Anne M Fitzpatrick

Emory University, Atlanta, Georgia, United States

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Publications (47)353.45 Total impact

  • Article: Reply.
    Anne M Fitzpatrick, Youngja Park, Lou Ann Brown, Dean P Jones
    The Journal of allergy and clinical immunology 03/2014; · 12.05 Impact Factor
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    ABSTRACT: AsthmaSESSION TYPE: Slide PresentationsPRESENTED ON: Saturday, March 22, 2014 at 12:15 PM - 01:15 PMPURPOSE: The progression and development of asthma across the menopausal transition has not been thoroughly addressed, or clearly separated from the effects of age. The present study evaluates the effects of menopause on asthma severity, quality of life and healthcare utilization using a propensity score model. The analyses were conducted using data from participants enrolled in the Severe Asthma Research program (SARP). Ten sites enrolled asthmatics between 2002 to 2011, and contributed a standardized set of data to a central coordinating center [AJRCCM 2012;185:356-62]. Data on 166 menopausal and 538 non-menopausal asthmatic women, older than 18 years of age was available for analyses. The effect of menopause on asthma control, asthma quality of life, and all secondary endpoints was analyzed after conducting a Propensity Score matching with subsequent multivariate analysis using conditional logistic regression to adjust for the effect of the covariates that remained unbalanced after matching. Those unbalanced covariates were: the age at enrollment, gastroesophageal reflux disease, and hypertension. Compared to non-menopaused women, menopaused women were older, reported more gastroesophageal reflux disease, sinusitis history and used more inhaled corticosteroids. They were less likely to have atopy or test positively on skin testing. Unadjusted analysis showed that menopaused women had an odds ratio of 5.62(95 CI: 3.83; 8.26) of severe asthma compared to non-menopaused women. They were more likely to require healthcare utilization. After Propensity Score matching with subsequent multivariate adjustment menopause was neither associated with greater incidence of severe asthma [OR:1.75 (95 CI: 0.52; 5.9)], or with a worse asthma quality of life [mean difference: 0.31 (95 CI: -0.30; 0.93)]. The increased unadjusted asthma severity, increased need for treatment and health care utilization in menopaused women are more likely due to other age associated co-morbidities and/or aging dependent conditions. In elderly women, menopause is unlikely to be the reason for increased risk of severe asthma or worse quality of life. Suzy Comhair: Grant monies (from sources other than industry): NIH (HL69170) The following authors have nothing to disclose: Joe Zein, Eugene Bleecker, William Busse, William Calhoun, Mario Castro, K. Fan Chung, Raed Dweik, Anne Fitzpatrick, Benjamin Gaston, Elliot Israel, Nizar Jarjour, Wendy Moore, Gerald Teague, Sally Wenzel, Serpil ErzurumNo Product/Research Disclosure Information.
    Chest 03/2014; 145(3 Suppl):22A. · 5.85 Impact Factor
  • Anne M Fitzpatrick, Youngja Park, Lou Ann S Brown, Dean P Jones
    The Journal of allergy and clinical immunology 01/2014; 133(1):258-261.e8. · 12.05 Impact Factor
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    ABSTRACT: The Eunice Kennedy Shriver National Institute of Child Health and Human Development convened an Asthma Group in response to the Best Pharmaceuticals for Children Act. The overall goal of the Best Pharmaceuticals for Children Act Program is to improve pediatric therapeutics through preclinical and clinical drug trials that lead to drug-labeling changes. Although significant advances have been made in the understanding and management of asthma in adults with appropriately labeled medications, less information is available on the management of asthma in children. Indeed, many medications are inadequately labeled for use in children. In general, the younger the child, the less information there is available to guide clinicians. Because asthma often begins in early childhood, it is incumbent on us to continue to address the primary questions raised in this review and carefully evaluate the medications used to manage asthma in children. Meanwhile, continued efforts should be made in defining effective strategies that reduce the risk of exacerbations. If the areas of defined need are addressed in the coming years, namely prevention of exacerbations and progression of disease, as well as primary intervention, we will see continuing reduction in asthma mortality and morbidity along with improved quality of life for children with asthma.
