Psychosocial characteristics of inner-city children with asthma: a description of the NCICAS psychosocial protocol. National Cooperative Inner-City Asthma Study

Previous research has demonstrated a significant reciprocal relationship between psychosocial factors and asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated both asthma-specific and non-specific psychosocial variables, including asthma knowledge beliefs and management behavior, caregiver and child adjustment, life stress, and social support. This article presents these psychosocial characteristics in 1,528 4-9-year-old asthmatic urban children and their caretakers. Caretakers demonstrated considerable asthma knowledge, averaging 84% correct responses on the Asthma Information Quiz. However, respondents provided less than one helpful response for each hypothetical problem situation involving asthma care, and most respondents had more than one undesirable response, indicating a potentially dangerous or maladaptive action. Both adults and children reported multiple caretakers responsible for asthma management (adult report: average 3.4, including the child); in addition, children rated their responsibility for self-care significantly higher than did adults. Scores on the Child Behavior Checklist indicated increased problems compared to normative samples (57.3 vs. 50, respectively), and 35% of children met the criteria for problems of clinical severity. On the Brief Symptom Inventory, adults reported elevated levels of psychological distress (56.02 vs norm of 50); 50% of caretakers had symptoms of clinical severity. Caretakers also experienced an average of 8.13 undesirable life events in the 12 months preceding the baseline interview. These findings suggest that limited asthma problem-solving skills, multiple asthma managers, child and adult adjustment problems, and high levels of life stress are significant concerns for this group and may place the inner-city children in this study population at increased risk for problems related to adherence to asthma management regimens and for asthma morbidity.     

Third-level hospital emergency department visits by patients with acute asthma. 1990

BACKGROUND: In the natural history of an asthmatic patient's disease, emergency room visits can be significant, incidental, or accidental occurrences from the therapeutic, preventive, clinical, or epidemiological perspective. METHODS: In order to find out the characteristics of the severely asthmatic patients who visit the third-level emergency room of the hospital asking for medical attention, we studied their visits, as opposed to those of other patients, for a one-year period. RESULTS: We registered 477 emergency care patients for asthma (1.30/day) which implies visits to the hospital watch of 0.71%. It is maintained 24 hours a day, predominantly in the first three days of the week (52.41%), the last ten days of the month (36.68%), the second trimester of the year (34.48%), and the month of May (20%). Compared to the rest of the population who also went for emergency room care, the asthmatic patient had lower average age (44 vs. 50), a majority of women (67.29% vs. 48%) and more frequent visits (36.74% vs. 18.59%). In comparison with studies in other countries, we register a higher number of admission but a lower of relapses (4.06%). CONCLUSIONS: Emergency room visits by severely asthmatic patients is an epidemiological index of the public health significance of the disease as it is a reflection of the degree of control and type of asthma. It is an important factor in determining demand of emergency care given the frequency of visits and the rates of admission and relapse.     

Knowledge of asthma among parents of asthmatic children

The knowledge and attitude towards asthma, of parents, of 85 asthmatic children was assessed using a 17 item questionnaire. Results showed that 34.1% believed asthma to be contagious, 48.2% of the parents hesitated in referring to their child's illness as asthma. Other commonly held beliefs were that asthma is a life long illness (35.3%); food items are important precipitating factors for acute attacks (88.2%); mild exacerbations need to be treated with bronchodilators (6.3%); bronchodilators should be started at home before consulting a physician in case of an acute attack (61.2%); and cure of asthma is possible through modern drugs (30.6%) or through alternative systems of medicine (65%). Ninety one per cent of parents lacked an awareness of the side effects of anti-asthma medication. It is concluded that parental education through improved physician parent communication is necessary for enhancing the quality of care being provided to children with asthma, a fact also highlighted by the International Consensus Report on Management of Asthma.     

