Improving Care for Urban Children with Asthma: Design and Methods of the School-Based Asthma Therapy (SBAT) Trial

The School Based Asthma Therapy (SBAT) trial builds on a pilot study in which we found that school-based administration of preventive asthma medications for inner-city children reduced asthma symptoms. However, the beneficial effects of this program were seen only among children not exposed to environmental tobacco smoke (ETS). The current study is designed to establish whether this intervention can be enhanced by more stringent adherence to asthma guidelines through the addition of symptom-based medication dose adjustments, and whether smoke-exposed children benefit from the intervention when it is combined with an ETS reduction program. The intervention consists of both administration of preventive asthma medications in school (with dose adjustments according to NHLBI guidelines) and a home-based ETS reduction program utilizing motivational interviewing principles. This paper describes the methodology, conceptual framework, and lessons learned from the SBAT trial. Results of this study will help to determine whether this type of comprehensive school-based program can serve as a model to improve care for urban children and reduce disparities.     

Prevalence,Demographics, and Health Outcomes of Comorbid Asthma and Overweight in Urban Children

Background. Asthma and overweight are epidemic in urban children but the relationship between these conditions is not fully understood. This study presents demographic and risk profiles of comorbidity for overweight asthmatic children, characterizes morbidity by comparing health outcomes among overweight asthmatics and healthy weight asthmatics, and examines socioeconomic factors associated with comorbidity. Objective. To construct a demographic profile of overweight asthmatic children in an urban setting and identify factors that contribute to prevalence. Method. Cross-sectional study of 5250 children in New York City public elementary schools using a parent-report questionnaire on body mass index, socioeconomic status, asthma, and asthma-related outcomes. Results. Prevalence of overweight (body mass index ≥ 85th percentile for age and gender) was 50.9%. The prevalence of overweight and ever being diagnosed with asthma was 10.9%. The prevalence of overweight with current asthma was 6.2%. Overweight current asthmatics had more night symptoms, missed school days, and asthma medication use than healthy weight asthmatics. Almost 50% of overweight current asthmatic children reported emergency department visits for asthma compared with 30% of healthy weight asthmatics. Comorbidity was most prevalent among males, Latinos, and children in low-income households, with the highest prevalence among Puerto Ricans. In multivariate analysis stratified by gender, the most significant factors associated with comorbidity among girls were low income and minority race/ethnicity, while among boys significant factors were parental education and parental history of asthma. Interestingly, there were few underweight children (7.8%) but they had high prevalence of asthma (13.8%). Conclusions. The comorbidity of overweight and asthma has a large impact on urban populations, causing greater disease burden than asthma alone. Overweight asthmatics show more uncontrolled asthma, evidenced by emergency department visits, quick-relief medication use, and days with asthma symptoms. The relationship between socioeconomic factors and the asthma–obesity comorbidity may vary by gender and requires further study to identify successful interventions to reduce disease in children.     

Rural Children with Asthma: Impact of a Parent and Child Asthma Education Program

The goal of this study was to determine the effectiveness of an asthma educational intervention in improving asthma knowledge, self-efficacy, and quality of life in rural families. Children 6 to 12 years of age (62% male, 56% white, and 22% Medicaid) with persistent asthma (61%) were recruited from rural elementary schools and randomized into the control standard asthma education (CON) group or an interactive educational intervention (INT) group geared toward rural families.

Parent/caregiver and child asthma knowledge, self-efficacy, and quality of life were assessed at baseline and at 10 months post enrollment. Despite high frequency of symptom reports, only 18% children reported an emergency department visit in the prior 6 months. Significant improvement in asthma knowledge was noted for INT parents and young INT children at follow-up (Parent: CON = 16.3; INT = 17.5, p < 0.001; Young children: CON = 10.8, INT = 12.45, p < 0.001). Child self-efficacy significantly increased in the INT group at follow-up; however, there was no significant difference in parent self-efficacy or parent and child quality of life at follow-up. Asthma symptom reports were significantly lower for the INT group at follow-up. For young rural children, an interactive asthma education intervention was associated with increased asthma knowledge and self-efficacy, decreased symptom reports, but not increased quality of life.     

