The purpose of this research was to calibrate an item bank for a computerized adaptive test (CAT) of asthma impact on health-related quality of life (HRQOL), test CAT versions of varying lengths, conduct preliminary validity testing, and evaluate item bank readability.
Asthma Impact Survey (AIS) bank items that passed focus group, cognitive testing, and clinical and psychometric reviews were administered to adults with varied levels of asthma control. Adults self-reporting asthma (N=1106) completed an Internet survey including 88 AIS items, the Asthma Control Test (ACT), and other HRQOL outcome measures. Data were analyzed using classical and modern psychometric methods, real-data CAT simulations, and known groups validity testing.
A bi-factor model with a general factor (asthma impact) and several group factors (cognitive function, fatigue, mental health, physical function, role function, sexual function, self-consciousness/stigma, sleep, and social function) was tested. Loadings on the general factor were above 0.5 and were substantially larger than group factor loadings, and fit statistics were acceptable. Item functioning for most items and fit to the model was acceptable. CAT simulations demonstrated several options for administration and stopping rules. AIS distinguished between respondents with differing levels of asthma control.
The new 50-item AIS item bank demonstrated favorable psychometric characteristics, preliminary evidence of validity, and accessibility at moderate reading levels. Developing item banks for CAT can improve the precise, efficient, and comprehensive monitoring of asthma outcomes, and may facilitate patient-centered care.
asthma control; Asthma Impact Survey; item response theory; patient-reported outcome; health-related quality of life
Racial/ethnic disparities have been well documented in asthma. While socioeconomic status (SES) has been repeatedly implicated as a root cause, the role of limited health literacy has not been extensively studied. The purpose of this study was to examine the independent contributions of SES and health literacy in explaining asthma disparities.
A cohort study was conducted in a Chicago-based sample of 353 adults aged 18–40 years with persistent asthma from 2004 to 2007. Health literacy, SES, and asthma outcomes including disease control, quality of life, emergency department visits, and hospitalizations were assessed in person at baseline, and asthma outcomes were measured every 3 months for 2 years by phone. Multivariate models were used to assess racial/ethnic disparities in asthma outcomes and the effect of health literacy and SES on these estimates.
Compared with White participants, African American adults fared significantly worse in all asthma outcomes (p < .05) and Latino participants had lower quality of life (β = −0.47; 95% confidence interval [CI]= −0.79, −0.14; p = .01) and worse asthma control (risk ratio [RR] = 0.63; 95% CI = 0.41, 0.98; p = .04). Differences in SES partially explained these disparities. Health literacy explained an additional 20.2% of differences in quality of life between Latinos and Whites, but differences in hospitalization rates between African American and White adults remained (RR = 2.97; 95% CI = 1.09, 8.12, p = .03).
Health literacy appears to be an overlooked factor explaining racial and ethnic disparities in asthma. Evidence-based low literacy strategies for patient education and counseling should be included in comprehensive interventions.
control; hospitalization; quality of life; race/ethnicity
The prevalence of written “action plans” (APs) among emergency department (ED) patients with acute asthma is unknown.
To determine the prevalence of APs among ED patients, to describe the demographic and clinical profile of patients with and without APs, and to examine the appropriateness of response to an asthma exacerbation scenario.
Using a standard protocol, 49 North American EDs performed a prospective cohort study involving interviews of 1,756 patients, ages 2–54, with acute asthma. Among children only, a random sample was contacted two years after the index ED visit to assess current AP status and parents’ self-management knowledge.
The overall prevalence of APs was 32% (95% confidence interval [CI], 30%–34%), and was higher among children than adults (34% vs. 26%, respectively; p = 0.001). Patients with APs had worse measures of chronic asthma severity (p < 0.05) and were more likely to be hospitalized (multivariate odds ratio, 1.5; 95%CI, 1.1–2.1). After 2 years, most children with an AP at the index ED visit still had one but only 20% of those without an AP had obtained one; moreover, many of the APs appeared inadequate. Parents of children with a current AP performed slightly better on the asthma scenario, but both groups overestimated their asthma knowledge.
The prevalence of APs among ED patients with acute asthma is unacceptably low, and many of these APs appear inadequate. “Confounding by severity” will complicate any non-randomized analysis of the potential impact of APs on asthma outcomes in ED patients.
asthma; action plans; emergency medicine; education; self-management
The purpose of this study was to examine: (a) the extent to which caregivers and children asked asthma management questions during pediatric asthma visits, (b) the extent to which providers engaged in shared decision-making with these caregivers and children, and (c) the factors associated with question-asking and shared decision-making.
Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in non-urban areas of North Carolina. All of the medical visits were audio-tape recorded. Generalized estimating equations were used to analyze the data.
Only 13% of children and 33% of caregivers asked one or more questions about asthma management. Caregivers were most likely to ask questions about their child’s medications. Providers obtained child input into their asthma management treatment plan during only 6% of encounters and caregiver input into their child’s asthma management treatment plan during 10% of visits.
Given the importance of involving patients during health care visits, providers need to consider asking for and including child and caregiver input into asthma management treatment plans so that shared decision-making can occur more frequently.
Urban minority populations experience increased rates of obesity and increased asthma prevalence and severity.
We sought to determine whether obesity, as measured by body mass index (BMI), was associated with asthma quality of life or asthma-related emergency department (ED)/urgent care utilization in an urban, community-based sample of adults.
This is a cross-sectional analysis of 352 adult subjects (age 30.9±6.1, 77.8% females, FEV1%pred=87.0%±18.5) with physician diagnosed asthma from a community-based Chicago cohort. Outcome variables included the Juniper Asthma Quality of Life Questionnaire (AQLQ) scores and health care utilization in the previous 12 months. Bivariate tests were used as appropriate to assess the relationship between BMI or obesity status and asthma outcome variables. Multivariate regression analyses were performed to predict asthma outcomes, controlling for demographics, income, depression score, and beta-agonist use.
191 (54.3%) adults were obese (BMI>30 kg/m2). Participants with a higher BMI were older (p=0.008), African American (p<0.001), female (p=0.002), or from lower income households (p=0.002). BMI was inversely related to overall AQLQ scores (r =−0.174, p=0.001) as well as to individual domains. In multivariate models, BMI remained an independent predictor of AQLQ. Obese participants were more likely to have received ED/urgent care for asthma than non-obese subjects (OR=1.8, p=0.036).
In a community-based sample of urban asthmatic adults, obesity was related to worse asthma-specific quality of life and increased ED/urgent care utilization. However, compared to other variables measured such as depression, the contribution of obesity to lower AQLQ scores was relatively modest.
Asthma; obesity; urban; healthcare disparities; health outcomes
This cross-sectional study examines parents’ perceptions of their neighborhoods and general and respiratory health among low-income Chicago families. Asthma disproportionately affects non-white, urban, and low socioeconomic status (SES) populations, but Chicago’s burden, and the national epidemic, are not well-explained by known risk factors. Urban dwellers experience acute and chronic stressors that produce psychological distress and are hypothesized to impact health through biological and behavioral pathways. Identifying factors that covary with lower SES and minority-group status -- e.g. stress -- is important for understanding asthma’s social patterning.
We used survey data from 319 parents of children 5–13 years with asthma/respiratory problems and principal components analysis to create exposure variables representing parents’ perceptions of two aspects of neighborhoods: collective efficacy (“CE”) and physical/social order (“order”). Adjusted binomial regression models estimated risk differences (RD) and 95% confidence intervals (CI) for eight binary outcomes.
Magnitude was generally as expected, i.e., RD for low versus high (most favorable) exposure groups (RDlow v. high) was larger than for the middle vs. high contrast (RDmid v. high). “Parent general health” was strongly associated with “CE” [RDlow v. high=20.8 (95% CI: 7.8, 33.9)] and “order” [RDmid v. high=11.4 (95% CI: 2.1, 20.7)] unlike “child general health” which had nearly null associations. Among respiratory outcomes, only “waking at night” was strongly associated with “CE” [RDlow v. high=16.7 (95% CI: 2.8, 30.6)] and “order” [RDlow v. high=22.2 (95% CI: 8.6, 35.8)]. “Exercise intolerance” [RDlow v. high=15.8 (95% CI: 2.1, 29.5)] and “controllability” [RDmid v. high=12.0 (95% CI: 1.8, 22.3)] were moderately associated with “order” but not with “CE,” while “school absences,” “rescue medication use,” and “unplanned visits” had nearly null associations with both exposures.
More negative perceptions tended to be associated with higher risk of undesirable outcomes, adding to evidence that the social environment contributes to health and supporting research on stress’ health impact among disadvantaged populations. Interventions must address not only traditional “environmental” factors but individuals’ reactions to stress and attempt to mitigate effects of stressors while structural solutions to health inequities are sought.
To evaluate the effect of the timeliness of asthma diagnosis on chest X-ray (CXR) and antibiotic utilization in children.