    The Journal of allergy and clinical immunology 11/2013; · 12.05 Impact Factor
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    ABSTRACT: Food allergy affects 8% of preschool children, but factors responsible for food allergy in children are poorly understood. Use of antacid medication may be a contributing factor. The purpose of this study was to determine if parent-reported antacid medication use was associated with higher prevalence of food allergy in atopic children. In this cross-sectional study, parents of children with atopic diseases completed a questionnaire relating to a history of treatment with antacid medication and food allergy. Charts were independently reviewed for food-specific IgE and/or skin-prick test results. Food allergy was defined as a reaction to a food consistent with the anaphylaxis consensus statement and either an elevated food-specific IgE or a positive food skin-prick test. One hundred four questionnaires were completed. Mean age of the participating children was 7.0 ± 4.3 years (range, 5 months to 18 years of age). Forty-seven (45%) individuals were reported to have taken an antacid medication in the past. History of taking antacid medication was associated with an increased prevalence (57% (27)/47 versus 32% (18)/57) and higher prevalence of food allergy of having food allergy (aPR, 1.7 [1.1-2.5]). Mean peanut food-specific IgE was higher in those with a history of taking antacid medication (11.0 ± 5.0 versus 2.0 ± 5.5.; p = 0.01). History of treatment with antacid medication is associated with an increased prevalence of having food allergy.
    Allergy and Asthma Proceedings 05/2013; 34(3):227-32. · 2.19 Impact Factor
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    ABSTRACT: Diesel exhaust particle (DEP) exposure enhances allergic inflammation and has been linked to the incidence of asthma. Oxidative stress on the thiol molecules cysteine (Cys) and glutathione (GSH) can promote inflammatory host responses. The effect of DEP on the thiol oxidation/reduction (redox) state in the asthmatic lung is unknown. To determine if DEP exposure alters the Cys or GSH redox state in the asthmatic airway. Bronchoalveolar lavage fluid was obtained from a house dust mite (HDM) induced murine asthma model exposed to DEP. GSH, glutathione disulfide (GSSG), Cys, cystine (CySS), and s-glutathionylated cysteine (CySSG) were determined by high pressure liquid chromatography. DEP co-administered with HDM, but not DEP or HDM alone, decreased total Cys, increased CySS, and increased CySSG without significantly altering GSH or GSSG. DEP exposure promotes oxidation and S-glutathionylation of cysteine amino acids in the asthmatic airway, suggesting a novel mechanism by which DEP may enhance allergic inflammatory responses.
    PLoS ONE 01/2013; 8(3):e60632. · 3.73 Impact Factor
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    ABSTRACT: Although studies in adults have shown a non-TH2 obese asthma phenotype, whether a similar phenotype exists in children is unclear. We hypothesized that asthmatic children with obesity, defined as a body mass index above the 95th percentile for age and sex, would have poorer asthma control as well as decreased quality of life, increased health care utilization, and decreased pulmonary function measures as a function of increased TH1 versus TH2 polarization. This study involved a post hoc analysis of cross-sectional data from 269 children 6 to 17 years of age enrolled in the National Heart, Lung, and Blood Institute Severe Asthma Research Program. Children answered questionnaires and underwent spirometry, plethysmography, exhaled nitric oxide determination, and venipuncture for TH1/TH2 cytokine determination. Asthma control was defined according to national asthma treatment guidelines that are based on prespecified thresholds for lung function and symptom frequency. Fifty-eight children (22%) were overweight and 67 (25%) were obese. Obese children did not have poorer asthma control but were more likely to report nonspecific symptoms such as dyspnea and nocturnal awakenings. Obese children did have decreased asthma-related quality of life and increased health care utilization, but this was not associated with airflow limitation. Instead, obese children had decreased functional residual capacity. A unique pattern of TH1 or TH2 polarization was not observed. Poor asthma control in obese children with asthma may be overestimated because of enhanced perception of nonspecific symptoms such as dyspnea that results from altered mechanical properties of the chest wall. Careful assessment of physiologic as well as symptom-based measures is needed in the evaluation of obese children with respiratory symptoms.
    The journal of allergy and clinical immunology in practice. 01/2013; 1(1):39-45.e2.
