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PubMed2024

Rhinovirus infection of airway epithelial cells uncovers the non-ciliated subset as a likely driver of genetic susceptibility to childhood-onset asthma.

Asthma is a complex disease caused by genetic and environmental factors. Epidemiological studies have shown that in children, wheezing during rhinovirus infection (a cause of the common cold) is associated with asthma development during childhood. This has led scientists to hypothesize there could be a causal relationship between rhinovirus infection and asthma or that RV-induced wheezing identifies individuals at increased risk for asthma development. However, not all children who wheeze when they have a cold develop asthma. Genome-wide association studies (GWAS) have identified hundreds of genetic variants contributing to asthma susceptibility, with the vast majority of likely causal variants being non-coding. Integrative analyses with transcriptomic and epigenomic datasets have indicated that T cells drive asthma risk, which has been supported by mouse studies. However, the datasets ascertained in these integrative analyses lack airway epithelial cells. Furthermore, large-scale transcriptomic T cell studies have not identified the regulatory effects of most non-coding risk variants in asthma GWAS, indicating there could be additional cell types harboring these "missing regulatory effects". Given that airway epithelial cells are the first line of defense against rhinovirus, we hypothesized they could be mediators of genetic susceptibility to asthma. Here we integrate GWAS data with transcriptomic datasets of airway epithelial cells subject to stimuli that could induce activation states relevant to asthma. We demonstrate that epithelial cultures infected with rhinovirus significantly upregulate childhood-onset asthma-associated genes. We show that this upregulation occurs specifically in non-ciliated epithelial cells. This enrichment for genes in asthma risk loci, or 'asthma heritability enrichment' is also significant for epithelial genes upregulated with influenza infection, but not with SARS-CoV-2 infection or cytokine activation. Additionally, cells from patients with asthma showed a stronger heritability enrichment compared to cells from healthy individuals. Overall, our results suggest that rhinovirus infection is an environmental factor that interacts with genetic risk factors through non-ciliated airway epithelial cells to drive childhood-onset asthma.

Preprint↗
PubMed1997

Factors associated with emergency department dependence of patients with asthma.

BACKGROUND: Dependence on crisis-oriented care rather than continuous ambulatory care for asthma is thought to contribute to asthma morbidity and mortality. We contrasted the characteristics of patients who depend on emergency department (ED) care for the management of their asthma exacerbations to the characteristics of patients employing self-management plans in an ambulatory setting. METHODS: In prospective fashion, we used a structured interview and charted information to survey two cohorts of patients suffering from an acute exacerbation of asthma; those seen in a hospital ED (n = 80) and those seen in an ambulatory asthma care facility (Asthma Center [AC]) (n = 40) at the same hospital. We looked for differences in socioeconomic characteristics, asthma severity, asthma knowledge, and asthma self-management skills between groups. RESULTS: There were no significant differences in mean age (SD) (ED vs AC: 36.65 [13.8] vs 40 [13.8] years) or female to male ratio (ED vs AC: 2/1 vs 2.5/1) between the two groups. There were no major differences in ethnic origin, educational status, marital status, smoking history, employment status, number of children in the household, possession of an extended health insurance plan, sick leave benefits, and child care availability between the two groups. Patients seeking ED care were more likely to have resided in the city for < 5 years (34% vs 8%; p < 0.05), and more likely to be living alone (35% vs 15%; p < 0.05). Significantly more patients from the ED group had a below average gross annual income (55% vs 3%; p < 0.05). There were several significant differences between groups in their knowledge of asthma and its therapy. Most striking, 79% of AC patients reported having a predetermined crisis plan vs just 23% of ED patients (p < 0.001). Although measurements of airflow (percent predicted FEV1) were significantly lower in the ED group than the AC group (mean, 50% vs 78.4%; p < 0.001), other indexes reflecting the degree of asthma severity over the long term such as past use of oral steroids, history of hospitalization, or ICU admission for asthma and the mean total days of disability within the preceding year were not significantly different between the two groups. Most of the ED patients had more than one previous visit to the ED for asthma exacerbation within the preceding year while most exacerbations of AC patients had been treated in the ambulatory care setting. Only 17% of ED patients initiated or increased inhaled or oral steroids before seeking medical care vs 89% of AC patients (p < 0.001). CONCLUSION: We conclude that a subgroup of asthmatics depends primarily on crisis-oriented care for the management of asthma. These patients are more likely to have lower income, to live alone, and to have resided at their current address for less time than patients seeking less urgent ambulatory care. Moreover, such patients are less knowledgeable about asthma and its management and are less likely to have a predetermined crisis plan.