Airways remodeling is a distinctive feature of asthma and is related to severity of disease

PURPOSE: Airways remodeling, evaluated as the subepithelial layer thickness, was compared in asthmatic patients with that of healthy subjects, and was related to clinical grading of disease, presence of atopy, and length of asthmatic history. SUBJECTS AND METHODS: Thirty-four patients with stable asthma (mean age+/-SD: 26.5+/-9.2 years; 10 female) treated with only inhaled beta2-agonists and eight healthy volunteers (mean age+/-SD: 24.6+/-2.5 years; four female) were recruited for the study. Twenty-seven of 34 asthmatics had atopy. Eleven patients had newly diagnosed conditions (duration of disease < or = 1 year), nine patients had long asthmatic history (> 1 year and < or = 10 years), and 14 had prolonged asthmatic history (> 10 years). Bronchial responsiveness to methacholine (M) was expressed as provocative concentration of M causing a 20% fall in FEV1 (PC20) (mg/mL). Degree of asthma severity was assessed using a 0- to 12-point score based on symptoms, bronchodilator use, and daily peak expiratory flow variability over a 3-week period. Bronchoscopy and bronchial biopsy were performed successfully for all subjects; the subepithelial layer thickness, in biopsy samples, was measured from the base of bronchial epithelium to the outer limit of reticular lamina. RESULTS: In asthmatics, baseline FEV1 values (percent of predicted) ranged from 75.7 to 137.0%, and PC20 M ranged from 0.15 to 14.4 mg/mL. According to the asthma severity score, 14 asthmatics were classified as having mild disease, 14 as having moderate disease, and six as having severe disease. The mean values of subepithelial layer thickness were 12.4+/-3.3 microm (range, 6.8 to 22.1 microm) in asthmatics, and 4.4+/-0.5 microm (range, 3.8 to 5.2 microm) in healthy subjects (p<0.001). Subepithelial layer thickness of those with severe asthma differed significantly from that of patients with moderate and mild asthma (16.7+/-3.1 microm vs 12.1+/-2.7 microm and 10.8+/-2.4 microm, p<0.01 and p<0.003, respectively). Moreover, in asthmatics, degree of thickening was positively correlated to asthma severity score (Spearman rank correlation coefficient [rs]=0.581; p<0.001), and negatively correlated with baseline FEV1 (rs=-0.553; p<0.001) and PC20 M (rs=-0.510; p<0.01). No difference was found between degree of thickening observed in atopic asthmatics, compared with that of nonatopic asthmatics, or between degree of thickening in patients with different lengths of asthmatic history. Lastly, multiple regression analysis revealed that asthma severity score was the significant predictive factor for thickness of subepithelial layer. CONCLUSIONS: We confirmed that airways remodeling is a very distinctive and characteristic pathologic finding of asthma. We also demonstrated that it is related to the clinical and functional severity of asthma, but not to atopy or length of asthmatic history.     

Diagnosis and management of asthma: a summary of the National Asthma Education and Prevention Program guidelines. National Institutes of Health

Asthma is a common disease that affects persons of all ages. It is responsible for more than 5,000 deaths annually in the United States and countless days absent from school and work. For these reasons, the National Institutes of Health established the National Asthma Education Program whose expert panels have published two reports: Guidelines for the Diagnosis and Management of Asthma in 1991 and a revised report in 1997. A summary of the Expert Panel Report 2 published in 1997 is presented with emphasis on the outpatient diagnosis, prevention, and treatment of asthma. Education of the clinician and the patient is essential for effective management of asthma, and effective communication between clinician and patient is essential for implementing asthma education. The goal of this summary is to communicate and disperse the asthma education provided by the Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2 in hopes of improving asthma care and decreasing morbidity and mortality-attributed asthma.     

Deaths due to childhood asthma. Are they preventable?

Seven cases of death in patients with severe asthma are presented. The cause of death in asthmatic children is discussed under the following headings: mucus plugs, insufficient treatment, infection, aspiration, concomitant disease, oversedation, theophylline toxicity, overuse of metered dose pressurized aerosols, inadequate steroid therapy, and sudden cardiopulmonary arrest. The authors conclude that asthmatic deaths are preventable.     