Patients and methods
This was a retrospective cohort study of 276 asthmatic children aged 5–12 years from Rochester, Minnesota. From the time when children met our predetermined asthma criteria, the frequency of CXR and antibiotic utilizations for respiratory illnesses were collected from medical records until age 18 years. Using a Poisson regression model, the frequency of CXR and antibiotic utilizations were compared in children with timely, delayed, or no clinician diagnosis of asthma.
Of the 276 asthmatic patients, 97 (35%) had a timely diagnosis, 122 (44%) had a delayed diagnosis, while 57 patients (21%) had no clinician diagnosis of asthma. There was no significant difference in CXR or antibiotic utilization for respiratory illness between these groups. In addition, this was true for the comparison between the timely diagnosed group and the delayed diagnosed group combining both the group with a delay in asthma diagnosis and the group who never had asthma diagnosis.
A delay in the diagnosis of asthma in children is common and overall it may not influence antibiotic and CXR utilization for respiratory symptoms by clinicians. However, its impact on access to asthma-related therapies and other healthcare utilizations could be possible and was not assessed in this study. Given the limitations of our study, a larger prospective study needs to be considered.
adolescent; antibacterial agents; child; health services; radiography; therapeutics; thoracic
To evaluate the cross-sectional relationship between asthma and pre-gravid body mass index (BMI); and to assess the risk of adult weight change among women with history asthma diagnosed in childhood or adulthood, respectively.
Study participants were 3,737 pregnant women enrolled in a cohort study. Information on history of asthma, pre-gravid BMI, adult weight change (difference between BMI at age 18 and pre-gravid BMI) and other socio demographic characteristics was collected using interviewer-administered questionnaires. Pre-gravid BMI was categorized into lean (BMI <18.5 kg/m2), overweight (BMI 25–24.9 kg/m2) and obese (BMI ≥30 kg/m2). Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI).
Approximately 13.1% of study participants reported history of asthma. Compared with the reference group (BMI 18.5–24.9 kg/m2), the odds of asthma was higher among overweight (OR=1.51; 95%CI 1.18–1.93) and obese (OR=1.47; 95% CI 1.06–2.03) women while it was lower among lean women (OR=0.42; 95% CI 0.21–0.84) (trend p-value <0.001). Women who gained ≥20 kg, compared with those who maintained their weight (±2.5 kg) had a 2.7-fold increased odds of asthma (95% CI 1.02–7.00).
Overweight and obese women were more likely to have history of asthma. Adult weight gain was positively associated with asthma diagnosis. Longitudinal studies designed to prospectively assess patterns of adult weight change in relation to asthma are warranted.
Asthma; Pediatric Asthma; Body Mass Index; Obesity; Adult Weight Change
Adherence with inhaled controller medications for asthma is known to be highly variable with many patients taking fewer doses than recommended for consistent control of lung inflammation. Adherence also worsens as children become teenagers, although the exact causes are not well established.
To use focus group methodology to examine beliefs, feelings, and behaviors about inhaled asthma controller medication in adolescents and young adults who had previously participated in a longitudinal study of asthma treatment adherence and outcome in order to develop more effective management strategies.
Twenty-six subjects participated in 6 focus groups comprised of 3-5 young adults (age range 12-20 years). Verbatim transcripts of these groups were analyzed using the long-table method of content analysis to identify key themes raised by participants.
A variety of beliefs, feelings and behaviors influence the adolescent’s decision about how to use their asthma medication. Some of the adolescents understood the importance of daily medication and were committed to the treatment plan prescribed by their provider. Poorer adherence was the product of misinformation, incorrect assumptions about their asthma, and current life situations.
These results, by highlighting potential mechanisms underlying both better and worse adherence inform the development of strategies to improve adherence behavior in adolescents and young adults with asthma. Knowledge of the specific beliefs, feelings and behaviors that underlie adolescents’ use of inhaled asthma controller medication will help providers maximize treatment adherence in this notoriously difficult patient population.
asthma; adherence; adolescence; beliefs; behaviors; controller; decision-making
Obesity is a risk factor for asthma. Obese asthmatics often have poor asthma control and respond poorly to therapy. It has been suggested that co-morbidities associated with obesity, such as reflux and obstructive sleep apnea, could be important factors contributing to poor asthma control in obese patients.
The purpose of this study was to determine if (i) reflux and/or (ii) symptoms of sleep apnea contribute to poor asthma control in obesity.
We studied asthmatic subjects participating in a trial of reflux treatment. Participants underwent baseline evaluation of asthma symptoms and lung function. 304 participants underwent esophageal pH probe testing. 246 participants were evaluated for obstructive sleep apnea symptoms.