Adult↗
PubMedDate not supplied

Patient factors and medication guideline adherence among older women with asthma.

BACKGROUND: Asthma guidelines are well established but often followed poorly. Determinants of adherence among older persons may differ from younger persons and have not been well characterized. OBJECTIVES: To assess adherence to asthma medication guidelines among older women with asthma and evaluate predictors of adherence with emphasis on asthma characteristics, comorbid medical conditions, work-related factors, social supports, caregiving, and emotional well-being. METHODS: We assessed adherence to the National Asthma Education and Prevention Program medication guidelines among participants in the Nurses' Health Study who reported a physician diagnosis of asthma and reconfirmed the diagnosis on a separate questionnaire, excluding those with chronic obstructive pulmonary disease. RESULTS: Among 121 700 participants in the Nurses' Health Study, 5107 reported physician-diagnosed asthma meeting inclusion criteria. Mean +/- SD age was 63 +/- 7 years in 1998. Adherence with asthma medication guidelines was 57% for mild persistent, 55% for moderate persistent, and 32% for severe persistent asthma (P =.001). In multivariate analysis, nonadherence was associated with severe asthma, increasing age, lower socioeconomic status, current smoking, earlier onset of asthma, and number of comorbid medical conditions. Measures of social isolation, caregiving, and emotional well-being were not associated with nonadherence. CONCLUSIONS: Asthma is undertreated among older women, even those who are health care professionals. Women with advanced age and severe asthma were particularly at risk. Given that the greatest increase in asthma mortality has occurred among older women, further research is needed to examine physician prescribing patterns and patient beliefs in this vulnerable population.

Adult↗
PubMed2001

Clinical predictors of health-related quality of life depend on asthma severity.

The National Asthma Education and Prevention Program guidelines define asthma severity before treatment by lung function and symptoms. It has been assumed, but not demonstrated, that improvement in these measures would translate into improvement in health-related quality of life (HRQL). Because HRQL is an important outcome in asthma management, we asked what are the determinants of HRQL? To address this question, we retrospectively analyzed HRQL data, as measured by the Juniper Asthma Quality of Life Questionnaire, in subjects with mild versus moderate-severe asthma from two clinical trials. We examined whether these traditional clinical outcomes have different relationships to HRQL depending on asthma severity. We also assessed whether the relationship between clinical outcomes and HRQL in subjects with moderate-severe asthma would change when subjects improved to mild-moderate disease with controller medication treatment. Lung function was not an independent predictor or determinant of HRQL at any level of asthma severity, whereas intensity of shortness of breath predicted HRQL at all levels of asthma severity. Rescue beta-agonist use independently predicted HRQL in subjects with mild asthma, but not in those with moderate-severe asthma. In subjects with moderate-severe asthma who improved to mild-moderate disease with controller treatment, rescue beta-agonist use predicted HRQL. We conclude that the independent determinants of HRQL vary according to asthma severity and change with asthma treatment.

Adult↗
PubMed1998

Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience.