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    ABSTRACT: Introduction: Increasing BMI has been associated with less fractional exhaled nitric oxide. This may be explained by an increase in the concentration of asymmetric di-methyl arginine (ADMA) relative to L-arginine, which can lead to greater nitric oxide synthase uncoupling. This mechanism may differ across age of asthma onset and predict asthma morbidity. METHODS: Cross sectional study of participants from the Severe Asthma Research Program (SARP), across early (<12 yrs.) and late (> 12 yrs.) onset asthma phenotypes RESULTS: Late onset asthmatics had a higher median plasma ADMA level (0 .48 μM [IQR 0.35 - 0.7] compared to early onset: (0.37 μM [IQR 0.29 - 0.59], p=0.01), and lower median plasma L-arginine (late onset 52.3 [IQR 43 - 61]) compared to 51 μM [IQR 39 - 66] (early onset); p=0.02). The log of plasma L-arginine/ADMA was inversely correlated with BMI in the late (r = -0.4, p=0.0006) in contrast to the early onset phenotype (r = -0.2, p=0.07). Although FeNO was inversely associated with BMI in the late onset phenotype (p=0.02), the relationship was lost after adjusting for L-arginine/ADMA. Also in this phenotype, a reduced L-arginine/ADMA was associated with less IgE, increased respiratory symptoms, lower lung volumes, and worse asthma quality of life. CONCLUSIONS: In late onset asthma phenotype, plasma ratios of L-arginine to ADMA may explain the inverse relationship of BMI to FeNO. In addition, these lower L-arginine/ADMA ratios are associated with reduced lung function, and increased respiratory symptoms frequency, suggesting a role in the pathobiology of the late onset phenotype.
    American Journal of Respiratory and Critical Care Medicine 11/2012; · 11.04 Impact Factor
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    ABSTRACT: Vitamin D deficiency is common in HIV-infected individuals. In adults, traditional and HIV-related factors play a role in vitamin D status, and deficiency appears to impair immune restoration and exacerbate HIV complications, like cardiovascular disease (CVD). This study sought to determine factors contributing to vitamin D status in HIV-infected youth and investigate the relationship with CVD risk, inflammation and immune restoration. HIV-infected subjects (1-25 years old) were enrolled prospectively along with healthy controls that were group-matched by age, sex and race. HIV data were collected for the HIV-infected group, while traditional risk factors, including vitamin D intake, sun exposure, skin pigmentation, physical activity level and body mass index (BMI) were collected for both groups. Fasting lipids, plasma 25-hydroxyvitamin D (25[OH]D), and inflammation markers were measured. In total, 200 HIV-infected subjects and 50 controls were enrolled. HIV group had 53% male, 95% Black and a mean age of 17.2 ±4.6 years. There was no difference in 25(OH)D between groups; 77% of HIV+ and 74% of controls had 25(OH)D<20 ng/ml. Only Fitzpatrick skin type was independently associated with 25(OH)D. No HIV variables were associated with 25(OH)D, even when HIV sub-populations were examined. Inflammation, CVD risk factors and immune restoration were not independently associated with 25(OH)D. Vitamin D deficiency is common among HIV-infected youth. However, HIV factors, CVD risk, inflammation and immune restoration do not appear to have the same relationship with vitamin D as has been shown in adults. Supplementation trials are needed to determine if increasing 25(OH)D concentrations could better elucidate these relationships.
    Antiviral therapy 08/2012; 17(6):1069-78. · 3.07 Impact Factor
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    ABSTRACT: Genetic variants that contribute to asthma susceptibility might be present at varying frequencies in different populations, which is an important consideration and advantage for performing genetic association studies in admixed populations. We sought to identify asthma-associated loci in African American subjects. We compared local African and European ancestry estimated from dense single nucleotide polymorphism genotype data in African American adults with asthma and nonasthmatic control subjects. Allelic tests of association were performed within the candidate regions identified, correcting for local European admixture. We identified a significant ancestry association peak on chromosome 6q. Allelic tests for association within this region identified a single nucleotide polymorphism (rs1361549) on 6q14.1 that was associated with asthma exclusively in African American subjects with local European admixture (odds ratio, 2.2). The risk allele is common in Europe (42% in the HapMap population of Utah residents with Northern and Western European ancestry from the Centre d'Etude du Polymorphisme Humain collection) but absent in West Africa (0% in the HapMap population of Yorubans in Ibadan, Nigeria), suggesting the allele is present in African American subjects because of recent European admixture. We replicated our findings in Puerto Rican subjects and similarly found that the signal of association is largely specific to subjects who are heterozygous for African and non-African ancestry at 6q14.1. However, we found no evidence for association in European American or Puerto Rican subjects in the absence of local African ancestry, suggesting that the association with asthma at rs1361549 is due to an environmental or genetic interaction. We identified a novel asthma-associated locus that is relevant to admixed populations with African ancestry and highlight the importance of considering local ancestry in genetic association studies of admixed populations.