Of 402 participants in this trial, 51% were obese.
Role of reflux in asthma control
Those with higher body mass index reported a higher prevalence of reflux symptoms, but the prevalence of pH probe acid reflux was similar in all groups. Reflux was not associated with measures of asthma control in obese patients.
Role of obstructive sleep apnea in asthma control
Symptoms and self-report of obstructive sleep apnea were more common with increasing body mass index and associated with worse asthma control as measured by the Juniper Asthma Control Questionnaire and Asthma Symptom Utility Index.
Our data suggest that obstructive sleep apnea, but not gastroesophageal reflux disease may contribute significantly to poor asthma control in obese patients.
Obesity; Asthma; lung function; reflux; obstructive sleep apnea
Dyspnea is a prominent symptom in asthma. The Dyspnea-12 (D-12), an instrument that quantifies breathlessness using 12 descriptors that tap the physical and affective aspects, has shown promise for the measurement of dyspnea in cardiorespiratory disease.
We report the results of a study designed to test the validity and reliability of the D-12 in a population of patients with asthma.
This cross-sectional study included 102 patients with asthma. Subjects completed the D-12, Hospital Anxiety and Depression Scale (HAD), St George’s Respiratory Questionnaire (SGRQ), MRC scale. Confirmatory factor analysis confirmed the two-component structure of the D-12 (i.e. 7 items that tap the Physical aspects of breathlessness and 5 items that tap the Affective aspects).
The D-12 subscales had excellent internal reliability (Cronbach’s alpha for the ‘Physical’ score was 0.94 and the Affective score was 0.95). The D-12 Physical component was more strongly correlated with SGRQ Symptoms (r = 0.648), SGRQ Activities (r = 0.635) and MRC grade (r = 0.636), while the Affective component was more strongly correlated with SGRQ Impacts (r = 0.765) and HAD scores (anxiety r = 0.641 and depression r = 0.602).
This study supports validity of the D-12 for use in the assessment of dyspnea of patients with asthma. It assesses one of the most pertinent symptoms of asthma from two viewpoints -physical and affective.
asthma; dyspnea; symptoms; patient reported outcome measures; quality of life; adults
The forced expiratory volume in one second (FEV1), felt to be an objective measure of airway obstruction, is often normal in asthmatic children. The forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) reflects small airway patency and has been found to be reduced in children with asthma. The aim of this study was to determine if FEF25-75 is associated with increased childhood asthma severity and morbidity in the setting of a normal FEV1, and to determine if bronchodilator responsiveness (BDR) as defined by FEF25-75 identifies more childhood asthmatics than does BDR defined by FEV1.
The Children’s Hospital Boston Pulmonary Function Test database was queried and the most recent spirometry result was retrieved for 744 children diagnosed with asthma between 10–18 years of age between October 2000 and October 2010. Electronic medical records in the 1 year prior and the 1 year following the date of spirometry were examined for asthma severity (mild, moderate or severe) and morbidity outcomes for three age, race and gender-matched subgroups: group A (n= 35) had a normal FEV1, FEV1/FVC and FEF25-75; Group B (n= 36) had solely a diminished FEV1/FVC; and Group C (n=37) had a normal FEV1, low FEV1/FVC and low FEF25-75. Morbidity outcomes analyzed included the presence of hospitalization, emergency department visit, intensive care unit admission, asthma exacerbation, and systemic steroid use.
Subjects with a low FEF25-75 (Group C) had nearly 3 times the odds (OR 2.8, p<0.01) of systemic corticosteroid use and 6 times the odds of asthma exacerbations (OR 6.3, p>0.01) compared with those who had normal spirometry (Group A). Using FEF25-75 to define bronchodilator responsiveness identified 53% more subjects with asthma than did using a definition based on FEV1.
A low FEF25-75 in the setting of a normal FEV1 is associated with increased asthma severity, systemic steroid use and asthma exacerbations in children. In addition, using the percent change in FEF25-75 from baseline may be helpful in identifying bronchodilator responsiveness in asthmatic children with a normal FEV1.
spirometry; childhood asthma; FEF25-75; bronchodilator responsiveness
To examine the association of social and environmental factors with levels of second hand smoke (SHS) exposure, as measured by salivary cotinine, in young inner city children with asthma.
We used data drawn from a home-based behavioral intervention for young high risk children with persistent asthma post emergency department (ED) treatment (N=198). SHS exposure was measured by salivary cotinine and caregiver report. Caregiver demographic and psychological functioning, household smoking behavior and asthma morbidity were compared with child cotinine concentrations. Chi-square and ANOVA tests and multivariate regression models were used to determine the association between cotinine concentrations with household smoking behavior and asthma morbidity.
