syndrome data were available for 870 (87%) of 997 surviving participants. RESULTS: Mean television viewing time between ages 5 and 15 years was associated with metabolic syndrome at 45 years of age. This association persisted after adjusting for sex, socioeconomic status, and BMI at age 5 (odds ratio: 1.30; 95% confidence interval: 1.08 to 1.58; P = .006) and after further adjustment for adult television viewing (odds ratio: 1.26; 95% confidence interval: 1.03 to 1.54; P = .026). Childhood television viewing was also associated with lower cardiorespiratory fitness and higher BMI at 45 years of age. CONCLUSIONS: Time spent watching television during childhood and adolescence is associated with the risk of metabolic syndrome in mid-adulthood. Interventions to reduce screen time for children and young people may have long-lasting benefits for health.

Genetic associations with parental investment from conception to wealth inheritance in six cohorts.

Genetic inheritance is not the only way parents' genes may affect children. It is also possible that parents' genes are associated with investments into children's development. We examined evidence for links between parental genetics and parental investments, from the prenatal period through to adulthood, using data from six population-based cohorts in the UK, US and New Zealand, together totalling 36,566 parents. Our findings revealed associations between parental genetics-summarized in a genome-wide polygenic score-and parental behaviour across development, from smoking in pregnancy, breastfeeding in infancy, parenting in childhood and adolescence, to leaving a wealth inheritance to adult children. Effect sizes tended to be small at any given time point, ranging from RR = 1.12 (95% confidence interval (95%CI) 1.09, 1.15) to RR = 0.76 (95%CI 0.72, 0.80) during the prenatal period and infancy; ß = 0.07 (95%CI 0.04, 0.11) to ß = 0.29 (95%CI 0.27, 0.32) in childhood and adolescence, and RR = 1.04 (95%CI 1.01, 1.06) to RR = 1.11 (95%CI 1.07, 1.15) in adulthood. There was evidence for accumulating effects across development, ranging from ß = 0.15 (95%CI 0.11, 0.18) to ß = 0.23 (95%CI 0.16, 0.29) depending on cohort. Our findings are consistent with the interpretation that parents pass on advantages to offspring not only via direct genetic transmission or purely environmental paths, but also via genetic associations with parental investment from conception to wealth inheritance.

Continuities in maternal substance use from early adolescence to parenthood: findings from the intergenerational cohort consortium.

BACKGROUND: This study assessed the extent to which women's preconception binge drinking, tobacco use and cannabis use, reported prospectively in adolescence and young adulthood, predicted use of these substances during pregnancy and at 1 year postpartum. METHODS: Data were pooled from two intergenerational cohort studies: the Australian Temperament Project Generation 3 Study (395 mothers, 691 pregnancies) and the Victorian Intergenerational Health Cohort Study (398 mothers, 609 pregnancies). Alcohol, tobacco and cannabis use were assessed in adolescence (13-18 years), young adulthood (19-29 years) and at ages 29-35 years for those transitioning to parenthood. Exposures were weekly or more frequent preconception binge drinking (5 + drinks in one session), tobacco use and cannabis use. Outcomes were any alcohol, tobacco and cannabis use prior to awareness of the pregnancy, after awareness of pregnancy (up to and including the third trimester pregnancy) and at 1 year postpartum. RESULTS: Frequent preconception binge drinking, tobacco use and cannabis use across both adolescence and young adulthood were strong predictors of continued use post-conception, before and after awareness of the pregnancy and at 1 year postpartum. Substance use limited to young adulthood also predicted continued use post-conception. CONCLUSIONS: Persistent alcohol, tobacco use and cannabis use that starts in adolescence has a strong continuity into parenthood. Reducing substance use in the perinatal period requires action well before pregnancy, commencing in adolescence and continuing into the years before conception and throughout the perinatal period.

Investigating attitudes and insights into the global warming impact of inhalers.

INTRODUCTION: Inhalers are commonly used in the management of respiratory diseases. The propellants used in pressurised metered dose inhalers (pMDIs) are potent greenhouse gases and carry a substantial global warming potential. Dry powder inhalers (DPIs) are propellant-free alternatives that have fewer consequences on the environment, while being equally effective. In this study, we assessed patients' and clinicians' attitudes towards choosing inhalers that have a lesser environmental impact. METHODS: Surveys of patients and practitioners were undertaken in primary and secondary care settings in Dunedin and Invercargill. Fifty-three patient and 16 practitioner responses were obtained. RESULTS: Sixty-four percent of patients were using pMDIs, while 53% were using DPIs. Sixty-nine percent of patients believed that the environment is an important consideration when switching inhalers. Sixty-three percent of practitioners were aware of the global warming potential of inhalers. Despite this, 56% of practitioners predominantly prescribe or recommend pMDIs. The 44% of practitioners who mostly prescribe DPIs were more comfortable doing so based on environmental impact alone. CONCLUSION: Most respondents believe global warming is an important issue and would consider changing their inhaler to a more environmentally friendly type. Many people were not aware that pressurised metered dose inhalers have a substantial carbon footprint. Greater awareness of their environmental impacts may encourage the use of inhalers with lower global warming potential.