Is the Prevalence of Asthma and Related Symptoms Among Brazilian Children Related to Socioeconomic Status?

Objective. To evaluate the relationship between socioeconomic status (SES) and the prevalence of asthma and related symptoms among Brazilian children. Methods. The International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire was applied to 23,457 six- to seven- year-old schoolchildren (SC) and 58,144 thirteen- to fourteen-year-old adolescents (AD) from 20 Brazilian cities. SES was evaluated by infant mortality index, poverty index, and average nominal income for people older than 10 years of age. Results. Current asthma ranged from 16.5% to 31.2% among SC and from 11.8% to 30.5% among AD and severe asthma from 2.9% to 8.5% (SC) and 2.6% to 9.1% (AD). Higher values were observed in Brazilian-Northern, -Northeastern and -Southeastern centers. No significant association between SES and prevalence of asthma and related symptoms was observed. Conclusions. In Brazil, the prevalence of asthma and related symptoms is quite variable and independent of SES.     

Associations of Doctor-Diagnosed Asthma with Immigration Status,Age at Immigration,and Length of Residence in the United States in a Sample of Mexican American School Children in Chicago

Objectives. Among Mexican Americans in the United States, children who were born in the US had higher rates of asthma than their Mexico-born peers. The purpose of this study was to examine the associations of doctor-diagnosed asthma with immigration-related variables and to investigate whether these associations could be explained by factors that may change with migration. Methods. We surveyed parents of 2,023 school children of Mexican descent and examined the associations of asthma with nativity, age at immigration, and length of residence in the US after adjusting for potential confounding variables. Results. In multivariate analyses, US-born children had a 2.42-fold (95% confidence interval [CI]: 1.52–3.83) increased odds of asthma compared with their Mexico-born peers. Mexico-born participants who moved to the US before 2 years of age were almost twice as likely to experience asthma compared with Mexico-born children who moved to the US ≥2 years of age. In addition, Mexico-born participants who lived in the US for 10 years or more were 2.37 times more likely to have asthma than Mexico-born students who lived in the US for less than 10 years. These associations were not explained by a wide variety of factors such as place of residence in infancy; exposure to animals/pets; history of infections, Tylenol use, and antibiotic use in infancy; breastfeeding; exposure to environmental tobacco smoke; daycare attendance and number of siblings; and language use. Conclusions. Our findings point to the effects of nativity, age at immigration, and duration of residence in the US on the risk of asthma in Mexican American children, suggesting that potentially modifiable factors that change with migration may be linked with the disease. The findings of this study should stimulate further research to explain factors that may be responsible for the observed differentials in the risk of asthma among Mexican Americans.     

Exploring the Supportiveness and Preparedness of Child Care Settings for Children with Asthma: A Needs Assessment

Background. The role of child care centers has increased to extreme importance as the majority of young children are in some form of child care setting. Child care centers are increasingly faced with providing health-related care to children with asthma. Purpose. The purpose of this study was to examine child care workers' perceived knowledge and confidence and their perceptions of their child care setting's preparedness to handle asthma-related issues. Methods. The study used a cross-sectional postal survey design that followed a modified Dillman's protocol. Questionnaires were sent to staff in 235 randomly selected child care centers across four Ontario public health regions. The questionnaire assessed several asthma-related areas: identifying and caring for children with asthma, emergency plans for asthma, and confidence in ability to handle asthma-related issues. Results: A total of 489 (69% overall response rate) questionnaires were returned and 180 centers (76.6%) of the 235 child care centers participated. Most child care workers (67%) cared for a child with asthma, but only 21% ever received formal training on caring for a child with asthma. When asked about having an emergency plan for a child having an asthma flare-up/attack, 52.3% of the workers reported that their center lacked such a plan or they were unaware of it. Many (45%) reported feeling uncertain about how to manage worsening asthma. The area of trigger identification and management was also an issue regarding child center preparedness: 43.6% of centers had a plan or process and 48% of staff felt uncertain of their abilities in this area. Child care workers who reported receiving formalized training were more likely to have higher confidence scores in their ability to handle asthma-related issues compared with those who did not receive training in many areas. Conclusions. Gaps in asthma care preparedness exist within the child care system. The provision of formalized learning opportunities is one strategy that could narrow these gaps.     