Over half (53%) of the children had cotinine levels compatible with SHS exposure and mean cotinine concentrations were high at 2.42 ng/ml (SD 3.2). The caregiver was the predominant smoker in the home (57%) and (63%) reported a total home smoking ban. Preschool age children, and those with caregivers reporting depressive symptoms and high stress had higher cotinine concentrations than their counterparts. Among children living in a home with a total home smoking ban, younger children had significantly higher mean cotinine concentration than older children (Cotinine: 3–5 year olds, 2.24 ng/ml (SD 3.5); 6–10 year olds, 0.63 ng/ml (SD 1.0); p <0.05). In multivariate models, the factors most strongly associated with high child cotinine concentrations were increased number of household smokers (β = 0.24) and younger child age (3–5 years) (β = 0.23; P <0.001, R2 = 0.35).
Over half of young inner-city children with asthma were exposed to second hand smoke and caregivers are the predominant household smoker. Younger children and children with depressed and stressed caregivers are at significant risk of smoke exposures, even when a household smoking ban is reported. Further advocacy for these high-risk children is needed to help caregivers quit and to mitigate smoke exposure.
asthma; children; cotinine; second hand smoke
Low-income, minority teens have disproportionately high rates of asthma morbidity and are at high-risk for non-adherence to preventive medications.
To assess the feasibility and preliminary effectiveness of an innovative school-based asthma program to enhance the delivery of preventive care for 12–15 year olds with persistent asthma. We hypothesized that this intervention would; 1) be feasible and acceptable among this population, and 2) yield reduced asthma morbidity.
Teens with persistent asthma and a current preventive medication prescription in Rochester, NY.
Single group pre-post pilot study during the 2009–10 school year.
Teens visited the school nurse daily for 6–8 weeks at the start of the school year to receive directly observed therapy (DOT) of preventive asthma medications; 2–4 weeks following DOT initiation, they received 3 counseling sessions (1 in-home and 2 via telephone) using motivational interviewing (MI) to explore attitudes about asthma management, build motivation for medication adherence, and support transition to independent preventive medication use.
Number of symptom-free days (SFDs)/2 weeks; outcome data were collected 2 months after baseline and at the end of school year.
We enrolled 30 teens; 28 participated in the intervention. All teens initiated a trial of school-based DOT. All in-home MI visits were completed successfully, and 89% completed both follow-up sessions. Teens experienced an overall reduction of symptoms with more SFDs/2 weeks from baseline to 2-month and final (end of school year) assessments (8.71 vs. 10.79 vs. 12.89, respectively, p=.046 and .004). Teens also reported fewer days with symptoms, less activity limitation, and less rescue medication use (all p<.05). Exhaled nitric oxide levels decreased (p=.012), suggesting less airway inflammation. At the final assessment, teens reported significantly higher motivation to take their preventive medication every day (p=.043). At the end of the study, 79% of teens stated that they were better at managing asthma on their own, and 93% said they would participate in a similar program again.
This pilot study provides preliminary evidence of the feasibility and effectiveness of a novel school-based intervention to promote independence in asthma management and improve asthma outcomes in urban teens.
Asthma in children and adolescents is a heterogeneous syndrome comprised of multiple subgroups with variable disease expression and response to environmental exposures. The goal of this study was to define homogeneous phenotypic clusters within a cohort of children and adolescents with asthma and to determine overall and within-cluster associations between environmental tobacco smoke (ETS) exposure and asthma characteristics.
A combined hierarchical/k-means cluster analysis of principal component variables was used to define phenotypic clusters within a cohort of 6 to 20 year-old urban and largely minority subjects.
Among the 154 subjects, phenotypic cluster analysis defined three independent clusters (Cluster 1 [n=57]; Cluster 2 [n=33]; Cluster 3 [n=58]). A small fourth cluster (n=6) was excluded. Patients in Cluster 1 were predominantly males with a relative abundance of neutrophils in their nasal washes. Patients in Cluster 2 were predominantly females with high body mass index percentiles and later-onset asthma. Patients in Cluster 3 had higher eosinophil counts in their nasal washes and lower Asthma Control Test™ (ACT) scores. Within-cluster regression analysis revealed several significant associations between ETS exposure and phenotypic characteristics that were not present in the overall cohort. ETS exposure was associated with a significant increase in nasal wash neutrophils (Beta Coefficient = 0.73 [95%CI: 0.11 to 1.35]; P=0.023) and a significant decrease in ACT score (−5.17 [−8.42 to −1.93]; P=0.003) within Cluster 1 and a significant reduction in the bronchodilator-induced % change in FEV1 (−36.32 [−62.18 to −10.46]; P=0.009) within Cluster 3.