BACKGROUND: To improve asthma disease management, the National Asthma Education Program (NAEP) Expert Panel published Guidelines for the Diagnosis and Management of Asthma in 1991. OBJECTIVES: To compare the current status of asthma disease management among patients in a large health maintenance organization with the NAEP guidelines and to identify the factors that may be associated with medical care (eg, emergency department visits and hospital admissions) and adherence to the guidelines. METHODS: Analyses of 1996 survey data from 5580 members with asthma (age range, 14 to 65 years) covered by a major health maintenance organization in California (Health Net). RESULTS: In general, adherence to NAEP guidelines was poor. Seventy-two percent of respondents with severe asthma reported having a steroid inhaler, and of those, only 54% used it daily. Only 26% of respondents reported having a peak flowmeter, and of those, only 16% used it daily. Age (older), duration of asthma (longer), increasing current severity of disease, and treatment by an asthma specialist correlated with daily use of inhaled steroids. Ethnicity (African American and Hispanic) correlated negatively with inhaled steroid use but positively with emergency department visits and hospital admissions for asthma. Increasing age and treatment by an asthma specialist were also identified as common factors significantly related to the daily use of a peak flowmeter and, interestingly, to overuse of beta2-agonist metered-dose inhalers. CONCLUSIONS: Although the NAEP guidelines were published 7 years ago, compliance with the guidelines was low. It was especially poor for use of preventive medication and routine peak-flow measurement. Furthermore, the results showed that asthma specialists provided more thorough care than did primary care physicians in treating patients with asthma. Combining the results of the regression analyses revealed that some of the variation in rates of emergency department visits and hospitalizations among some subpopulations can be explained by the underuse of preventive medication. This study serves the goal of documenting the quality of care and services currently provided to patients with asthma through a large health maintenance organization and provides baseline information that can be used to design and assess effective population-based asthma disease management intervention programs.

Adolescent↗
PubMed1999

Effect of functional endoscopic sinus surgery on bronchial asthma outcomes.

BACKGROUND: For more than 70 years, the coexistence of asthma and paranasal rhinosinusitis has been noted in the medical literature. Causal relationships have been proposed but not proved. To date, limited evidence exists suggesting that asthma improves after surgical correction of rhinosinusitis. OBJECTIVE: To determine whether asthma control improved after first-time functional endoscopic sinus surgery (FESS). PATIENTS AND METHODS: A retrospective medical record analysis was performed on 13 patients with chronic bronchial asthma who underwent FESS for medically refractory chronic rhinosinusitis. Patients received comprehensive asthma care before and after FESS (mean, 19.3 and 33.1 months, respectively). Outcomes analyzed included pre- and post-FESS individual and group mean asthma symptom scores, medication use scores, pulmonary function test results, and emergency department visits or hospital admissions for asthma. Patient medical records were obtained from a private allergy-immunology practice affiliated with a medical school. The surgical procedure was performed at a tertiary care teaching hospital by a single ear, nose, and throat surgeon (R.L.). RESULTS: Following FESS, there was no statistically significant change in group mean asthma symptom scores, asthma medication use scores, pulmonary function test results, and the number of emergency department visits or hospital admissions. Only a few patients demonstrated statistically significant improvement after FESS in asthma symptom scores (1 patient), medication use scores (1 patient), or pulmonary function test results (2 patients). CONCLUSIONS: The data do not support the hypothesis that first-time FESS for medically refractory chronic rhinosinusitis in adult patients with chronic asthma leads to reduced postoperative asthma symptoms or asthma medication use or improved pulmonary function. Based on this limited study, a reexamination of the benefits of sinus surgery to coexisting asthma is in order.

Adolescent↗
PubMed2002

Identification of population subgroups of children and adolescents with high asthma prevalence: findings from the Third National Health and Nutrition Examination Survey.

OBJECTIVES: To provide national estimates of asthma prevalence in African-American, Mexican American and white (non-Latino) children and adolescents using several common definitions; to evaluate familial, sociodemographic, and environmental risk factors that are independently associated with current asthma in children; and to identify subgroups at particular risk for current asthma using 2 complementary data analytic approaches. DESIGN: Cross-sectional study, using the Third National Health and Nutrition Examination Survey, 1988-1994. SETTING: Eighty-nine mobile examination centers in the United States. PARTICIPANTS: Twelve thousand three hundred eighty-eight African American, Mexican American, and white (non-Latino) children and adolescents, aged 2 months through 16 years, selected from a systematic random, population-based, nationally representative sample. MAIN OUTCOME MEASURE: Current asthma, defined by caregivers who reported that their child currently had doctor-diagnosed asthma. RESULTS: The overall prevalence of current asthma was 6.7% (95% confidence interval [CI], 5.6-7.8). Odds ratios for current asthma from the multiple regression analysis were 4.00 (95% CI, 2.90-5.52) for children with a parental history of asthma or hay fever, 1.94 (95% CI, 1.09-3.46) for children with body mass index (calculated as weight in kilograms divided by the square of height in meters) greater than or equal to the 85th percentile, and 1.64 (95% CI, 1.20-2.26) for children of African American ethnicity. African American and Mexican American children showed a consistent prevalence of current asthma across age while white children showed an increase in prevalence with age. The 2 highest-risk subgroups identified by the signal detection analysis were composed of children with a parental history of asthma or hay fever who were 10 years or older with a body mass index greater than or equal to the 85th percentile (31.0% current asthma), and children with a parental history who were 10 years or younger and of African American ethnicity (15.6% current asthma). CONCLUSIONS: The findings from this analysis show a strong independent association between obesity and current asthma in children and adolescents, and confirm previous reports of a parental history of asthma or hay fever and African American ethnicity as additional important risk factors.