Demographics,Clinical Course,and Outcomes of Children with Status Asthmaticus Treated in a Pediatric Intensive Care Unit: 8-Year Review

Objective. This study was done to understand the demographics, clinical course, and outcomes of children with status asthmaticus treated in a tertiary care pediatric intensive care unit (PICU). Methods. The medical charts of all patients above 5 years of age admitted to the PICU at Nationwide Children’s Hospital, Columbus, OH, USA, with status asthmaticus from 2000 to 2007 were reviewed retrospectively. Data from 222 encounters by 183 children were analyzed. Results. The mean age at admission in years was 11 ± 3.8. The median PICU stay was 1 day (range, 1–12 days) and median hospital stay was 3 days. The ventilated group (n = 17) stayed a median of 2 days longer in the PICU and hospital. Nearly half of the children (n = 91; 50%) did not receive daily controller asthma medications. Adherence to asthma medications was reported in 125 patient charts of whom 43 (34%) were compliant. Exposure to smoking was reported in 167 of whom 70 (42%) were exposed. Among patients receiving metered dose inhaler (MDI), only 39 (18%) were using it with a spacer. Among 105 patient charts asthma severity data were available, of them 21 (20%) were labeled as mild intermittent, 29 (28%) were mild persistent, 26 (25%) were moderate persistent, and 29 (28%) were severe persistent. Compared to children with only one PICU admission during the study period (n = 161), children who had multiple PICU admissions (n = 22) experienced more prior emergency department visits and hospitalizations for asthma symptoms. There were no fatalities. Conclusion. Asthmatics with any disease severity are at risk for life-threatening asthma exacerbations requiring PICU stay, especially those who are not adherent with their daily medications.     

The Impact of Financial Barriers on Access to Care, Quality of Care and Vascular Morbidity Among Patients with Diabetes and Coronary Heart Disease

BACKGROUND

The prevalence and consequences of financial barriers to health care among patients with multiple chronic diseases are poorly understood.

OBJECTIVE

We sought to assess the prevalence of self-reported financial barriers to health care among individuals with diabetes and coronary heart disease (CHD) and to determine their association with access to care, quality of care and clinical outcomes.

DESIGN

The 2007 Centers for Disease Control Behavioral Risk Factor Surveillance Survey.

PARTICIPANTS

Diabetic patients with CHD.

MAIN MEASURES

Financial barriers to health care were defined by a self-reported time in the past 12 months when the respondent needed to see a doctor but could not because of cost. The primary clinical outcome was vascular morbidity—a composite of stroke, retinopathy, nonhealing foot sores or bilateral foot amputations.

KEY RESULTS

Among the 11,274 diabetics with CHD, 1,541 (13.7 %) reported financial barriers to health care. Compared to individuals without financial barriers, those with financial barriers had significantly reduced rates of medical assessments within the past 2 years, hemoglobin (Hgb) A1C measurements in the past year, cholesterol measurements at any time, eye and foot examinations within the past year, diabetic education, antihypertensive treatment, aspirin use and a higher prevalence of vascular morbidity. In multivariable analyses, financial barriers to health care were independently associated with reduced odds of medical checkups (Odds Ratio [OR], 0.61; 95 % Confidence Intervals [CI], 0.55–0.67), Hgb A1C measurement (OR, 0.85; 95 % CI, 0.77–0.94), cholesterol measurement (OR, 0.76; 95 % CI, 0.67–0.86), eye (OR, 0.85; 95 % CI, 0.79–0.92) and foot (OR, 0.92; 95 % CI, 0.84–1.00) examinations, diabetic education (OR, 0.93; 95 % CI, 0.87–0.99), aspirin use (OR, 0.88; 95 % CI, 0.81–0.96) and increased odds of vascular morbidity (OR, 1.23; 95 % CI, 1.14–1.33).