Interpreting indirect replies

PROBLEM/CONDITION: Asthma is one of the most common chronic diseases in the United States, and it has increased in importance during the preceding 20 years. Despite its importance, no comprehensive surveillance system has been established that measures asthma trends at the state or local level. REPORTING PERIOD: This report summarizes and reviews national data for specific end-points: self-reported asthma prevalence (1980-1994), asthma office visits (1975-1995), asthma emergency room visits (1992-1995), asthma hospitalizations (1979-1994), and asthma deaths (1960-1995). DESCRIPTION OF SYSTEM: The National Center for Health Statistics (NCHS) annually conducts the National Health Interview Survey, which asks about self-reported asthma in a subset of the sample. NCHS collects physician office visit data with the National Ambulatory Medical Care Survey, emergency room visit data with the National Hospital Ambulatory Medical Care Survey, and hospitalization data with the National Hospital Discharge Survey. NCHS also collects mortality data annually from each state and produces computerized files from these data. We used these datasets to determine self-reported asthma prevalence, asthma office visits, asthma emergency room visits, asthma hospitalizations, and asthma deaths nationwide and in four geographic regions of the United States (i.e., Northeast, Midwest, South, and West). RESULTS: We found an increase in self-reported asthma prevalence rates and asthma death rates in recent years both nationally and regionally. Asthma hospitalization rates have increased in some regions and decreased in others. At the state level, only death data are available for asthma; death rates varied substantially among states within the same region. INTERPRETATION: Both asthma prevalence rates and asthma death rates are increasing nationally. Available surveillance information are inadequate for fully assessing asthma trends at the state or local level. Implementation of better state and local surveillance can increase understanding of this disease and contribute to more effective treatment and prevention strategies.     

Population based study of risk factors for underdiagnosis of asthma in adolescence: Odense schoolchild study

OBJECTIVE: To describe factors related to underdiagnosis of asthma in adolescence. DESIGN: Subgroup analysis in a population based cohort study. SETTING: Odense municipality, Denmark. SUBJECTS: 495 schoolchildren aged 12 to 15 years were selected from a cohort of 1369 children investigated 3 years earlier. Selection was done by randomisation (n = 292) and by a history indicating allergy or asthma-like symptoms in subject or family (n = 203). MAIN OUTCOME MEASURES: Undiagnosed asthma defined as coexistence of asthma-like symptoms and one or more obstructive airway abnormalities (low ratio of forced expiratory volume in 1 second to forced vital capacity, hyperresponsiveness to methacholine or exercise, or peak flow hypervariability) in the absence of physician diagnosed asthma. Risk factors (odds ratios) for underdiagnosis. RESULTS: Undiagnosed asthma comprised about one third of all asthma identified. Underdiagnosis was independently associated with low physical activity, high body mass, serious family problems, passive smoking, and the absence of rhinitis. Girls were overrepresented among undiagnosed patients with asthma (69%) and underrepresented among diagnosed patients (33%). Among the risk factors identified, low physical activity and problems in the family were independently associated with female sex. The major symptom among those undiagnosed was cough (58%), whereas wheezing (35%) or breathing trouble (50%) was reported less frequently than among those diagnosed. Less than one third of those undiagnosed had reported their symptoms to a doctor. CONCLUSIONS: Asthma, as defined by combined symptoms and test criteria, was seriously underdiagnosed among adolescents. Underdiagnosis was most prevalent among girls and was associated with a low tendency to report symptoms and with several independent risk factors that may help identification of previously undiagnosed asthmatic patients.     

