Thorax. 2010 Jul;65(7):612-8. Gershon AS, Wang C, Guan J, To T. Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto Ontario, M4N 3M5, Canada.

Background and aims: Asthma comorbidity, such as depression and obesity, has been associated with greater healthcare use, decreased quality of life and poor asthma control. Treating this comorbidity has been shown to improve asthma outcomes as well as overall health. Despite this, asthma comorbidity remains relatively under-recognised and understudied-perhaps because most asthma occurs in young people who are believed to be healthy and relatively free of comorbidity. The aim of this study was to quantify empirically the amount of comorbidity associated with asthma.

Methods: A population-based cohort study was conducted using the health administrative data of the 12 million residents of Ontario, Canada in 2005. A validated health administrative algorithm was used to identify individuals with asthma.

Results: The amount of comorbidity among individuals with asthma, as reflected in rates of hospitalisations, emergency department visits and ambulatory care claims, was found to be substantial and much greater than that observed among individuals without asthma. Together, asthma and asthma comorbidity (the extra comorbidity found in individuals with asthma compared with those without asthma) were associated with 6% of all hospitalisations, 9% of all emergency room visits and 6% of all ambulatory care visits that occurred in Ontario.

Conclusions: Asthma comorbidity places a significant burden on individuals and the healthcare system and should be considered in the management of asthma. Further research should focus on which types of asthma comorbidity are responsible for the greatest burden and how such comorbidity should be prevented and managed.

Lung Function Impairment Evidenced by Sequential Specific Airway Resistance in Childhood Persistent Asthma: A Longitudinal Study.

J Asthma. 2010 Jul 9. Mahut B, Trinquart L, Bokov P, Peiffer C, Delclaux C. 1Cabinet La Berma, Antony, France.

Background: Specific airway resistance (sRaw) is virtually independent of lung growth, height, and gender, thus facilitating longitudinal follow-up.

Objective: To assess whether a specific phenotype of asthmatic children with a decline in lung function can be evidenced using sRaw.

Methods: The authors hypothesized that sequential sRaw measurements over a long period would detect subtle trends. Clinical and functional data of children with persistent asthma under inhaled corticosteroids, evaluated at least three times per year for at least 4 years, were retrieved from a database.

Results: One hundred fourteen children (30 girls) were followed for (median [interquartile range]) 6.9 years [5.6-7.9]. Data from 1699 measurements of sRaw (median 14/child) allowed the calculation of individual slopes of sRaw plotted against time demonstrating stable values in the group as a whole between 4 and 18 years. A positive correlation between individual slopes and the degree of intraindividual variation of sRaw was observed (R(2) = .16; p < .0001). Children with more than one positive skin test showed larger intrasubject variation of sRaw (p = .011). In 19/114 children (17%), a significant increase in sRaw of 12.3% per year (median) was observed. As compared to children without, those with a significant increase in sRaw were boys (p < .0001), had a lower initial (p = .008) and a higher final resistance (p = .025) but did not differ in terms of inhaled corticosteroid dose.

Conclusion: This retrospective study identifies a specific phenotype of asthmatic children that develops an impairment of lung function, confirming the results of a post hoc analysis of the Childhood Asthma Management Program study.

Impact of Rhinitis on Asthma Control in Children: Association With FeNO.

J Asthma. 2010 Jul 14. Chiron R, Vachier I, Khanbabaee G, Molinari N, Varrin M, Godard P, Chanez P. Department of Respiratory Diseases, CHU Montpellier, Hospital Arnaud de Villeneuve, Montpellier, France.

Background: The prevalence of rhinitis is high and frequently observed in association with asthma. Although the persistence of predisposing factors such as rhinitis is frequently observed in adults, this has not yet been confirmed in children.

Aims: The aim of this present work is to show the relationship between rhinitis and asthma control in asthmatic children.

Methods: The authors carried out a cross-sectional study by collecting clinical, spirometric, and fractional exhaled nitric oxide (FeNO) data in children aged from 4 to 17 years.