CONCLUSIONS

In diabetic adults with CHD, financial barriers to health care were associated with impaired access to medical care, inferior quality of care and greater vascular morbidity. Eliminating financial barriers and adherence to guideline-based recommendations may improve the health of individuals with multiple chronic diseases.     

The Association between Leisure-Time Physical Activities and Asthma Symptoms among 10- to 12-Year-Old Children: The Effect of Living Environment in the PANACEA Study

Objective. This study evaluated the interrelationships of living environment, physical activity, lifestyle/dietary habits, and nutritional status on the prevalence of childhood asthma. Methods. In a cross-sectional survey 1125 children (529 boys), 10 to 12 years old, were selected from 18 schools located in an urban environment (Athens, n = 700) and from 10 schools located in rural areas (n = 425) in Greece. Results. Children living in Athens had higher likelihood of “ever had” asthma compared with children living in rural areas (odds ratio (OR) = 1.78, 95% confidence interval (CI) = 1.25–2.54), after adjusting for age and sex. After adjusting for age, sex, body mass index, and adherence to the Mediterranean diet (KIDMED score), leisure-time physical activity was inversely associated with “ever had” asthma. When stratifying by county of residence, a trend toward reduced asthma symptoms among children engaged in outdoor physical activities during their leisure time who reside in rural (but not urban) environment was observed (OR = 0.88, 95% CI = 0.77–1.01). Conclusions. The inverse relationship between asthma symptoms and leisure-time physical activity in the rural environment and the lack of an association between asthma symptoms and organized sports-related activities should draw the attention of public healthcare authorities. Their efforts should focus on the planning of a sustainable natural environment, which will promote the physical health of children and reduce the burden of childhood asthma.     

Family Perceptions of the Usual Source of Care among Children with Asthma by Race/Ethnicity, Language, and Family Income

A usual source of care (USC) can serve as the foundation for good primary health care and is critical for children living with a chronic health condition. This study applies national data to the following objectives: (1) describe family reports of the presence and characteristics of the USC for children with asthma; (2) examine evidence of systematic differences in the USC for these children with asthma by race/ethnicity, English language proficiency in Hispanic respondents, and family income; and (3) conduct multivariate analysis adjusting for possible confounding factors to examine independent effects of race/ethnicity, language, and income. Data from the 1996-2000 Medical Expenditure Panel Survey (MEPS) were analyzed. Overall, 95% of children with asthma had a USC, with Spanish-speaking Hispanics least likely to report a USC (89%). There were significant differences in USC attributes by race/ethnicity, language, and income, with the largest differences by type of provider and accessibility. Hispanics with poor English language proficiency had the greatest accessibility barriers.     

Family Perceptions of the Usual Source of Care among Children with Asthma by Race/Ethnicity,Language, and Family Income

A usual source of care (USC) can serve as the foundation for good primary health care and is critical for children living with a chronic health condition. This study applies national data to the following objectives: (1) describe family reports of the presence and characteristics of the USC for children with asthma; (2) examine evidence of systematic differences in the USC for these children with asthma by race/ethnicity, English language proficiency in Hispanic respondents, and family income; and (3) conduct multivariate analysis adjusting for possible confounding factors to examine independent effects of race/ethnicity, language, and income. Data from the 1996–2000 Medical Expenditure Panel Survey (MEPS) were analyzed. Overall, 95% of children with asthma had a USC, with Spanish-speaking Hispanics least likely to report a USC (89%). There were significant differences in USC attributes by race/ethnicity, language, and income, with the largest differences by type of provider and accessibility. Hispanics with poor English language proficiency had the greatest accessibility barriers.     