Clustering techniques defined more homogeneous subgroups allowing for the detection of otherwise undetectable associations between environmental tobacco smoke exposure and asthma characteristics.
Asthma; Phenotype; Cluster Analysis; Tobacco Smoke Pollution; Eosinophils; Neutrophils
Obesity-mediated changes in plasma adipokines have been associated with increased systemic inflammation and oxidative stress. However, it is unknown whether obesity induces similar changes in airway levels of these adipokines and whether these changes are associated with increased airway biomarkers of inflammation and oxidative stress.
Lean and obese asthmatics and controls underwent bronchoscopy with bronchoealveaolar lavage (BAL), spirometry, and provided fasting plasma leptin and adiponectin. Biomarkers of oxidation and inflammation in the BAL included exhaled nitric oxide, 8-isoprostanes, pH and nitrogen oxide products (NOx).
Out of a total of 48 subjects 44% had asthma and 56% were healthy controls. Among subjects with asthma 66% were obese, 10% overweight, and 24% were lean; in the controls these proportions were respectively 63%, 11% and 26%. After adjusting for age, sex, smoking history, ethnicity, pre-bronchodilator forced exhalation in one second (FEV1), obesity was associated with higher BAL and plasma leptin levels in asthmatics and controls. Increasing BMI was associated with increased BAL leptin and was marginally and inversely associated with BAL adiponectin. Significant associations between BAL and plasma levels were only observed for leptin. No significant associations were observed between BAL or plasma adipokines with the airway biomarkers of oxidation and inflammation.
Increasing BMI is associated with changes in the concentrations of airway adipokines in asthmatics and healthy controls; however, these associations are not related with biomarkers of airway oxidation or inflammation.
Asthma; obesity; leptin adiponectin; oxidative stress
Asthma is a highly-prevalent chronic disease. Prevalence and mortality are particularly high in Puerto Ricans living in the US as compared with other populations.
To determine asthma mortality rates in Puerto Rico (1980 to 2007) and to assess the socio-demographic variables that may be associated with these rates.
Data was obtained from the Vital Statistics Office at the Puerto Rico Department of Health. Crude mortality rates and their 95% confidence intervals were used to evaluate differences between age groups and across years. Mortality risk ratios by socio-demographic variables were estimated using generalized lineal models with a Poisson link function to identify at-risk groups.
. During the study period, there were 4,232 deaths recorded with asthma as the cause of death. From 1980 to 1998 annual asthma mortality rates fluctuated between 3.32 and 6.56 deaths per 100,000 (Mean 4.77), followed by a decline after implementation of the ICD-10 for reporting cause of death in 1999. Between 1999 and 2007 the mean asthma death rate declined to 3.01 (4.89 in 1999 to 2.02 in 2007). Overall, asthma mortality rates were between 1.77 and 4.0 times higher in Puerto Rico than in the US. Throughout the whole study period, mortality rates were higher in older age groups. In addition, the adjusted regression model for asthma deaths showed that persons divorced or widowed, and persons with only elementary education had significantly higher risk of asthma mortality than their counterparts.
. Asthma death rates were higher in Puerto Rico than in the US general population. Although asthma mortality in Puerto Rico declined, rates continued to be significantly higher than those recorded in the US. There was a progressive decline in asthma mortality rates after 1999 that may be explained by changes in reporting classification, increased use of corticosteroids, and improved asthma awareness. After controlling for possible confounding variables, age and elementary education were found to increase the risk of mortality due to asthma among Puerto Ricans.
asthma; cause of death; epidemiology; mortality rate; vital statistics
Obstructive sleep apnea (OSA) or habitual snoring and asthma are known comorbid conditions in men and non-pregnant women. This comorbidity has not been evaluated among pregnant women. We assessed the habitual snoring-asthma relationship among pregnant women.
A cohort of women (N=1,335) were interviewed during pregnancy, and we ascertained participants’ asthma status and collected information about habitual snoring, before and during pregnancy. Logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).
Compared with non-asthmatics, the adjusted OR among asthmatics for snoring before pregnancy was 2.13 (95%CI 1.10–4.12). The odds of snoring during early pregnancy was 1.79-fold (OR=1.79; 95%CI 1.07–3.01). Associations were more pronounced among overweight (≥25 kg/m2) asthmatics (OR=5.39; 95%CI 2.27–12.75).