    The Journal of allergy and clinical immunology 05/2012; 130(3):622-629.e9. · 12.05 Impact Factor
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    Sheena D Brown, H Hardie Calvert, Anne M Fitzpatrick
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    ABSTRACT: Asthma, one of the most prevalent diseases affecting people worldwide, is a chronic respiratory disease characterized by heightened airway inflammation, airway hyperresponsiveness and airflow obstruction in response to specific triggers. While the specific mechanisms responsible for asthma are not well understood, changing environmental factors associated with urban lifestyles may underlie the increased prevalence of the disorder. Vitamin D is of particular interest in asthma since vitamin D concentrations decrease with increased time spent indoors, decreased exposure to sunlight, less exercise, obesity, and inadequate calcium intake. Additionally, a growing body of literature suggests that there is a relationship between vitamin D status and respiratory symptoms, presumably through immunomodulatory effects of vitamin D. This review discusses vitamin D as it relates to asthma across the age spectrum, with a focus on human studies.
    Dermato-endocrinology. 04/2012; 4(2):137-45.
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    ABSTRACT: Children with severe asthma have a high degree of respiratory morbidity despite treatment with high doses of inhaled corticosteroids and are therefore very difficult to treat. This review will discuss phenotypic and pathogenic aspects of severe asthma in childhood, as well as remaining knowledge gaps. As a group, children with severe asthma have a number of distinct phenotypic features compared with children with mild-to-moderate asthma. Clinically, children with severe asthma are differentiated by greater allergic sensitization, increased exhaled nitric oxide, and significant airflow limitation and air trapping that worsens as a function of age. These findings are accompanied by structural airway changes and increased and dysregulated airway inflammation and oxidant stress which may explain the differential nature of corticosteroid responsiveness in this population. Because children with severe asthma themselves are a heterogeneous group, current efforts are focused on improved definition and sub-phenotyping of the disorder. Whereas the clinical relevance of phenotyping approaches in severe asthma is not yet clear, they may provide important insight into the mechanisms underlying the disorder. Improved classification of severe asthma through unified definitions, careful phenotypic analyses, and mechanism-focused endotyping approaches may ultimately advance knowledge and personalized treatment.
    Current Opinion in Allergy and Clinical Immunology 04/2012; 12(2):193-201. · 3.40 Impact Factor
  • Anne M Fitzpatrick, Dean P Jones, Lou Ann S Brown
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    ABSTRACT: Asthma is a chronic inflammatory disorder of the airways associated with airway hyper-responsiveness and airflow limitation in response to specific triggers. Whereas inflammation is important for tissue regeneration and wound healing, the profound and sustained inflammatory response associated with asthma may result in airway remodeling that involves smooth muscle hypertrophy, epithelial goblet-cell hyperplasia, and permanent deposition of airway extracellular matrix proteins. Although the specific mechanisms responsible for asthma are still being unraveled, free radicals such as reactive oxygen species and reactive nitrogen species are important mediators of airway tissue damage that are increased in subjects with asthma. There is also a growing body of literature implicating disturbances in oxidation/reduction (redox) reactions and impaired antioxidant defenses as a risk factor for asthma development and asthma severity. Ultimately, these redox-related perturbations result in a vicious cycle of airway inflammation and injury that is not always amenable to current asthma therapy, particularly in cases of severe asthma. This review will discuss disruptions of redox signaling and control in asthma with a focus on the thiol, glutathione, and reduced (thiol) form (GSH). First, GSH synthesis, GSH distribution, and GSH function and homeostasis are discussed. We then review the literature related to GSH redox balance in health and asthma, with an emphasis on human studies. Finally, therapeutic opportunities to restore the GSH redox balance in subjects with asthma are discussed.