Fever,Use of Antibiotics,and Acute Gastroenteritis During Infancy as Risk Factors for the Development of Asthma in Korean School-Age Children

Objective. The hygiene hypothesis postulates that infections early in life might influence the development of asthma later in childhood. However, this hypothesis is controversial. The objective of this study was to determine whether there is a relationship between infection-related risk factors during infancy and development of asthma later in childhood. Methods. Data were obtained by a nationwide, population-based, cross-sectional study of 26,400 children, 7 to 12 years of age. Parents completed a questionnaire on symptoms of and risk factors for asthma, including the number of fever episodes, acute gastroenteritis, use of antibiotics, and immunization during infancy. The presence of asthma was defined by parental report of “wheeze in the last 12 months” or “asthma ever.” Data were analyzed by logistic regression analysis. Results. The occurrence of fever during infancy was weakly associated with the development of asthma (P < 0.05). A higher frequency of episodes of fever was associated with a higher risk of development of asthma. The relationship between antibiotic use during infancy and development of asthma was also significant (P < 0.0001). The adjusted odds ratios of childhood asthma increased in proportion to the number of antibiotic courses during infancy. A history of acute gastroenteritis during infancy increased the risk of developing asthma in later life (P < 0.001). In contrast, immunization in infancy was not related to development of asthma in childhood (P > 0.05). Conclusions. These data suggest that the development of childhood asthma is associated with episodes of fever, antibiotic use, and acute gastroenteritis during infancy.     

Asthma Severity,Psychiatric Morbidity,and Quality of Life: Correlation with Inhaled Corticosteroid Dose

Objectives.?Psychiatric phenomena in asthma has been debated for some time. Inhaled corticosteroids (ICS) are a significant part of treatment. We attempted to quantify the prevalence of psychiatric morbidity relative to asthma severity, quality of life (QOL), and ICS dose. Data Sources.?Fifty asthmatic patients (18 ≥ X ≤ 75 years) on ICS, attending an urban clinic had asthma and ICS dose stratified by symptom severity and preparation potency. Peak flow and forced expiratory volume in 1 second (FEV₁) were measured. Patients completed general QOL and disease-specific QOL questionnaires, along with psychiatric rating scales. Results.?Patients (n = 50) clustered in the 40–59 year range (n = 27, 54%) and were predominantly female (n = 44, 88%) Hispanics (n = 30, 60%), with mild-moderate asthma (n = 18, 36%) and on low-dose ICS (n = 22, 44%). FEV₁ ranged from 32 to 123 (mean 76.98, SE 3.01). Peak flow ranged from 210 to 590 (mean 407.83, SE 13.24). Prevalence of anxiety and depressive symptoms were higher than expected (Kendall's tau-c, n = 50, P < .01). Independently, high ICS dose and asthma severity correlated directly with all measures of psychiatric morbidity (Pearson's r 0.781, P < .01). High ICS dose correlated inversely with SF-36 Mental Component Scale (Pearson's r 0.681, P < .01) and directly with FEV₁ and peak flow when age/sex adjusted (Spearman's rho: 0.660, P < .001). Conclusions.?Psychiatric morbidity is more prevalent in this population and impacts negatively on QOL. Use of high-dose ICS benefited pulmonary function and “physical” QOL, yet may have negatively affected patients' mental well-being. Longitudinal follow-up, extension of sample size, and better study control would allow closer approximation of possible negative associations with ICS.     

Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003

OBJECTIVES: To examine vaccination in seniors in the five U.S. communities of the Racial and Ethnic Adult Disparities in Immunization Initiative. DESIGN: Cross-sectional telephone survey in spring 2003 using stratified sampling by ZIP code and race/ethnicity. SETTING: New York, Texas, Wisconsin, Illinois, and Mississippi. PARTICIPANTS: Four thousand five hundred seventy-seven Medicare beneficiaries. MEASUREMENTS: Outcomes were pneumococcal vaccination ever and influenza vaccination in 2002/03 and were determined according to race/ethnicity, awareness of vaccination, and provider recommendation. Survey questions also asked about future plans for vaccination, whether respondents believed they had become sick from prior influenza vaccination, and whether unvaccinated respondents would be vaccinated if a health professional recommended it. RESULTS: Pneumococcal vaccination coverage was 70.3% for whites, 40.8% for blacks, and 53.2% for Hispanics, and the proportion reporting provider recommendation for vaccination differed significantly according to race/ethnicity. In multivariate regression, provider recommendation (risk ratio (RR) = 2.32, 95% confidence intervals (CI) = 2.10-2.57) and awareness of vaccination (RR = 1.60, 95% CI = 1.40-1.82) were associated with greater pneumococcal vaccination. Influenza vaccination coverage was 76.2% for whites, 50.7% for blacks, and 65.7% for Hispanics. A little more than half of respondents reported provider recommendation for influenza vaccination, with no differences according to race/ethnicity. Provider recommendation was associated with influenza vaccination (RR = 1.31, 95% CI = 1.25-1.38). More blacks and Hispanics believed they had become sick from prior influenza vaccination than whites, and this belief was associated with lower vaccination rates. CONCLUSION: This survey details vaccination patterns in an ethnically and geographically diverse sample of seniors and identifies some differences between blacks, Hispanics, and whites that may contribute to disparities in vaccination coverage. Survey findings highlight the importance of provider vaccination recommendations.     

Polymorphism of the ADRB2 Gene and Response to Inhaled Beta- agonists in Children with Asthma: A Meta-analysis

Background. About 9% of children have asthma, corresponding to almost 6.8 million children in the USA and 1.1 million in the UK. Asthma exacerbations are the leading cause of pediatric emergency room visits and impose a large burden on the individual, family, and society. There is mounting evidence that therapeutic failure of inhaled beta-agonists is associated with polymorphisms of the β₂-adrenergic receptor gene (ADRB2); specifically, mutations leading to amino acid changes at positions 16 and 27, which alter down-regulation of the β₂-adrenergic receptor (β₂AR), induce resistance to the smooth-muscle relaxing effect of β₂-adrenergic agonists. Methods. We conducted a meta-analysis to examine the association between ADRB2 polymorphisms and the response to inhaled β₂-adrenergic agonists in children with asthma. We included all published studies until November 2008, in which asthmatic children underwent testing for acute bronchodilator response, defined as ≥ 15% improvement in forced expiratory volume in 1 second (FEV₁) and single nucleotide polymorphism (SNP) genotyping for positions 16 and/or 27 of the β₂AR. Individual and summary odds ratios were calculated using a random effects model. Results. We identified three case-control or family-based studies involving 960 asthmatic children (692 children with negative β₂-bronchodilator response, defined as < 15% improvement in FEV₁ and 268 children with positive bronchodilator response). We found a significant association between favorable therapeutic response to inhaled β₂-adrenergic agonists in asthmatic children and the Arg/Arg phenotype at position 16 of the β₂AR [OR = 1.77; 95% CI (1.01; 3.1); p = 0.029], compared with the Arg/Gly or Gly/Gly phenotypes. The beneficial effect of Arg at position 16 of the β₂AR was most pronounced in African-American asthmatic children [OR = 3.54; 95% CI (1.37, 9.13)]. There was no association between clinical response to β₂-agonists and polymorphism at amino acid position 27 of the β₂AR (OR = 1.04; 95% CI [0.76,1.42]). Conclusions. Failure of bronchodilator response to inhaled beta-agonists in asthmatic children is associated with the Gly allele (Arg/Gly and Gly/Gly genotypes) at position 16 of the β₂-adrenergic receptor. Genetic typing for β₂AR polymorphism may help identify children with drug-resistant asthma.     