Chronobiology and chronotherapy of asthma

There is no doubt that many pathophysiologic conditions change over a 24-hour period and thus therapy needs to be directed at these changes. In particular, asthma has been one of the better-studied disease processes in regard to circadian changes in pathophysiology. As we continue to learn more about circadian changes, better approaches to treating the disease with the same medications will emerge. It should be remembered that many asthmatics do not perceive their degree of bronchoconstriction. This was brought forth in Turner-Warwick's epidemiologic study in that less than one half of the asthmatic individuals who had problems with their asthma every night describe their asthma as being severe. The majority stated they either had mild or moderate asthma. Therefore, it is important that we use objective criteria such as peak flow meters in determining an individual patient's day-to-night changes in lung function. Then, any therapeutic intervention can be objectively determined at home with both the patient and physician gaining knowledge about the ongoing asthmatic process.     

Psychiatric family history in adolescents with severe asthma

OBJECTIVE: To examine the hypothesis that an association exists between severe asthma and familial affective and anxiety disorders. METHOD: A parent, usually the mother, of 62 adolescents admitted to a tertiary care asthma center was administered the Family History-Research Diagnostic Criteria Interview. Lifetime prevalence rates of psychiatric disorders in first-degree relatives were compared with previously reported rates. RESULTS: In relatives of asthmatic adolescents, rates for depression, mania (females only), substance abuse (males only), and antisocial personality disorder were significantly higher than the rates in the non-ill comparison sample. Rates for substance abuse (males only) and antisocial personality disorder were higher than the rates for relatives of the depressed comparison sample. Rates for anxiety disorders were not higher than rates in epidemiological samples. Rates of attention-deficit hyperactivity disorder (females only) and posttraumatic stress disorder in relatives were higher than in community samples. CONCLUSIONS: These results support the presence of a link between severe asthma and familial affective disorders, posttraumatic stress disorder, antisocial personality disorder, and substance abuse. Whether these disorders are genetically associated with asthma or represent an association with severe asthma because of environmental effects on the growing child is discussed.     

Genetics of asthma and atopy

Asthma and airways hyperresponsiveness are the respiratory manifestations of sensitization to exogenous materials including protein allergens and chemical sensitizers that may trigger ongoing inflammation and respiratory symptomatology in those people who are predisposed to develop the asthmatic syndrome. That genetics plays a major role in this particular syndrome is without question, since twin studies have shown a greater prevalence of disease for monozygotic as opposed to dizygotic twins. There have been the beginnings of the development of an approach to a number of candidate genes for major genetic input in the asthmatic syndrome. However, unlike cystic fibrosis or even other autoimmune and inflammatory diseases such as juvenile diabetes and/or multiple sclerosis, a single gene or a significant set of major genes may not be easily identified. Rather the small contribution of multiple genes and/or sets of genes may be summed together and added to environmental exposure in people who will develop asthmatic syndromes. The identification of a genetic component to asthma would be of great significance. Even without a major or predominant gene, identification of the minor sets of genes interacting to cause asthma would represent a great advance. Knowledge of those minor genetic alleles involved in asthma susceptibility would allow great latitude in offering diagnostic screening and new therapeutic interventions in asthma.     

Pharmacological management of asthma

Asthma management is changing, and there are many potential new drugs undergoing early and late phase trials. Nonetheless, it is unlikely that any dramatic alterations in therapy will occur within the next 3 years. The asthma treatment paradigm has altered over the past 10 or so years, with the emphasis on symptom relief from short acting beta agonists giving way to preventive treatment of underlying airway inflammation with inhaled corticosteroids. More recently, long acting beta agonists have been demonstrated to reduce the need for increasing doses of inhaled steroids in patients with poorly controlled asthma. This article reviews these trends.     

Increased prevalence of sleep disturbances and daytime sleepiness in subjects with bronchial asthma: a population study of young adults in three European countries