    Antioxidants & Redox Signaling 02/2012; 17(2):375-408. · 8.20 Impact Factor
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    ABSTRACT: While several studies suggest that traffic-related air pollutants are detrimental for respiratory health, few studies have examined relationships between residential proximity to a major roadway and asthma control in children. Furthermore, a major limitation of existing research is reliance on self-reported outcomes. We therefore determined the spatial relationship between the distance from a major roadway and clinical, physiologic and inflammatory features of asthma in a highly characterized sample of asthmatic children 6-17 years of age across a wide range of severities. We hypothesized that a closer residential proximity to a major roadway would be associated with increased respiratory symptoms, altered pulmonary function and a greater magnitude of airway and systemic inflammation. 224 children 6-17 years with confirmed asthma completed questionnaires and underwent spirometry, plethysmography, exhaled nitric oxide determination, exhaled breath condensate collection and venipuncture. Residential distance from a major roadway was determined by mapping the geographic coordinates of the residential address in Geographic Information System software. The distance between the home address and the nearest major roadway was calculated according to the shortest distance between the two points (i.e., "as the crow flies"). Asthmatic children living in closer proximity to a major roadway had an increased frequency of wheezing associated with increased medication requirements and more hospitalizations even after controlling for potential confounders. These children also had increased airway resistance, increased airway inflammation reflected by a lower breath condensate pH, and higher plasma EGF concentrations. These findings suggest that closer residential proximity to a major roadway is associated with poorer asthma control in school-age children. Assessment of residential proximity to major roadways may be useful in the clinical evaluation of asthma in children.
    PLoS ONE 01/2012; 7(5):e37044. · 3.73 Impact Factor
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    ABSTRACT: TGF-β1 is thought to play a role in airway remodeling in asthmatic subjects. TGF-β1 expression might be mediated by an excessive burden of reactive oxygen species and oxidant stress. Given the profound airway oxidant stress we have previously observed in children with severe asthma, we sought to (1) quantify TGF-β1 protein and mRNA gene expression in the airways of children with mild-to-moderate and severe atopic asthma and (2) determine the relationship of airway TGF-β1 concentrations to oxidant burden (ie, lipid peroxidation), T(H)2-mediated eosinophilic inflammation, and airflow limitation. Bronchoalveolar lavage fluid was collected from 68 atopic children with asthma (severe asthma, n = 28) and 12 atopic adult control subjects. Airway TGF-β1 expression and activation were assessed in relation to airway IL-13, 8-isoprostane, and malondialdehyde concentrations. The relationship of airway TGF-β1 expression to airflow limitation in children with asthma was also assessed. Children with severe asthma had higher total airway concentrations of TGF-β1 that were associated with increased protein and mRNA expression of TGF-β1 in airway macrophages and an increase in concentrations of the lipid peroxidation biomarkers 8-isoprostanes and malondialdehyde. TGF-β1 activation was also greater in children with severe asthma and was associated with higher airway 8-isoprostane, malondialdehyde, and IL-13 concentrations. Total airway TGF-β1 concentrations were further associated with airflow limitation. Children with severe asthma have increased airway TGF-β1 expression and activation associated with an increased airway oxidant burden. Oxidant stress might mediate the effects of TGF-β1 and promote airway remodeling in children with severe asthma.
    The Journal of allergy and clinical immunology 12/2011; 129(2):388-96, 396.e1-8. · 12.05 Impact Factor
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    The Journal of allergy and clinical immunology 11/2011; 129(3):867-9. · 12.05 Impact Factor
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    ABSTRACT: The National Heart, Lung, and Blood Institute Severe Asthma Research Program (SARP) has characterized over the past 10 years 1,644 patients with asthma, including 583 individuals with severe asthma. SARP collaboration has led to a rapid recruitment of subjects and efficient sharing of samples among participating sites to conduct independent mechanistic investigations of severe asthma. Enrolled SARP subjects underwent detailed clinical, physiologic, genomic, and radiological evaluations. In addition, SARP investigators developed safe procedures for bronchoscopy in participants with asthma, including those with severe disease. SARP studies revealed that severe asthma is a heterogeneous disease with varying molecular, biochemical, and cellular inflammatory features and unique structure-function abnormalities. Priorities for future studies include recruitment of a larger number of subjects with severe asthma, including children, to allow further characterization of anatomic, physiologic, biochemical, and genetic factors related to severe disease in a longitudinal assessment to identify factors that modulate the natural history of severe asthma and provide mechanistic rationale for management strategies.