Adolescent↗
PubMed2006

Classification of asthma severity in children: the contribution of pulmonary function testing.

BACKGROUND: Despite increasing awareness of the National Asthma Education and Prevention Program guidelines, the relative contribution of symptom frequency or pulmonary function to the recommended asthma severity levels remains poorly understood. OBJECTIVE: To determine whether adding lung function measurements to clinical history substantially changes the asthma severity classification, thereby influencing treatment decisions. DESIGN: Baseline data were studied from children enrolled in 2 multicenter studies: phase 1 of the National Cooperative Inner-City Asthma Study (1992-1994) (cohort 1) and the Inner-City Asthma Study (1998-2001) (cohort 2). SETTING: Fifteen (8 for cohort 1 and 7 for cohort 2) major metropolitan inner-city areas in the United States. PARTICIPANTS: Inner-city children aged 8 through 11 years with asthma. MAIN OUTCOME MEASURES: Proportion of children reclassified from less severe asthma categories based on symptom frequency into more severe categories because of lung function. RESULTS: Of children with symptoms of mild intermittent asthma, 22.8% in cohort 1 and 27.7% in cohort 2 would be reclassified as having either moderate or severe persistent asthma. Of children with symptoms of mild persistent asthma, 31.2% in cohort 1 and 33.3% in cohort 2 would be similarly reclassified. CONCLUSIONS: In 2 different studies of inner-city children with asthma, approximately one third of the participants were reclassified into higher National Asthma Education and Prevention Program asthma severity categories when pulmonary function was considered in addition to symptom frequency. This may have direct implications for the undertreatment of asthma.

Black or African American↗
PubMed2001

How pediatricians manage asthma in Thailand.

Currently, there is no existing information regarding prescribing practices for the management of childhood asthma among pediatricians in Thailand. In order to evaluate the management standards for childhood asthma in Thailand, 400 self-administered questionnaires were randomly mailed to nonacademic pediatricians throughout Thailand, asking questions about their preferences in the treatment of childhood asthma. One hundred and seventy-four of these 400 questionnaires were returned (a response rate of 43.5%). Data were analyzed using the descriptive module of the Epi-info 6 program. For acute asthma, 17% of the respondents used objective measures such as peak flow meters in assessing asthma severity and severity of acute asthma attacks. The drug of first choice for treating acute attacks was a nebulized beta-agonist q 20 min (81.8%). Although 93% indicated that they had used theophylline for treating acute attacks, most would reserve the drug for patients with severe symptoms. Corticosteroids were reserved for those with severe attacks (91.7% both for clinic and for in-hospital settings). Hydrocortisone was the most preferred corticosteroid preparation (59.8%). Ninety-seven percent used antibiotics in treating acute asthma, but only with appropriate indications. For chronic asthma, a strong preference was observed for oral beta-agonists as the bronchodilator of choice (88%). For moderately severe asthmatics, theophylline was still preferred by 41% of the responders. Among prophylactic agents, ketotifen was the most favored drug (90.4%), whereas inhaled steroids and cromolyn were chosen by 9.6% and 2.4%, respectively. Eighty-five percent indicated that they would prescribe prophylactic agents for 1 year or less. Forty-two percent never considered allergy evaluation as a part of a workup for childhood asthma. Certain prescribing practices of childhood asthma management in Thailand were observed among pediatricians, i.e., 1) low frequency of using objective measures in assessing asthma severity among pediatricians; 2) frequent use of theophylline and antibiotics in the treatment of acute asthma; 3) late introduction of corticosteroids in treating acute asthma; 4) preference for oral bronchodilators; and 5) preference of ketotifen as the prophylactic drug of choice. This survey provides baseline data and will aid in the evaluation of management guidelines for childhood asthma in Thailand.