Early Life Factors Associated with Incidence of Physician-diagnosed Asthma in Preschool Children: Results from the Canadian Early Childhood Development Cohort Study

Background. Asthma is a common childhood illness. The objective of this study is to determine the incidence of physician-diagnosed asthma in preschool years and its relationship to host, prenatal and postnatal factors, early childhood factors, parental factors, household factors and demographic factors. Methods. The study sample was comprised of 8,499 infants and toddlers (<2 years at baseline) enrolled in the Canadian Early Childhood Development Study. Incidence of asthma was determined when the children were in preschool age (2 to 5 years). Results. The 4-year cumulative incidence at preschool age was 13.7% for physician-diagnosed asthma. History of early childhood wheezing before 2 years of age was a significant risk factor for incidence of asthma in preschool years (hazard ratio (HR): 2.32; 95% confidence interval (CI): 2.04–2.65). Factors that were protective for the development of asthma were breastfeeding more than 3 months (HR: 0.82; 95% CI: 0.69–0.97); history of nose or throat infection often in childhood (HR: 0.79; 95% CI: 0.67–0.93); early daycare attendance (HR: 0.85; 95% CI: 0.74–0.98); presence of two or more siblings at birth, (HR: 0.79; 95% CI: 0.64–0.97); and dwelling in rural non- central metropolitan areas (HR: 0.81; 95% CI: 0.69–0.95). Male sex, low birth weight, childhood allergy, single parent, maternal smoking during pregnancy, maternal medication use, parental atopy, and low SES at baseline were significant risk factors for the incidence of physician-diagnosed asthma in preschool years. Conclusion. This study emphasizes the role of wheezing in infant and toddler age on early onset of asthma during preschool years. The results also provide additional importance of early exposures to environmental factors such as early infections, daycare attendance, and rural environment in the development of proper immune dynamics to prevent asthma.     

Impact of Depression and Anxiety on Quality of Life, Health Behaviors, and Asthma Control Among Adults in the United States with Asthma, 2006

Background. Psychological factors such as anxiety and depression are increasingly being recognized as influencing the onset and course of asthma. Methods. We obtained Patient Health Questionnaire 8 depression data from 41 states and territories using the 2006 Behavioral Risk Factor Surveillance System. Heath risk behaviors, social and emotional support, life satisfaction, disability, and four health-related quality-of-life (HRQOL) questions were available for all states and territories (n = 18,856 with asthma). Five additional HRQOL questions were asked in three states (n = 1345 persons with asthma), and questions assessing asthma control were available for nine states (n = 3943 persons with asthma). Results. Persons with asthma were significantly more likely than those without asthma to have current depression (19.4% vs. 7.7%), a lifetime diagnosis of depression (30.6% vs. 14.4%), and anxiety (23.5% vs. 10.2%). For most domains examined, there was a dose-response relationship between level of depression severity and mean number of days of impaired HRQOL in the past 30 days, as well as an increased prevalence of life dissatisfaction, inadequate social support, disability, and risk behaviors, such as smoking, physical inactivity, and obesity, among those with asthma. Moreover, depression and anxiety were associated with a decreased level of asthma control, including more visits to the doctor or emergency room, inability to do usual activities, and more days of symptoms compared to those without depression or anxiety. Conclusion. This research indicates that a multidimensional, integrative approach to health care should be considered when assessing patients with asthma.     

Impact of Depression and Anxiety on Quality of Life,Health Behaviors,and Asthma Control Among Adults in the United States with Asthma, 2006

Background. Psychological factors such as anxiety and depression are increasingly being recognized as influencing the onset and course of asthma. Methods. We obtained Patient Health Questionnaire 8 depression data from 41 states and territories using the 2006 Behavioral Risk Factor Surveillance System. Heath risk behaviors, social and emotional support, life satisfaction, disability, and four health-related quality-of-life (HRQOL) questions were available for all states and territories (n = 18,856 with asthma). Five additional HRQOL questions were asked in three states (n = 1345 persons with asthma), and questions assessing asthma control were available for nine states (n = 3943 persons with asthma). Results. Persons with asthma were significantly more likely than those without asthma to have current depression (19.4% vs. 7.7%), a lifetime diagnosis of depression (30.6% vs. 14.4%), and anxiety (23.5% vs. 10.2%). For most domains examined, there was a dose-response relationship between level of depression severity and mean number of days of impaired HRQOL in the past 30 days, as well as an increased prevalence of life dissatisfaction, inadequate social support, disability, and risk behaviors, such as smoking, physical inactivity, and obesity, among those with asthma. Moreover, depression and anxiety were associated with a decreased level of asthma control, including more visits to the doctor or emergency room, inability to do usual activities, and more days of symptoms compared to those without depression or anxiety. Conclusion. This research indicates that a multidimensional, integrative approach to health care should be considered when assessing patients with asthma.     

