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1.  Association of Socioeconomic Status with the Use of Chronic Therapies and Healthcare Utilization in Children with Cystic Fibrosis 
The Journal of pediatrics  2009;155(5):634-9.e1-4.
Objective
To determine whether previously reported socioeconomic status (SES)-related disparities in cystic fibrosis (CF) health outcomes vary by the indicator used (median household income by zip code [MIZ], maternal educational attainment [MEA], and state insurance coverage [MA]), and whether these disparities can be explained by differences in medical treatment.
Study design
A cross-sectional analysis of data on patients age <18 years from the Epidemiologic Study of Cystic Fibrosis (ESCF).
Results
Disease severity showed a similar inverse correlation with all 3 SES measures. The number of stable clinic visits was unrelated to SES. Patients with MA had more sick outpatient visits and more courses of intravenous (IV) antibiotics for pulmonary exacerbations, and were more likely to be prescribed all chronic therapies. Low-MIZ patients had slightly fewer sick visits and more courses of IV antibiotics, and were more likely to receive oral nutrition supplements but less likely to receive macrolide prescriptions. Low-MEA patients were less likely to receive IV antibiotics at home, more likely to receive oral nutrition supplements, but less likely to receive macrolide prescriptions.
Conclusions
CF health outcomes are correlated with the SES spectrum, but these disparities are not explained by differential use of health services or prescription of chronic therapy. Future investigations should focus on the possible impact of environmental exposures and differences in disease self-management.
doi:10.1016/j.jpeds.2009.04.059
PMCID: PMC4161122  PMID: 19608199
2.  Key findings and clinical implications from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study 
Patients with severe or difficult-to-treat asthma are an understudied population but account for considerable asthma morbidity, mortality, and costs. The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study was a large, 3-year, multicenter, observational cohort study of 4756 patients (n = 3489 adults ≥18 years of age, n = 497 adolescents 13-17 years of age, and n = 770 children 6-12 years of age) with severe or difficult-to-treat asthma. TENOR's primary objective was to characterize the natural history of disease in this cohort. Data assessed semiannually and annually included demographics, medical history, comorbidities, asthma control, asthma-related health care use, medication use, lung function, IgE levels, self-reported asthma triggers, and asthma-related quality of life. We highlight the key findings and clinical implications from more than 25 peer-reviewed TENOR publications. Regardless of age, patients with severe or difficult-to-treat asthma demonstrated high rates of health care use and substantial asthma burden despite receiving multiple long-term controller medications. Recent exacerbation history was the strongest predictor of future asthma exacerbations. Uncontrolled asthma, as defined by the 2007 National Heart, Lung, and Blood Institute guidelines’ impairment domain, was highly prevalent and predictive of future asthma exacerbations; this assessment can be used to identify high-risk patients. IgE and allergen sensitization played a role in the majority of severe or difficult-to-treat asthmatic patients.
doi:10.1016/j.jaci.2012.04.014
PMCID: PMC3622643  PMID: 22694932
TENOR; severe or difficult-to-treat asthma; asthma control; asthma exacerbations; burden; medication; quality of life; allergy; IgE
3.  Assessment of asthma control and asthma exacerbations in the epidemiology and natural history of asthma: outcomes and treatment regimens (TENOR) observational cohort 
Current Respiratory Care Reports  2012;1(4):259-269.