Adrenal Cortex Hormones↗
PubMed1992

Asthma severity: a factor analytic investigation.

PURPOSE: Reviewers of the asthma research literature have called for improved questionnaires and other measures, particularly for assessing the severity of asthma. To help meet this need, standard multivariate and psychometric techniques were used with data from asthma patients to develop and evaluate a series of scaled questions. Since there is no "gold standard" for assessing asthma severity, we hope this analysis will help improve our ability to more precisely define these important parameters. PATIENTS AND METHODS: Data were collected through interviews and review of clinic records for 199 adult patients with asthma from a university clinic population. For evaluating the severity of asthma, eight scales assessed asthma duration, the incidence of asthma symptoms, the extent to which asthma is an inconvenience to patients, the incidence of respiratory diseases, medication regimens, medication side effects, and health care utilization. Forced expiratory volume in 1 second as a percentage of predicted normal was included as an objective measure of pulmonary function. A physician rating scale assessed the severity of the underlying disease, not the severity of a particular episode, as either (1) mild (infrequent attacks with interim symptomatic treatment), (2) moderate (more frequent attacks with continuous daily treatment), and (3) severe (continuous symptom with continuous multiple drug regimen, including some systemic steroids). RESULTS: In the current analysis of data from adult asthma patients, the scales correlated positively with a physician judgment scale. Factor analysis with an oblique rotation yielded three factors that provided a concise summary of asthma severity. We have named the factors (A) Symptom Intensity, (B) Airflow Impairment, and (C) Management Intensity. CONCLUSION: Asthma severity appears to be multidimensional rather than unidimensional, including at least three components. The physician rating scale, in combination with measures of the three identified factors, could easily be included in other asthma research protocols to provide a standard, brief assessment of asthma severity and might thus promote greater comparability among studies.

Adult↗
PubMed2005

Clinical applications of exhaled nitric oxide for the diagnosis and management of asthma: a consensus report.

BACKGROUND: Patients with asthma routinely exhibit elevated levels of fractionated exhaled nitric oxide (FE(NO)), and this observation has led to studies investigating FE(NO) as a potential marker of airway inflammation. FE(NO) has been shown to enhance the diagnosis of asthma, detect deterioration in control of patients with asthma, and monitor response to anti-inflammatory therapy. OBJECTIVES: The aim of this work was to determine if FE(NO) measurement provides a noninvasive, well-tolerated, and standardized technique to monitor airway inflammation, and if it has the potential to complement standard asthma monitoring tools (eg, symptom diaries, control questionnaires, and pulmonary function testing) and to improve asthma control and patient outcomes. METHODS: Thirteen experts in the diagnosis and treatment of asthma met to discuss the use of FE(NO) in the diagnosis and management of patients with asthma. Participants were selected by Aerocrine, a medical, technical company with headquarters in Stockholm, Sweden, in consultation with their medical education partner Cadent Medical Communications located in Irving, Texas, to represent a diversity of specialists, including both clinicians and investigators, in the fields of allergy, immunology, and pulmonology. All participants were nominally compensated for their time to attend this closed scientific roundtable discussion. The meeting was supported by an educational grant from Aerocrine. This report represents the overall consensus reached by the participants on the clinical applicability of this technique. RESULTS: Our understanding of asthma has expanded so that investigators are now focusing on inflammation in addition to airway obstruction and hyper-reactivity. Whereas patient history, symptoms, and pulmonary function testing can assist in diagnosing asthma, they are not direct measures of the extent of airway inflammation. Elevated FE(NO) levels have been shown to reflect airway inflammation and to occur together with other conventional markers used to detect inflammation. Studies have confirmed increased levels of FE(NO) in both adults and children with asthma. In most studies, FE(NO) was found to be elevated 2- to 3-fold compared with normal controls. There are many determinants of FE(NO) levels, however, and factors other than inflammation must be considered when FE(NO) measurement is used to diagnose and monitor asthma. FE(NO) measurement alone is not sufficient for diagnosing or monitoring asthma, but it can be a valuable addition to current clinical tools. CONCLUSIONS: FE(NO) measurement is a noninvasive and reproducible test that is a surrogate measure of airway inflammation in patients with asthma. The test has demonstrated utility in diagnosing and managing asthma and in predicting response to therapy and, therefore, may be an important tool to incorporate into clinical care.