The aim of this study was to investigate whether asthma is associated with decreased quality of sleep and increased daytime sleepiness. The study involved a random population of 2,202 subjects supplemented by 459 subjects with suspected asthma, aged 20-45 yrs. The subjects were from Reykjavik (Iceland), Uppsala and G?teborg (Sweden) and Antwerp (Belgium), and participated in the European Community Respiratory Health Survey. The investigation included a structured interview, methacholine challenge, skinprick tests and a questionnaire on sleep disturbances. Participants in Iceland and Sweden also estimated their sleep times and made peak expiratory flow (PEF) recordings during a period of 1 week. Asthma was defined as self-reported physician-diagnosed asthma with current asthma-related symptoms (n = 267). Difficulties inducing sleep (DIS) and early morning awakenings (EMA) were about twice as common, and daytime sleepiness 50% more common, in asthmatics compared with subjects without asthma. After adjusting for possible confounders, a positive association was found between asthma and: DIS (odds ratio (OR) = 1.8); EMA (OR = 2.0); daytime sleepiness (OR = 1.6); snoring (OR = 1.7); and self reported apnoeas (OR = 3.7). Allergic rhinitis, which was reported by 71% of subjects with asthma, was independently related to DIS (OR = 2.0) and daytime sleepiness (OR = 1.3). A significant correlation was found between the number of asthma-related symptoms and sleep disturbances (p < 0.001). Asthma is associated with decreased subjective quality of sleep and increased daytime sleepiness. Concurrent allergic rhinitis may be an important underlying cause of sleep impairment in asthmatic patients.     

Activation of hsr203, a plant gene expressed during incompatible plant-pathogen interactions, is correlated with programmed cell death

The purpose of this work was to describe methods of retaining participants in studies of inner-city populations, including the timing and intensity of contacts; and to describe the characteristics of participants who did not complete all follow-up interviews and/or return all peak flow diaries in the National Cooperative Inner-City Asthma Study. A cohort study design was used involving hospital emergency rooms and community clinics in seven major urban areas. Participants included 1337 4- to 9-year-old asthmatic children and their caretakers. Nearly 89% of participants completed 3-, 6-, and 9-month follow-up interviews. The 15% of participants who completed a baseline interview on the weekends were significantly more likely to complete follow-up interviews on a weekend. The percent of follow-up interviews conducted in person increased over time from 5% to 8%. The percent of participants with complete follow-up increased as the number of contact names increased (86% with zero contacts, 91% with two contracts; p = 0.03, test for trend). Participants who required at least four phone calls to complete the 3- and 6-month assessment were significantly more likely to be black, have higher participant stress, and have a smoker in the household (p < 0.05). Multiple logistic regression suggests that higher social support and lower parental stress were both predictors of completed interviews. Within our study sample of inner-city minority participants with asthmatic children, only a small proportion of participants missed any follow-up interviews. Increased caretaker stress, decreased social support, and inability to provide several alternate contacts were all predictive of retention problems. Having a flexible staff, computer tracking, and face-to-face recruitment appear essential to achieving nearly complete follow-up within a population historically difficult to follow.     

Small airways dimensions in asthma and in chronic obstructive pulmonary disease

The purpose of this study was to compare the dimensions of the peripheral airways in fatal asthma with those from patients with nonfatal asthma, mild COPD, and normal lung function. Lung specimens from eight individuals who had fatal asthmatic attacks were obtained at postmortem and compared with similar specimens from three asthmatic patients who died of an unrelated cause and four specimens obtained from known asthmatic patients who required lung resection for tumor. These 15 asthmatic lungs were also compared with lungs resected for peripheral neoplasms from 15 patients with normal airway function (FEV1, % of predicted > 85) and 15 patients with mild chronic airflow obstruction (FEV1, % of predicted < 85). All membranous airways with a long-short diameter ratio of 3:1 or less were examined. The smooth muscle and the tissue areas external and internal to the muscle layer were traced using a Bioquant BQ System 4. The same system was used to evaluate the fraction of the submucosa and adventitia taken up by blood vessels. The adventitial, submucosal, and muscle area of the asthmatic airways were greater than those of COPD and control (p < 0.01), and the muscle area was greater in COPD than in control lungs (p < 0.05). These parameters were also greater in the 8 patients with fatal asthma compared with the 7 patients with nonfatal asthma (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Relationship of asthma severity and psychological problems in children

