Asthma diagnosis and treatment: filling in the information gaps

Current approaches to the diagnosis and management of asthma are based on guideline recommendations, which have provided a framework for the efforts. Asthma, however, is emerging as a heterogeneous disease, and these features need to be considered in both the diagnosis and management of this disease in individual patients. These diverse or phenotypic features add complexity to the diagnosis of asthma, as well as attempts to achieve control with treatment. Although the diagnosis of asthma is often based on clinical information, it is important to pursue objective criteria as well, including an evaluation for reversibility of airflow obstruction and bronchial hyperresponsiveness, an area with new diagnostic approaches. Furthermore, there exist a number of treatment gaps (ie, exacerbations, step-down care, use of antibiotics, and severe disease) in which new direction is needed to improve care. A?major morbidity in asthmatic patients occurs with exacerbations and in patients with severe disease. Novel approaches to treatment for these conditions will be an important advance to reduce the morbidity associated with asthma.     

Asthma deaths and the athlete

Asthma has recently become more prevalent, more severe, and more deadly. Approximately 4500 individuals die from asthma annually in the United States, an unacceptable number for a condition that can be managed effectively. Sudden death with exercise may result from a variety of causes, including previously unrecognized cardiac conditions. Asthma has also been recognized as a cause of death in association with sports. Recent data indicate those who suffer from mild to moderate asthma are also at risk for asthma fatality. The absolute magnitude of the increase in risk of death from asthma during sports, however, is very small. For this reason, individuals with asthma should not be discouraged from active participation in sports. Rather, this should reinforce the message that asthma is a condition that may be potentially serious, but can, and should be, well controlled with proper management.     

The Effects of Combining Web-Based eHealth With Telephone Nurse Case Management for Pediatric Asthma Control: A Randomized Controlled Trial

Background

Asthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games.

Objectives

To test the effects of (1) CHESS+CM, a system for parents and children ages 4–12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children.

Methods

We identified eligible parent–child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data.

Results

Of 305 parent–child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child’s Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = –0.31, 95% confidence limits [CL] –0.56, –0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL –0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL –8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM’s effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64).

Conclusions

Integrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00214383","term_id":"NCT00214383"}}NCT00214383; http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00214383","term_id":"NCT00214383"}}NCT00214383 (Archived by WebCite at http://www.webcitation.org/68OVwqMPz)     

An Association Study of 13 SNPs from Seven Candidate Genes with Pediatric Asthma and a Preliminary Study for Genetic Testing by Multiple Variants in Taiwanese Population

Introduction  Asthma is one of the most common chronic diseases in children. It is caused by complex interactions between various genetic factors and exposures to environmental allergens and irritants. Because of the heterogeneity of the disease and the genetic and cultural differences among different populations, a proper association study and genetic testing for asthma and susceptibility genes is difficult to perform. Materials and Methods  We assessed 13 single-nucleotide polymorphisms (SNPs) in seven well-known asthma susceptibility genes and looked for association with pediatric asthma using 449 asthmatic subjects and 512 non-asthma subjects in Taiwanese population. Results  CD14-159 C/T and MS4A2 Glu237Gly were identified to have difference in genotype/allele frequencies between the control group and asthma patients. Moreover, the genotype synergistic analysis showed that the co-contribution of two functional SNPs was riskier or more protective from asthma attack. Our study provided a genotype synergistic method for studying gene–gene interaction on polymorphism basis and genetic testing using multiple polymorphisms. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Asthma exacerbations: origin, effect, and prevention

Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children in the Western world. Despite advances in asthma management, acute exacerbations continue to occur and impose considerable morbidity on patients and constitute a major burden on health care resources. Respiratory tract viruses have emerged as the most frequent triggers for exacerbations in both children and adults; however, the mechanisms underlying these remain poorly understood. More recently, it has become increasingly clear that interactions might exist between viruses and other triggers, increasing the likelihood of an exacerbation. In this article we begin with an overview of the health, economic, and social burden that exacerbations of asthma carry with them. This is followed by a review of the pathogenesis of asthma exacerbations, highlighting the various triggers responsible and multiple interactions that exist between them. The final section first addresses what preventative measures are currently available for asthma exacerbations and subsequently examines which of the new treatments in development might lessen the burden of exacerbations in the future.     

Global Initiative for Asthma (GINA) guidelines: 15 years of application

The Global Initiative for Asthma (GINA), founded in 1993, embodies a network of public health organizations and medical societies, as well as other individuals concerned with asthma. Its first report, published in 1995 and entitled ‘A Global Strategy for Asthma Management and Prevention’, has been widely adopted, providing the foundation for asthma guidelines in many nations across the world. To this effect, the report has not only been translated into several languages but has also been frequently updated. Since its establishment 15 years ago, GINA has undergone two major paradigm shifts. The first was the change in the late 1990s from an opinion- to an evidence-based approach for the management of asthma severity. The second, an even more radical shift, was seen in 2006, when the revised GINA guidelines involved the classification of asthma severity according to the level of control as a guide to treatment. In order to classify asthma control, elements such as the significance of the partnership between the patient and caregiver, patient education, guided self-management and treatment goals were introduced. In addition to compiling guidelines and reports for the management of asthma, GINA is actively involved in organizing and coordinating the World Asthma Day, regional initiatives and GINA symposia. On the whole, during the 15 years since their original publication in 1995, the GINA guidelines have provided the basis for many national asthma strategies around the world. This course is most likely to continue in the future. In this paper, the history of the development of the guidelines and other issues regarding the GINA project will be addressed.     

Asthma, influenza, and vaccination

Exacerbations of asthma in children are usually triggered by virus infections. Many different respiratory viruses are associated with these exacerbations, but influenza viruses are frequently associated with those requiring hospitalization and are the only ones for which specific treatment and prophylaxis are available. Current studies have shown that influenza vaccines are safe for patients with asthma. The efficacy of inactivated influenza vaccines in preventing exacerbations of asthma has been questioned. The live attenuated influenza vaccine has been licensed recently in the United States, and studies have shown it to be safe and protective. A direct comparison of the inactivated and live attenuated influenza vaccines in children with asthma demonstrated superior protection by the latter. Live attenuated influenza vaccine, given by nasal spray, is better accepted by children for annual vaccination and is easier to administer. Universal vaccination of all children in school-based clinics will facilitate control of epidemic influenza and provide an infrastructure for control of future influenza pandemics.