We report a cross-sectional association of habitual snoring and asthma among pregnant women. If confirmed, pregnant asthmatics may benefit from more vigilant screening and management of OSA or habitual snoring during pregnancy.
Asthma; Obstructive Sleep Apnea; Sleep Disordered Breathing; Habitual Snoring; Obesity; Pregnancy
This case series reports the changes in the respiratory health of eight asthmatic subjects and the relationship to air quality associated with the October, 2007 firestorm in San Diego County of California.
Participants were eight subjects with asthma enrolled in Asthma Clinical Research Network (ACRN) (NIH# U10-HL074218) studies at the University of California San Diego, School of Medicine, (UCSD), who had study data collected immediately prior, during and one month after the five-day firestorm in San Diego County. Air quality deteriorated to an extreme average of 71.5 ug/m3small particulate matter less than 2.5 microns (PM2.5) during the firestorm. Respiratory health data included morning and evening peak expiratory flow rates [PEFR], morning and evening Forced Expiratory Volume in one second [FEV1], rescue medication usage, and sputum eosinophils. Morning and evening PEFR and FEV1 rates remained stable. The two subjects tested during the fires had elevated eosinophil counts and rescue medication usage was increased in five of the eight subjects.
Pulmonary function test values were stable during the wildfires for all eight subjects but there was a statistical significant increase in rescue medication usage during the wildfires which correlated with PM 2.5 values. The two subjects tested during the fires showed increases in sputum eosinophil counts consistent with increased airways inflammation.
These findings suggests that poor air quality associated with wildfires resulted in an increase airways inflammation in these asthmatic subjects, but pulmonary function tests remained stable, possibly due to increased rescue medication usage. This is especially pertinent as there is an increase in incidence of wildfires this decade.
asthma; fire; pollution; particles; eosinophil
To determine whether asthma-specific quality of life during pregnancy is related to asthma exacerbations and to perinatal outcomes.
This was a secondary analysis of data from a randomized controlled trial of inhaled beclomethasone versus theophylline in the treatment of moderate asthma during pregnancy. The Juniper Asthma Quality of Life Questionnaire (AQLQ) was administered to patients at enrollment. Exacerbations were defined as asthma symptoms requiring a hospitalization, unscheduled medical visit, or oral corticosteroid course.
Quality of life assessments were provided by 310 of the 385 participants who completed the study. There was more than a 25% decrease in the odds of a subsequent asthma exacerbation for every 1-point increase in AQLQ score for the overall score (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.55–0.96), emotion domain (OR 0.72, 95% CI 0.59–0.88), and symptoms domain (OR 0.73, 95% CI 0.57–0.94). These relationships were not significantly influenced by initial symptom frequency or forced expiratory volume in 1 s (FEV1). No significant relationships were demonstrated between enrollment AQLQ scores and preeclampsia, preterm birth, low birth weight, or small for gestational age.
Asthma-specific quality of life in early pregnancy is related to subsequent asthma morbidity during pregnancy but not to perinatal outcomes.
asthma; exacerbations; perinatal outcomes; pulmonary function; quality of life
Children spend a significant amount of time in school. Little is known about the role of allergen exposure in school environments and asthma morbidity.
The School Inner-City Asthma (SICAS) is an NIH funded prospective study evaluating the school/classroom specific risk factors and asthma morbidity among urban children
This paper describes the design, methods, and important lessons learned from this extensive investigation. A single center is recruiting 500 elementary school aged children, all of whom attend inner-city, metropolitan schools. The primary hypothesis is that exposure to common indoor allergens in the classroom will increase the risk of asthma morbidity in children with asthma, even after controlling for home allergen exposures. The protocol includes screening surveys of entire schools and baseline eligibility assessments obtained in the spring prior to the academic year. Extensive baseline clinical visits are being conducted among eligible children with asthma during the summer prior to the academic school year. Environmental classroom/school assessments including settled dust and air sampling for allergen, mold, air pollution, and inspection data are collected twice during the academic school year and one home dust sample linked to the enrolled student. Clinical outcomes are measured every 3 months during the academic school year.
The overall goal of SICAS is to complete the first study of its kind to better understand school-specific urban environmental factors on childhood asthma morbidity. We also discuss the unique challenges related to school-based urban research and lessons being learned from recruiting such a cohort.
Fractional Exhaled Nitric Oxide (FeNO) has been proposed as a biomarker of airway inflammation for cohort studies of asthma.