Results: One hundred seventeen children were included. Asthma control was optimal in 37.6%, suboptimal in 55.5% and poor in 7.3% of cases. A 74.3% of children were atopic and 62.5% had symptoms 34 of rhinitis. Rhinitis was more frequent when control of asthma was worse (p = .0001). Age (p = .002), asthma control (p < .001), atopy (p = .001), and presence of rhinitis (p = .012) were significantly associated with FeNO.

Conclusions: Our study confirms the strong relationship between upper airways and poor asthma control in the asthmatic child. Symptoms of rhinitis may be partly responsible for the increased fractional exhaled nitric oxide (FeNO) level, independently of the control of asthma. Evaluation of rhinitis should be included to improve assessment of asthma control in children.

Determinants of Exhaled Nitric Oxide Levels (FeNO) in Childhood Atopic Asthma: Evidence for Neonatal Respiratory Distress as a Factor Associated With Low FeNO Levels.

J Asthma. 2010 Jul 14 Ricciardolo FL, Silvestri M, Pistorio A, Strozzi MM, Tosca MA, Bellodi SC, Battistini E, Gardella C, Rossi GA. Pulmonary and Allergy Disease Paediatric Unit, G. Gaslini Institute, Genoa, Italy.

Background: In allergic asthmatic children exhaled nitric oxide (FeNO) levels are related to eosinophilic inflammation by correlation analysis. Whether FeNO can be modified by factors potentially influencing the natural history of asthma in early life is not known.

Objective: To evaluate the frequency of anamnestic factors influencing the natural history of asthma and to identify potential determinants for elevated or low FeNO levels by multivariate analysis.

Methods: One hundred seventy-one children with mild-moderate asthma were stratified according to their FeNO levels into three groups: low (<20 ppb), mid (20-40 ppb), and high (>40 ppb). The frequency of nine anamnestic factors together with indices of allergic sensitization (total and allergen-specific immunoglobulin E [IgE], blood eosinophil counts) and of airflow limitation (forced expiratory volume in one second [FEV(1)]% predicted) were evaluated.

Results: Among factors related to the patient history, neonatal respiratory distress was reported only in children with low FeNO levels, whereas this factor was never reported in children with mid-to-high FeNO levels (p = .008). As compared with low FeNO group, mid and high FeNO groups showed higher eosinophil counts and a tendency to have lower FEV(1) values. By multivariate analysis, four factors (eosinophils >300 cells/mm(3), cat-specific IgE, house dust mites [HDM]-specific IgE, FEV(1) </=86% predicted) turned out to be significantly associated with mid-high FeNO levels and two factors (eosinophils >600 cells/mm(3), total IgE >355 kU/L) with high FeNO levels.

Conclusions: Besides confirming the well-known tight association between blood eosinophilia and/or allergic sensitization and FeNO, these data provide new evidence for neonatal respiratory distress as potential factor associated with low FeNO levels in childhood atopic asthma

Asthma control and activity limitations: insights from the Real-world Evaluation of Asthma Control and Treatment (REACT) study.

Ann Allergy Asthma Immunol. 2010 Jun;104(6):471-7. Haselkorn T, Chen H, Miller DP, Fish JE, Peters SP, Weiss ST, Jones CA. Genentech, Inc., South San Francisco, California 94080, USA.

BACKGROUND: Uncontrolled asthma remains prevalent in the United States and confers a substantial burden on the health care system.

OBJECTIVES: To evaluate the association between uncontrolled asthma and activity limitations in a nationally representative sample of patients with moderate-to-severe-treated asthma and to assess the degree to which demographics and comorbidities were associated with activity limitations.

METHODS: Patients who participated in the Real-world Evaluation of Asthma Control and Treatment study were surveyed regarding type and degree of activity limitations in 4 categories: outdoor activity, physical activity, daily activity, and environmental triggers. Information about asthma control, demographics, and comorbidities was collected. Multivariable regression was used to assess the association between uncontrolled asthma and activity limitations while adjusting for demographic characteristics and comorbid conditions.