Parental history of positive development and child behavior in next generation offspring: A two-cohort prospective intergenerational study.

This study examined whether positive development (PD) in adolescence and young adulthood predicts offspring behavior in two Australasian intergenerational cohorts. The Australian Temperament Project Generation 3 Study assessed PD at age 19-28 (years 2002-2010) and behavior in 1165 infants (12-18 months; 608 girls) of 694 Australian-born parents (age 29-35; 2012-2019; 399 mothers). The Dunedin Multidisciplinary Health and Development Parenting Study assessed PD at age 15-18 (years 1987-1991) and behavior in 695 preschoolers (3-5 years; 349 girls) and their New Zealand born parents (age 21-46; 1994-2018; 363 mothers; 89% European ethnicity). In both cohorts, PD before parenthood predicted more positive offspring behavior (ßrange  = .11-.16) and fewer behavior problems (ßrange  = -.09 to -.11). Promoting strengths may secure a healthy start to life.

Impact of New Zealand teenagers' fertility intentions on childbearing.

Objective: To assess the impact of age 15 fertility intentions on childbearing outcomes three decades later. Background: Evidence is mixed about the implications of teenage fertility intentions on later childbearing. Taking a prospective life course approach to assessing intentions and outcomes may help clarify these mixed findings. Method: A general population birth cohort (born 1972/73) was asked about their fertility intentions at age 15 and 775 of this sample (384 women, 391 men) provided data on their childbearing between ages 15 and 45. Results: At age 15, almost all of the sample indicated they would like to have children in the future (93%). Most (79%) reported having had a biological child by they time they were 45; but those who professed to not wanting children as teenagers were significantly less likely to have had a child three decades later. Conclusion: Fertility intentions during adolescence are probably influenced by social, political and economic norms and may influence later childbearing decisions. This may be particularly true for those whose intentions counter established norms around childbearing. Implications: A life course framework is useful for examining the relationship between hypothetical fertility intentions and outcomes.

Childhood sexual abuse and pervasive problems across multiple life domains: Findings from a five-decade study.

The aim of this study was to use longitudinal population-based data to examine the associations between childhood sexual abuse (CSA) and risk for adverse outcomes in multiple life domains across adulthood. In 937 individuals followed from birth to age 45y, we assessed associations between CSA (retrospectively reported at age 26y) and the experience of 22 adverse outcomes in seven domains (physical, mental, sexual, interpersonal, economic, antisocial, multi-domain) from young adulthood to midlife (26 to 45y). Analyses controlled for sex, socioeconomic status, prospectively reported child harm and household dysfunction adverse childhood experiences, and adult sexual assault, and considered different definitions of CSA. After adjusting for confounders, CSA survivors were more likely than their peers to experience internalizing, externalizing, and thought disorders, suicide attempts, health risk behaviors, systemic inflammation, poor oral health, sexually transmitted diseases, high-conflict relationships, benefit use, financial difficulties, antisocial behavior, and cumulative problems across multiple domains in adulthood. In sum, CSA was associated with multiple persistent problems across adulthood, even after adjusting for confounding life stressors, and the risk for particular problems incremented with CSA severity. The higher risk for most specific problems was small to moderate, but the cumulative long-term effects across multiple domains reflect considerable individual and societal burden.

Asthma control with ICS-formoterol reliever versus maintenance ICS and SABA reliever therapy: a post hoc analysis of two randomised controlled trials.

BACKGROUND: In randomised controlled trials, as-needed inhaled corticosteroid (ICS)-formoterol reliever therapy reduces severe exacerbation risk compared with maintenance ICS plus short-acting beta2-agonist (SABA) reliever in adolescent and adult asthma, but results in slightly worse control of asthma symptoms, as measured by mean Asthma Control Questionnaire-5 (ACQ-5) score. OBJECTIVE: To assess the levels and changes in asthma control for as-needed budesonide-formoterol versus maintenance budesonide plus SABA in post hoc analyses from the Novel START and PRACTICAL clinical trials. METHODS: The number and proportion of participants at study end in each ACQ-5 category ('well-controlled', 'partly controlled' or 'inadequately controlled' symptoms), and in each responder category based on the minimal clinically important difference for ACQ-5 of 0.5 (improved, no change and worse) with as-needed budesonide-formoterol and maintenance budesonide plus SABA treatment were calculated. RESULTS: With last observation carried forwards, 189/214 (88.3%) and 354/434 (81.6%) of patients in the budesonide-formoterol group had 'well-controlled' or 'partly controlled' symptoms at the end of the study, vs 183/214 (85.5%) and 358/431 (83.1%) in the budesonide maintenance group, for Novel START and PRACTICAL, respectively. The proportion of patients whose symptom control was either improved or unchanged from baseline was 190/214 (88.8%) and 368/434 (84.8%) for budesonide-formoterol, vs 185/214 (86.4%) and 376/431 (87.2%) for maintenance budesonide, in Novel START and PRACTICAL respectively. CONCLUSIONS: There were no clinically important differences in the proportions of patients with 'well-controlled' or 'partly controlled' asthma symptoms, or proportions who improved or maintained their level of control, with as-needed budesonide-formoterol versus maintenance budesonide plus SABA.