Adult↗
PubMed2006

Prognostic factors of asthma severity: a 9-year international prospective cohort study.

BACKGROUND: The natural history of asthma severity is poorly known. OBJECTIVE: To investigate prognostic factors of asthma severity. METHODS: All current patients with asthma identified in 1991 to 1993 in the European Community Respiratory Health Survey were followed up, and their severity was assessed in 2002 by using the Global Initiative for Asthma categorization (n = 856). Asthma severity (remittent, intermittent, mild, moderate, severe) was related to potential determinants evaluated at baseline and during the follow-up by a multinomial logistic model, using the intermittent group as the reference category for relative risk ratios (RRRs). RESULTS: Asthma severity measured at baseline was a determinant of a patient's severity at the end of the follow-up. At baseline, severe persistent had a poorer FEV1% predicted, a poorer symptom control, higher IgE levels (RRR, 2.06; 95% CI, 1.38-3.06), and a higher prevalence of chronic cough/mucus hypersecretion (RRR, 4.90; 95% CI, 2.18-11.02) than patients with intermittent asthma. Moderate persistent showed the same prognostic factors as severe persistent, even if the associations were weaker. Mild persistent had a distribution of prognostic factors that was similar to patients with intermittent asthma, although the former showed a poorer symptom control than the latter. Remission mainly occurred in patients with less severe asthma and was negatively associated with a change in body mass index (RRR, 0.86; 95% CI, 0.75-0.97). Allergic rhinitis, smoking, and respiratory infections in childhood were not associated with asthma severity. CONCLUSION: Patients with moderate and severe persistent asthma are characterized by early deterioration of lung function. High IgE levels and persistent cough/mucus hypersecretion are strong markers of moderate/severe asthma, which seems to be a different phenotype from mild persistent or intermittent asthma. CLINICAL IMPLICATIONS: Our results suggest that the evolution of asthma severity is to a large extent predictable.

Adult↗
PubMed2006

Mild to moderate asthma affects lung growth in children and adolescents.

BACKGROUND: The effect of childhood asthma on lung growth is unclear. OBJECTIVE: To show the effect of mild to moderate childhood asthma on lung growth. METHODS: A total of 1041 children with mild to moderate asthma from the Childhood Asthma Management Program (CAMP) were compared with 5415 children without asthma from the Harvard Six Cities Study (H6CS). Sex-age-specific comparisons of lung growth in CAMP with the H6CS were made by using repeated-measures multiple linear regression models. Sex-age-specific percentages of children with asthma with abnormal (<5th percentile of H6CS) pulmonary function values were calculated. RESULTS: In both boys and girls, the ratio of FEV(1) to forced vital capacity (FVC) was significantly lower for children with than without asthma (P < .001), with corresponding increases for children with asthma in FVC (P < .001). FEV(1) was lower for boys with asthma than for boys without asthma (P < .001), but not for girls (P = .14). Percentages of CAMP children with abnormal FEV(1)/FVC ratios increased with age for both sexes (P < .001). The patterns of lung growth for children with asthma compared with children without asthma did not differ among children treated for 4.3 years with budesonide or nedocromil and placebo during the CAMP trial. CONCLUSION: Mild to moderate asthma results in a pattern of airway obstruction that increases in magnitude from age 5 to 18 years. CLINICAL IMPLICATIONS: Periodic spirometry is needed to monitor children with asthma for signs of increasing airway obstruction with appropriate intervention following national guidelines.

Adolescent↗
PubMed2006

Determinants of future long-term asthma control.