To assess the association between FeNO and asthma symptoms among seven-year old children living in an inner-city community. To test the association between ETS exposure (previous and current) and FENO among these children.
As part of a longitudinal study of asthma, children recruited in Head Start centers at age 4 years had offline FeNO and lung function testing at age 7 years. Children with allergen specific IgE (≥0.35 IU/ml) at age 7 were considered seroatopic. Environmental tobacco smoke (ETS) exposure at ages 4 and 7 was assessed by questionnaire.
Of 144 participating children, 89 had complete questionnaire data and achieved valid FeNO and lung function tests. Children with reported wheeze in the previous 12 months (n=19) had higher FeNO than those without wheeze (n=70) (geometric means 17.0 vs. 11.0ppb, p=0.005). FeNO remained significantly associated with wheeze (p=0.031), after adjusting for seroatopy and FEV1 in multivariable regression. FeNO at age 7 was positively associated with domestic ETS exposure at age 4 (29%)(β=0.36, p=0.015) but inversely associated with ETS exposure at age 7 (16%) (β= −0.74, p<0.001).
Given its association with current wheeze, independent of seroatopy and lung function, FeNO provides a relevant outcome measure for studies in inner-city communities. While compelling, the positive association between ETS exposure at age 4 and a marker of airway inflammation at age 7 should be confirmed in a larger study.
Exhaled Nitric Oxide; IgE; Inner-city; Wheeze; Environmental Tobacco Smoke
Cognitive variables such as knowledge, attitude and self-efficacy affect asthma patients’ abilities to be effective self-managers.
The objective of this cross-sectional analysis was to determine what patient and clinical factors were associated with these cognitive variables and to assess the contributions of these cognitive variables to clinical status.
Primary care asthma patients were interviewed using the three domains of the Knowledge, Attitude and Self-Efficacy Asthma Questionnaire (KASE), as well as established scales to measure social support, depressive symptoms, and ratings of asthma care. Clinical asthma status was measured with the Asthma Quality of Life Questionnaire (AQLQ).
In total, 180 patients were enrolled with a mean age of 43 years and 84% were women. Knowledge was low with only 50% of patients answering half or more questions correctly (mean score = 52, possible range 0–100, higher is more knowledge). Attitude toward asthma was generally positive (mean score = 82, possible range 20–100, higher is more positive attitude) and self-efficacy was moderate (mean score = 76, possible range 20–100, higher is more self-efficacy). In separate multivariate analyses: younger age and higher education level were associated with more knowledge (p ≤ .005); more social support, fewer depressive symptoms, and more favorable prior results of asthma care were associated with more positive attitude (p ≤ .05); and favorable prior results, more satisfaction with asthma status, not having stress-related triggers, and not having had a recent emergency department visit for asthma were associated with more self-efficacy (p ≤ .07 for all variables). In additional multivariate analyses, more knowledge (p = .0005), more positive attitude (p = .02) and more self-efficacy (p = .01) were associated with better AQLQ scores.
Different patient and clinical characteristics were associated with cognitive variables pertinent to self-management. These variables, in turn, were independently associated with asthma status. Thus, while fostering improvement in all three variables would be desirable, interventions that improve any of these variables potentially could be beneficial.
knowledge; attitude; self-efficacy; quality of life; asthma; self-management; cognitive variables
The coincidence of both an obesity epidemic and an asthma epidemic among children in the United States has suggested that childhood overweight and sedentary lifestyles may be risk factors for asthma development. We therefore conducted a study of those factors among children enrolled in Head Start Centers located in areas of New York City with high asthma hospitalization rates.
Data were gathered from 547 children through an intensive home visit, and physical activity was measured on 463 children using the Actiwatch accelerometer. Data on allergy and asthma symptoms and demographic variables were obtained from parents’ responses to a questionnaire and complete data were available from 433 children.
Overall physical activity was highest in warmer months, among boys, among children whose mothers did not work or attend school, and among children of mothers born in the United States. Activity was also positively associated with the number of rooms in the home. The season in which the activity data were collected modified many of the associations between demographic predictor variables and activity levels. Nearly half the children were above the range considered healthy weight. In cross-sectional analyses, before and after control for demographic correlates of physical activity, asthma symptoms were not associated with physical activity in this age group. Comparing the highest quartile of activity to the lowest, the odds ratio for asthma was 0.91 (95% CI = 0.46, 1.80).
However, the novel associations with physical activity that we have observed may be relevant to the obesity epidemic and useful for planning interventions to increase physical activity among preschool children living in cities in the northern United States.
physical activity; asthma; childhood; Head Start