Patients with severe or difficult-to-treat asthma account for substantial asthma morbidity, mortality, and healthcare burden despite comprising only a small proportion of the total asthma population. TENOR, a multicenter, observational, prospective cohort study was initiated in 2001. It enrolled 4,756 adults, adolescents and children with severe or difficult-to-treat asthma who were followed semi-annually and annually for three years, enabling insight to be gained into this understudied population. A broad range of demographic, clinical, and patient self-reported assessments were completed during the follow-up period. Here, we present key findings from the TENOR registry in relation to asthma control and exacerbations, including the identification of specific subgroups found to be at particularly high-risk. Identification of the factors and subgroups associated with poor asthma control and increased risk of exacerbations can help physicians design individual asthma management, and improve asthma-related health outcomes for these patients.
doi:10.1007/s13665-012-0025-x
PMCID: PMC3485530  PMID: 23136642
Severe asthma; Difficult-to-treat asthma; Asthma control; Exacerbation
4.  Subspecialty differences in asthma characteristics and management 
Objective
To determine the nature and extent to which asthma characteristics and management differ between allergy and pulmonary subspecialists.
Methods
We used baseline data from 3,342 adults enrolled in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study, a multicenter, observational cohort recruited from subspecialty practices across the United States. Information on physician subspecialty, asthma history, allergic status, lung function, medication use, and recent healthcare utilization were collected via study coordinator-administered interviews and self-administered validated questionnaires.
Results
In the TENOR study, 2,407 (72%) patients were treated by allergists and 935 (28%) by pulmonologists. Patients treated by pulmonologists were more likely to be black, less educated, and have lower incomes than those treated by allergists. Pulmonary patients had more severe asthma as indicated by physician-assessment, GINA classification, lung function, and number of asthma control problems. Regular use of a short-acting beta-agonist and systemic corticosteroid use was also higher among pulmonary patients than allergy patients, consistent with greater asthma severity. Although evidence of allergic disease was prevalent in both types of patients, allergist treated patients were more likely to receive skin testing or immunotherapy. In multivariate analyses adjusted for demographic differences, patients treated by pulmonologists were more likely to report healthcare utilization for asthma in the past 3 months.
Conclusion
In general, asthma patients treated by pulmonologists are of lower socioeconomic status, have more severe disease, require more medication, and report greater healthcare utilization than those treated by allergists.
PMCID: PMC3102298  PMID: 18613995
Asthma; Allergist; Pulmonologist; Specialty; Practice patterns; TENOR
5.  Genome-wide association study of asthma identifies RAD50-IL13 and HLA-DR/DQ regions 
Background
Asthma is a heterogeneous disease that is caused by the interaction of genetic susceptibility with environmental influences. Genome-wide association studies (GWAS) represent a powerful approach to investigate the association of DNA variants with disease susceptibility. To date, few GWAS for asthma have been reported.
Objectives
GWAS was performed on a population of severe or difficult-to-treat asthmatics to identify genes that are involved in the pathogenesis of asthma.
Methods
292,443 SNPs were tested for association with asthma in 473 TENOR cases and 1,892 Illumina general population controls. Asthma-related quantitative traits (total serum IgE, FEV1, FVC, and FEV1/FVC) were also tested in identified candidate regions in 473 TENOR cases and 363 phenotyped controls without a history of asthma to further analyze GWAS results. Imputation was performed in identified candidate regions for analysis with denser SNP coverage.
Results
Multiple SNPs in the RAD50-IL13 region on chromosome 5q31.1 were associated with asthma: rs2244012 in intron 2 of RAD50 (P = 3.04E-07). The HLA-DR/DQ region on chromosome 6p21.3 was also associated with asthma: rs1063355 in the 3’ UTR of HLA-DQB1 (P = 9.55E-06). Imputation identified several significant SNPs in the TH2 locus control region (LCR) 3’ of RAD50. Imputation also identified a more significant SNP, rs3998159 (P = 1.45E-06), between HLA-DQB1 and HLA-DQA2.
Conclusion
This GWAS confirmed the important role of TH2 cytokine and antigen presentation genes in asthma at a genome-wide level and the importance of additional investigation of these two regions to delineate their structural complexity and biologic function in the development of asthma.
doi:10.1016/j.jaci.2009.11.018
PMCID: PMC2824608  PMID: 20159242
Asthma; GWAS; RAD50; IL13; HLA-DQB1; TENOR

Results 1-5 (5)