Health-Related Quality of Life in Children and Adolescents with Asthma: Results from the ESTAR Study

Our aim was to assess the psychosocial well-being of asthmatic children and adolescents, the influencing factors, and to determine the effect of inpatient rehabilitation on their quality of life; 226 asthmatic children and adolescents participated in the inpatient rehabilitation (IG). The comparison group (CG) included 92 asthmatic children and adolescents receiving standard medical treatments. Patients were aged between 8 and 16 years and were predominantly male. The health-related quality of life was measured with the German version of the “Paediatric Asthma Quality of Life Questionnaire.” Interviews were carried out for IG 2 weeks before the commencement of their inpatient stay and 1 year after their stay ended. The same time schedule was carried out for CG. All patients reported a mild to moderate impairment of their quality of life. Girls described a slightly lower quality of life than boys. With increasing asthma severity, quality of life decreased. Inpatients described a lower quality of life than CG at enrollment. Inpatient rehabilitation resulted in a greater improvement of quality of life over time for IG than for CG. Gender and severity status had no effect on this time course. The only modestly affected quality of life may reflect the good adaptation to the disease and medical treatment. Children and adolescents in the IG recorded improvements in their quality of life. Differences in quality of life based on gender and disease severity were not shown to influence the improvements. In summary, inpatient rehabilitation results in an improvement of health-related quality of life. Further research concerning the psychosocial situation of children and adolescents in this setting is needed.     

Analysis of Single-breath Profiles of Exhaled Nitric Oxide in Children with Allergy and Asthma: Guideline-derived Plateau Concentrations Compared to Results of Automatic Evaluation by Two Analyzers

Current guidelines recommend the single-breath measurement of fractional concentration of exhaled nitric oxide (FE_NO) at the expiratory flow rate of 50 mL/s as a gold standard. The time profile of exhaled FE_NO consists of a washout phase followed by a plateau phase with a stable concentration. This study performed measurements of FE_NO using a chemiluminescence analyzer Ecomedics CLD88sp and an electrochemical monitor NIOX MINO in 82 children and adolescents (44 males) from 4.9 to 18.7 years of age with corticosteroid-treated allergic rhinitis (N = 58) and/or asthma (N = 59). Duration of exhalation was 6 seconds for children less than 12 years of age and 10 seconds for older children. The first aim was to compare the evaluation of FE_NO-time profiles from Ecomedics by its software in fixed intervals of 7 to 10 seconds (older children) and 2 to 4 seconds (younger children) since the start of exhalation (method A) with the guideline-based analysis of plateau concentrations at variable time intervals (method B). The second aim was to assess the between-analyzer agreement. In children over 12 years of age, the median ratio of FE_NO concentrations of 1.00 (95% CI: 0.99–1.02) indicated an excellent agreement between the methods A and B. Compared with NIOX MINO, the Ecomedics results were higher by 11% (95% CI: 1–22) (method A) and 14% (95% CI: 4–26) (method B), respectively. In children less than 12 years of age, the FE_NO concentrations obtained by the method B were 34% (95% CI: 21–48) higher and more reproducible (p < 0.02) compared to the method A. The Ecomedics results of the method A were 11% lower (95% CI: 2–20) than NIOX MINO concentrations while the method B gave 21% higher concentrations (95% CI: 9–35). We conclude that in children less than 12 years of age, the guideline-based analysis of FE_NO–time profiles from Ecomedics at variable times obtains FE_NO concentrations that are higher and more reproducible than those from the fixed interval of 2 to 4 seconds and higher than NIOX MINO concentrations obtained during a short exhalation (6 seconds). The Ecomedics FE_NO concentrations of children more than 12 years of age calculated in the interval of 7 to 10 seconds represent plateau values and agree well with NIOX MINO results obtained during a standard 10-second exhalation.