BACKGROUND: Asthma control has been hypothesized to be inversely related to asthma severity, directly related to effective management, and also related to other definable factors, but empiric data to support this construct are few. OBJECTIVE: We sought to identify independent prospective determinants of future long-term asthma control among asthma severity, management, demographic, and comorbidity predictors. METHODS: Surveys were completed by a random sample of 2250 health maintenance organization members aged 18 to 56 years with persistent asthma. Linked computerized pharmacy data provided baseline and follow-up year medication dispensings. The outcome was follow-up year long-term asthma control, as assessed by using a previously validated 4-level scale based on the number of short-acting beta-agonist canister dispensings. RESULTS: Oral corticosteroids (odds ratio [OR], 1.9) or unscheduled visits (OR, 1.2) in the prior year, any prior asthma hospitalizations (OR, 1.4), smoking (OR, 2.2), chronic obstructive pulmonary disease (OR, 1.9), male sex (OR, 1.5), black race (OR, 1.3), and lower educational level (OR, 1.1) were independently associated with poorer control in ordinal logistic regression analyses. Regular inhaled corticosteroids (OR, 0.7), long-acting beta-agonists (OR, 0.7) and asthma specialist care (OR, 0.6) were independently associated with better control. CONCLUSIONS: Markers of asthma severity and other patient characteristics are inversely related to future asthma control, but effective management strategies are associated with improved asthma control, even after accounting for these high-risk characteristics. CLINICAL IMPLICATIONS: Inhaled corticosteroids, long-acting beta-agonists, and asthma specialist care are associated with improved asthma control, even after accounting for markers of asthma severity.

Adolescent↗
PubMed2005

Asthma-related resource use and cost by GINA classification of severity in three European countries.

BACKGROUND: This study assessed the relationship between asthma burden and asthma severity in France, Italy, and Spain. METHODS: Adult asthmatics, 18-55 years of age, completed a questionnaire while visiting a respiratory physician in 1998 and 1999. Asthma severity was categorized by physicians as intermittent, mild persistent, moderate persistent, or severe persistent according to Global Initiative for Asthma (GINA) guidelines. RESULTS: Totals of 282 patients in France, 500 in Italy, and 296 in Spain entered the study. There were few differences between the three countries in the asthma symptom burden. Most patients with persistent asthma had used inhaled corticosteroids in the previous 14 days. Unexpectedly, 35% (Italy) to 83% (Spain) of patients with intermittent asthma also had used inhaled corticosteroids. In Spain, visits to the emergency department were more frequent (OR 7.0, 95% CI 4.9-10.0 with Italy as reference) and the costs of emergency care in all asthma severity categories were up to 10 times higher than in Italy and France. The frequency of hospitalizations did not differ systematically between the three countries. CONCLUSIONS: Inadequate control of asthma symptoms among patients with severe persistent asthma could not be entirely explained by under-prescribing of asthma medications. The use of inhaled corticosteroids by patients with intermittent asthma might reflect misclassification of asthma severity, possibly due to difficulty in interpreting the GINA guidelines. The relatively high cost of emergency care in Spain does not appear to be related to greater asthma severity or poorer symptom control, but may be a feature of the Spanish health care system.

Adolescent↗
PubMed2003

Elevated serum melatonin is associated with the nocturnal worsening of asthma.

BACKGROUND: Increased airway inflammation at night contributes to the nocturnal worsening of asthma. In vitro studies have shown exogenous melatonin to be pro-inflammatory in asthma, but it is unknown whether endogenous melatonin levels are a controller of airway inflammation in nocturnal asthma. OBJECTIVE: Our aim was to determine 24-hour patterns of serum melatonin and their relationship to overnight decline in physiology in subjects with nocturnal asthma, non-nocturnal asthma, and in healthy controls. METHODS: Observational study of pulmonary physiology and melatonin levels in patients with nocturnal asthma (n = 7), non-nocturnal asthma (n = 13), and healthy controls (n = 11). Subjects maintained a constant sleep-wake regimen for 7 days. On day 8, serum melatonin was measured every 2 hours by radioimmunoassay and analyzed by cosinor modeling. The correlation between serum melatonin levels and overnight change in spirometry was evaluated by Spearman's rank correlation analysis. RESULTS: In subjects with nocturnal asthma, peak melatonin levels were significantly elevated compared with healthy controls (67.6 +/- 5.0 pg/mL versus 53.5 +/- 4.0 pg/mL, P =.03). Melatonin acrophase was delayed in nocturnal asthma (02:54 versus 01:58 in healthy controls, P =.003, and 02:15 in non-nocturnal asthma, P =.01). In subjects with nocturnal asthma, increasing melatonin levels were significantly and inversely correlated with overnight change in FEV(1) (r = -.79, P =.04), a relationship that was not observed in non-nocturnal asthma or healthy controls. CONCLUSIONS: Nocturnal asthma is associated with elevation and phase delay of peak serum melatonin levels. Elevated melatonin levels might contribute to the pathogenesis of nocturnal asthma.