Feasibility study of the prevalence of latent tuberculosis infection for Maori in the Waikato region, Aotearoa New Zealand.

OBJECTIVE: This study aimed to assess the feasibility of conducting a representative tuberculin skin test (TST) survey for Maori in Aotearoa New Zealand and to estimate the prevalence of latent tuberculosis (TB) infection. METHODS: Participants were Maori in the Waikato region, recruited by a Maori nurse, through: 1) random household selection from the Electoral Roll; 2) randomly selected prison inmates; and 3) community and health settings. A TB history and symptoms questionnaire was completed, TST performed and investigation of those with TST induration ≥10mm. RESULTS: Random household selection was resource intensive and only contributed 14 participants. Repeated random selection of prison lists were required to recruit 207 participants and there were no positive TST cases. Community and health settings yielded the highest participation (n=370) and the three people (0.5%) with TST ≥10mm. Age ≥45 years and history of contact with a TB case were associated with TST induration ≥5mm (n=39; 6.6%). CONCLUSIONS: The community and health settings were the only feasible options for recruitment. The overall prevalence of a positive TST in the study population was low. A 5mm cut-off may be best to maximise sensitivity for future studies. IMPLICATIONS FOR PUBLIC HEALTH: A mixture of sample selection processes that are more targeted are needed to identify Maori with latent TB infection.

Clinical features of patients hospitalised with COVID-19 from February to October 2020, during the early waves of the pandemic in New Zealand.

AIM: As New Zealand transitions towards endemic SARS-CoV-2, understanding patient factors predicting severity, as well as hospital resourcing requirements will be essential for future planning. METHODS: We retrospectively enrolled patients hospitalised with COVID-19 from 26 February to 5 October 2020 as part of the COVID-19 HospitalisEd Patient SeverIty Observational Study NZ (COHESION). Data on demographics, clinical course and outcomes were collected and analysed as a descriptive case series. RESULTS: Eighty-four patients were identified across eight district health boards. Forty-one (49%) were male. The median age was 58 years [IQR: 41.7-70.3 years]. By ethnicity, hospitalisations included 38 NZ European (45%), 19 Pasifika (23%), 13 Maori (15%), 12 Asian (14%) and 2 Other (2%). Pre-existing co-morbidities included hypertension (26/82, 32%), obesity (16/66, 24%) and diabetes (18/81, 22%). The median length of stay was four days [IQR: 2-15 days]. Twelve patients (12/83, 14%) were admitted to an intensive care unit or high dependency unit (ICU/HDU). Ten (10/83, 12%) patients died in hospital of whom seven (70%) were not admitted to ICU/HDU; the median age at death was 83 years. CONCLUSION: Despite initially low case numbers in New Zealand during 2020, hospitalisation with COVID-19 was associated with a high mortality and hospital resource requirements.

Lifetime cannabis exposure and small airway function in a population-based cohort study.

Background and objective: The long-term effects of cannabis on small airway function remain unclear. We investigated associations between cannabis use and small airway function in a general population sample. Methods: Cannabis use was ascertained at multiple ages from age 18 to 45 years and quantified as joint-years among 895 participants in the Dunedin Multidisciplinary Health and Development Study. Small airway function at ages 38 and 45 years was measured using impulse oscillometry (IOS) before and after inhalation of salbutamol. Analyses used multiple linear regression adjusting for tobacco use, body mass index and height. Longitudinal analyses of cannabis use between 38 and 45 years also adjusted for IOS at age 38 years. Results: Associations between lifetime cannabis joint-years and IOS differed between men and women: in women, cannabis use was associated with pre-bronchodilator resistance at 5 Hz (R 5) and 20 Hz (R 20), reactance at 5 Hz, area of reactance and resonant frequency, and marginally associated with the difference between R 5 and R 20. Cannabis use was only statistically significantly associated with pre-bronchodilator resonant frequency in men. Cannabis use between the ages of 38 and 45 years was associated with a similar pattern of changes in IOS measures. After salbutamol, cannabis use was only statistically significantly associated with R 5 and R 20 among women and none of the IOS measures among men. Conclusions: Cannabis use is associated with small airway dysfunction at age 45 years, indicating an increase in peripheral airway resistance and reactance. These associations were greater and mostly only statistically significant among women. Associations were weaker and mostly nonsignificant after bronchodilator use, suggesting that cannabis-induced changes in small airways may be at least partially reversible.