OBJECTIVE: To determine whether physiological severity of asthma is associated with increased psychological symptoms in children. METHOD: Participants were 337 children, aged 7 to 19 years (mean 11.9, SE 0.13), and a parent of each child. Children's asthma severity was rated by experienced pediatric asthma specialists using current guidelines from the National Heart, Lung, and Blood Institute. Children filled out the Children's Manifest Anxiety Scale and the Weinberger Adjustment Inventory. Parents reported on their child's medical history, completed the Child Behavior Checklist (CBCL) about their child, and completed the Pennebaker Inventory of Linguid Languidness as a measure of their own physical symptoms. RESULTS: Child-rated anxiety symptoms were unrelated to asthma severity or to markers of asthma functional morbidity. Parental ratings of internalizing symptoms in their children were related to severity. Parent physical symptoms explained 10.2% of the variance in CBCL Internalizing symptoms, and asthma severity added an additional 6.7% to the variance. CONCLUSIONS: Asthma severity may be a more salient stressor to parents, who in turn report higher levels of child internalizing symptoms for children with severe asthma, than to children themselves. Contrary to prior hypotheses, children with severe asthma did not rate themselves as having higher levels of anxiety than those with mild or moderate asthma or than standardized norms.     

Costs of asthma according to the degree of severity

An increase in asthma-related morbidity and mortality has been reported recently, resulting in a substantial increase in the economic impact of this condition. Little information is available relating to the costs of asthma depending on the degree of severity of the disease. Total, direct and indirect costs generated by asthma patients who sought medical care for asthma control over a one-year period in a northern area of Spain were determined. Data were obtained from the patients themselves and severity of illness was classified into mild, moderate and severe according to the International Consensus Report on Diagnosis and Treatment of Asthma, 1992. The average total annual asthma-derived cost was estimated at US$2,879 per patient, with averages of US$1,336 in mildly asthmatic patients, US$2,407 in moderate asthma and US$6,393 in severe asthma. At all levels of severity, indirect costs were twice as high as direct costs, and at the same degree of severity, direct costs due to medication and hospitalization were higher among females than males. A minority of severe asthmatics incurred some 41% of the total costs. The cost of asthma was surprisingly high and varied substantially depending on the degree of severity of the disease. Further knowledge of the costs of asthma across various levels of severity will contribute to a better characterization of optimal intervention strategies for asthma care.     

Life-threatening asthma with dramatic resolution

The speed of onset of an asthma attack can be highly variable. Recent studies have tried to characterize a subgroup of patients with life-threatening asthma that occurs suddenly but often regresses very rapidly under treatment. We had the opportunity to observe the evolution of two asthmatic women hospitalized with extremely severe respiratory acidosis. One of them required immediate orotracheal intubation and mechanical ventilation during 13 h. The results of her pulmonary function tests were normal 35 h after admission. The second woman's condition improved so rapidly under treatment that she did not require intubation and mechanical ventilation. These observations suggest that bronchospasm might play an important role in the pathophysiology of transient life-threatening asthma.     

The epidemiology and genetics of asthma. II. Genetic aspects of the epidemiology of asthma and atopy

Asthma is regarded as a disease with a complex interaction between genetic and environmental factors. Since the end of the 1970s and during the 80s the world has seen an increase in the prevalence, morbidity and mortality linked to asthma. The rapidity of progress of this phenomenon means that it cannot be explained only by modification of genetic factors and stresses the preponderance of exogenous factors. The purpose of this review is to examine the epidemiological knowledge of these environmental factors and of the genetic factors in asthma in order to underline how these genetic and exogenous factors interact and modulate the occurrence of the asthmatic disease. In the first part of this general review we discussed the epidemiology of asthma in terms of prevalence, incidence, mortality, cost and socio-professional and scholastic repercussions and underlined for each environmental factor its causal role and/or exacerbation in asthma as well as its contribution in the increased prevalence and severity of asthma. In the second part of this general view we touch on the epidemiological knowledge of the genetics of asthma and of atopy.