    American Journal of Respiratory and Critical Care Medicine 11/2011; 185(4):356-62. · 11.04 Impact Factor
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    The Journal of allergy and clinical immunology 11/2011; 129(2):575-8, 578.e1-9. · 12.05 Impact Factor
  • Karen A DeMuth, Anne M Fitzpatrick
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    ABSTRACT: Epinephrine is the treatment of choice for anaphylaxis. Delay in administration of epinephrine is a known risk factor for food allergy reaction-related mortality; however, individuals with food allergy may not have epinephrine readily available. This study was designed to determine the percent of food-allergic children that have an epinephrine autoinjector readily available and factors associated with epinephrine autoinjector carriage rates. Parents completed a questionnaire on food allergy and food allergy preparedness. Staff recorded whether an epinephrine autoinjector and medical alert bracelet was immediately available in clinic. Parental responses from 63 food-allergic children were included. Fifty-nine percent (37/63) had an epinephrine autoinjector present in the clinic, and 79% (50/63) reported receiving training in epinephrine autoinjector use. There was no correlation between epinephrine autoinjector presence in the clinic and parental report of having an epinephrine autoinjector available at all times (phi = 0.21). Epinephrine autoinjector training was associated with increased odds of having an epinephrine autoinjector immediately available (adjusted odds ratio, 8.74 [1.69, 45.04]). Fewer school aged children (≥5 years old) reportedly had their epinephrine autoinjector with them when eating lunch (25% [8/32] versus 42% [13/31]; p = 0.002) or snacks (28% [9/32] versus 37% [13/31]; p = 0.005) when compared with those <5 years old. Many children do not have their epinephrine autoinjectors readily available despite parental report. Epinephrine autoinjector training improved the odds of having an epinephrine autoinjector readily available. Continued patient education on the importance of having an epinephrine autoinjector easily accessible, especially when eating, is important.
    Allergy and Asthma Proceedings 07/2011; 32(4):295-300. · 2.19 Impact Factor
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    ABSTRACT: Studies of asthma phenotypes have identified obesity as a component of a group characterized by a high proportion of subjects with adult-onset asthma. However, whether age of asthma onset modifies the association between obesity and asthma is unknown. We sought to compare the associations between body mass index (BMI) categories with physiological, inflammatory, and clinical parameters across age of asthma onset phenotypes; and to compare the rate of BMI change in relation to asthma duration, by age of onset asthma phenotypes. From the Severe Asthma Research Program, we defined age of asthma onset as early (<12 years of age) and late (≥12 years of age). Comparisons of BMI categories were done within age-of-onset groups, and obesity was also compared across these groups. Multivariable logistic regression analysis was done to evaluate the association between BMI categories with health care use and respiratory symptoms and multivariable linear regression for the association between duration of asthma and weight gain (BMI change per year). An interaction between obesity and age of asthma onset was included in the multivariable analyses. The study population consisted of 1049 subjects, and the median age for asthma onset was 10 years (interquartile range, 4-25 years); 48% had late-onset asthma (≥12 years of age), and 52% had early-onset asthma (<12 years of age). Compared with obese subjects with late-onset asthma, obese subjects with early-onset asthma had more airway obstruction, bronchial hyperresponsiveness, and higher odds ratios of ever having 3 or more previous oral steroid tapers per year or intensive care unit admissions for asthma per preceding year (interactions between obesity and age of asthma onset were P = .055 and P = .02, respectively). In subjects with early-onset asthma but not in subjects with late-onset asthma, there was a significant association between increasing BMI and duration of asthma after adjusting for confounders. The interaction between asthma duration and age of asthma onset was a P value of less than .01. Asthmatic subjects are differentially affected by obesity based on whether they had asthma early (<12 years of age) or later in life. These results highlight the need to understand obesity as a comorbidity that affects specific clinical phenotypes and not all asthma subjects alike.
    The Journal of allergy and clinical immunology 06/2011; 127(6):1486-93.e2. · 12.05 Impact Factor

Publication Stats

954 Citations
223 Downloads
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353.45 Total Impact Points

Institutions

  • 2007–2014
    • Emory University
      • Department of Pediatrics
      Atlanta, Georgia, United States
    • Wake Forest School of Medicine
      • Center for Cancer Genomics
      Winston-Salem, NC, United States
  • 2009–2012
    • University of Pittsburgh
      • • Division of Pediatric Pulmonology
      • • School of Medicine
      Pittsburgh, PA, United States