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2.  Risk Factors for Increased ED Utilization in a Multinational Cohort of Children with Sickle Cell Disease 
Academic Emergency Medicine  2012;19(6):664-672.
Objectives
To identify clinical, social, and environmental risk factors for increased emergency department (ED) use in children with sickle cell disease (SCD).
Methods
This study was a secondary analysis of ED utilization data from the international multicenter Silent Cerebral Infarct Transfusion (SIT) trial. Between December 2004 and June 2010, baseline demographic, clinical, and laboratory data were collected from children with SCD participating in the trial. The primary outcome was the frequency of ED visits for pain. A secondary outcome was the frequency of ED visits for acute chest syndrome.
Results
The sample included 985 children from the US, Canada, England, and France, for a total of 2,955 patient-years of data. There were 0.74 ED visits for pain per patient-year. A past medical history of asthma was associated with an increased risk of ED utilization for both pain (RR = 1.28, 95% CI = 1.04 to 1.58) and acute chest syndrome (RR = 1.60, 95% CI = 1.03 to 2.49). Exposure to environmental tobacco smoke in the home was associated with 73% more ED visits for acute chest syndrome (RR 1.73, 95% CI = 1.09 to 2.74). Each $10,000 increase in household income was associated with 5% fewer ED visits for pain (RR 0.95, 95% CI = 0.91 to 1.00, p = 0.05). The association between low income and ED utilization was not significantly different in the USA vs. countries with universal health care (p = 0.51).
Conclusions
Asthma and exposure to environmental tobacco smoke are potentially modifiable risk factors for greater ED use in children with SCD. Low income is associated with greater ED use for SCD pain in countries with and without universal health care.
doi:10.1111/j.1553-2712.2012.01364.x
PMCID: PMC3375948  PMID: 22687181
3.  In Utero Smoke Exposure and Impaired Response to Inhaled Corticosteroids in Children with Asthma 
Background
Few studies have examined the effects of in utero smoke exposure (IUS) on lung function in children with asthma, and there are no published data on the impact of IUS on treatment outcomes in asthmatic children.
Objectives
To explore whether IUS exposure is associated with increased airway responsiveness among children with asthma, and whether IUS modifies the response to treatment with inhaled corticosteroids (ICS).
Methods
To assess the impact of parent-reported IUS exposure on airway responsiveness in childhood asthma we performed a repeated-measures analysis of methacholine PC20 data from the Childhood Asthma Management Program (CAMP), a four-year, multicenter, randomized double masked placebo controlled trial of 1041 children ages 5–12 comparing the long term efficacy of ICS with mast cell stabilizing agents or placebo.
Results
Although improvement was seen in both groups, asthmatic children with IUS exposure had on average 26% less of an improvement in airway responsiveness over time compared to unexposed children (p=.01). Moreover, while children who were not exposed to IUS who received budesonide experienced substantial improvement in PC20 compared to untreated children (1.25 fold-increase, 95% CI 1.03, 1.50, p=.02) the beneficial effects of budesonide were attenuated among children with a history of IUS exposure (1.04 fold-increase, 95% CI 0.65, 1.68, p=.88).
Conclusions
IUS reduces age-related improvements in airway responsiveness among asthmatic children. Moreover, IUS appears to blunt the beneficial effects of ICS use on airways responsiveness. These results emphasize the importance of preventing this exposure through smoking cessation counseling efforts with pregnant women.
doi:10.1016/j.jaci.2010.06.016
PMCID: PMC2937829  PMID: 20673983
asthma; in utero smoke exposure; airway responsiveness; inhaled corticosteroids
4.  Violence, Abuse, and Asthma in Puerto Rican Children 
Rationale: Puerto Ricans have the highest prevalence of and morbidity from asthma of all ethnic groups in the United States. One potential contributor to the high burden of asthma in Puerto Rican children is exposure to stress and violence.
Objectives: To examine whether exposure to stress and violence is associated with an increased risk of asthma among Puerto Rican children.
Methods: This study was a population-based probability sample of children in the San Juan and Caguas metropolitan areas in Puerto Rico. Information was collected in a household survey of 1,213 children and their primary caretakers.
Measurements and Main Results: The prevalence of lifetime physician-diagnosed asthma was 39.6%. In the year before the survey, 14% of children had witnessed an act of violence, 7% had been victims of violence, and 6% had been victims of physical or sexual abuse. Although stressful life events and exposure to neighborhood violence were not associated with asthma, a history of physical or sexual abuse was associated with approximately twice the odds of current asthma (odd ratio [OR], 2.52; 95% confidence interval [CI], 1.27–5.00), health care use for asthma (OR, 1.95; 95% CI, 0.96–3.96), and medication use for asthma (OR, 2.35; 95% CI, 1.05–5.26).
Conclusions: Physical or sexual abuse is associated with high asthma morbidity among Puerto Rican children. To our knowledge, this is the first report of an association between childhood abuse and asthma. Our findings highlight the importance of screening for asthma among victims of childhood abuse, and to be aware of the possibility of physical or sexual abuse among children with asthma.
doi:10.1164/rccm.200711-1629OC
PMCID: PMC2542427  PMID: 18556622
asthma; children; stress; violence; abuse

Results 1-4 (4)