Adult↗
PubMed1997

Evaluation of a school-based asthma education program for inner-city children.

BACKGROUND: We have previously reported a high prevalence of current asthma-related symptoms affecting predominantly Hispanic, socioeconomically disadvantaged schoolchildren in Southeast San Diego. OBJECTIVE: We sought to assess the impact of a school-based education program on asthma outcomes. METHODS: In cooperation with the San Diego Unified Schools, we developed and implemented a school-based asthma education program. Based on the National Heart, Lung, and Blood Institute consensus guidelines for asthma, the five-session bilingual, interactive curriculum was conducted in 20-minute segments. Asthma knowledge was tested before and after the education program, and asthma severity was prospectively assessed at monthly intervals. Outcome parameters were compared in educated and control (noneducated) fourth grade students with asthma by using nonparametric techniques. RESULTS: After asthma education, students demonstrated improvement with increases in mean scores for: asthma knowledge quiz from 9.9 (SEM = 0.44, n = 34) to 13.7 (SEM = 0.30); peak flowmeter technique from 3.9 (SEM = 0.33, n = 32) to 6.4 (SEM = 0.29); and inhaler technique from 2.3 (SEM = 0.26, n = 32) to 4.3 (SEM = 0.26). All changes were highly significant (p < or = 0.00001 as determined by Wilcoxon matched-pairs signed-rank test). Mean score comparisons for asthmatic control students given paired examinations after a time interval matched with the educated students, did not reach statistical significance: quiz score of 11.3 (SEM = 0.80, n = 11) versus 10.9 (SEM = 0.68), peak flowmeter technique score of 2.6 (SEM = 0.50, n = 18) versus 3.1 (SEM = 0.37) , and inhaler technique score of 2.5 (SEM = 0.37, n = 18) versus 2.2 (SEM = 0.31). Prospective monthly data were collected on 27 educated and 15 control asthmatic subjects. Severity of asthma was not significantly different between groups at entry to the study. Symptom questionnaires, validated for functional asthma severity, revealed a significant reduction in mean symptom scores at 180 days for the educated (2.87, SEM = 0.447) versus the control (4.36, SEM = 0.573) groups (p = 0.0188 as determined by the Mann-Whitney U test). CONCLUSION: Child-centered asthma education can be successfully conducted in the school setting, resulting in increased asthma knowledge, improved skills for peak flowmeter and inhaler use, and a reduction in the severity of asthma symptoms.

Adolescent↗
PubMed2003

Prevalence and impact of asthma in children, Georgia, 2000.

BACKGROUND: Asthma is a common chronic condition with significant impact on those who have it. Information about children with asthma was sought to guide state program planning. METHODS: A random-digit-dial telephone survey of 1503 households with 2700 children was conducted in Georgia. Primary caretakers were interviewed. Results for households, children, and caretakers were weighted by number of telephone lines; results for children were also weighted to the Georgia 1998 estimated population. Data were collected and analyzed in 2000. RESULTS: Asthma prevalence among children in Georgia aged 0 to 17 years was 10.5% (95% confidence interval [CI]=9.2%-11.9%). Among children with asthma, 64.8% (95% CI= 58.5-71.1) had an attack and 30.0% (95% CI=24.2-35.8) visited an emergency department in the last year. In the past year, 53.9% (95% CI=46.8-61.0) of school-aged children with asthma and 29.7% (95% CI=23.7-35.7) of adults in households of children with asthma missed school or work because of the child's asthma. Among children with asthma, 56.1% (95% CI=48.6-63.6) lived in a household where neither caretaker nor child has taken a course or been taught about managing asthma, and 28.6% (95% CI=22.1-35.1) lived in a household where adults smoked inside the house. CONCLUSIONS: Asthma has a substantial effect on the lives of children in Georgia, including medical events and missed school, and on adult caretakers in terms of missed work due to the child's asthma. To reduce the burden of asthma in Georgia, exposure of people with asthma to tobacco smoke in the home should be eliminated and training in asthma management should be more widely available.

Adolescent↗