RESULTS: Uncontrolled asthma was associated with a greater than 2-fold risk of outdoor (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.90-3.51) or physical (OR, 2.62; 95% CI, 1.90-3.61) activity limitations and a 66% increased risk of daily activity limitations (OR, 1.66; 95% CI, 1.09-2.51). Comorbidities associated with activity limitation included hives, chronic sinusitis, arthritis, gastroesophageal reflux disease, hypercholesterolemia, and depression. The observed associations between uncontrolled asthma and activity limitation remained significant after controlling for demographic characteristics and comorbid conditions.

CONCLUSIONS: Compared with patients with controlled asthma, those with uncontrolled asthma are at higher risk for limitations in outdoor activity, physical activity, and daily activity. To help patients achieve optimal health, asthma management should include routine assessment of activity limitations and assessment and coordinated care for comorbid conditions.

Reducing consumption of sugar-sweetened beverages is associated with reduced blood pressure: a prospective study among United States adults.

Circulation. 2010 Jun 8;121(22):2398-406. Chen L, Caballero B, Mitchell DC, Loria C, Lin PH, Champagne CM, Elmer PJ, Ard JD, Batch BC, Anderson CA, Appel LJ. Program of Epidemiology, School of Public Health, Louisiana State University Health Science Center, New Orleans, LA 70112, USA.

BACKGROUND: Increased consumption of sugar-sweetened beverages (SSBs) has been associated with an elevated risk of obesity, metabolic syndrome, and type II diabetes mellitus. However, the effects of SSB consumption on blood pressure (BP) are uncertain. The objective of this study was to determine the relationship between changes in SSB consumption and changes in BP among adults.

METHODS AND RESULTS: This was a prospective analysis of 810 adults who participated in the PREMIER Study (an 18-month behavioral intervention trial). BP and dietary intake (by two 24-hour recalls) were measured at baseline and at 6 and 18 months. Mixed-effects models were applied to estimate the changes in BP in responding to changes in SSB consumption. At baseline, mean SSB intake was 0.9+/-1.0 servings per day (10.5+/-11.9 fl oz/d), and mean systolic BP/diastolic BP was 134.9+/-9.6/84.8+/-4.2 mm Hg. After potential confounders were controlled for, a reduction in SSB of 1 serving per day was associated with a 1.8-mm Hg (95% confidence interval, 1.2 to 2.4) reduction in systolic BP and 1.1-mm Hg (95% confidence interval, 0.7 to 1.4) reduction in diastolic BP over 18 months. After additional adjustment for weight change over the same period, a reduction in SSB intake was still significantly associated with reductions in systolic and diastolic BPs (P<0.05). Reduced intake of sugars was also significantly associated with reduced BP. No association was found for diet beverage consumption or caffeine intake and BP. These findings suggest that sugars may be the nutrients that contribute to the observed association between SSB and BP.

CONCLUSIONS: Reduced consumption of SSB and sugars was significantly associated with reduced BP. Reducing SSB and sugar consumption may be an important dietary strategy to lower BP.

Increased risk of myocardial infarction and stroke following exacerbation of COPD.

Chest. 2010 May;137(5):1091-7. Donaldson GC, Hurst JR, Smith CJ, Hubbard RB, Wedzicha JA. Academic Unit of Respiratory Medicine, Royal Free and University College Medical School, University College London, Rowland Hill Street, London, NW3 2PF, England.

OBJECTIVE: Patients with COPD are at risk for cardiovascular events. This is attributed to increased systemic inflammation. The course of COPD is punctuated by exacerbations, which further increase systemic inflammation, but the risk of vascular events in the postexacerbation period has never been defined.

METHODS: We analyzed data from 25,857 patients with COPD entered in The Health Improvement Network database over a 2-year period. Exacerbations were defined using a health-care use definition of prescription of oral corticosteroids > 20 mg/d and/or selected oral antibiotics. The risk of myocardial infarction (MI) and stroke in the postexacerbation period was calculated relative to the patient's baseline risk using the self-controlled case series approach.

RESULTS: We identified 524 MIs in 426 patients and 633 ischemic strokes in 482 patients. The incidence rates of MI and stroke were 1.1 and 1.4 per 100 patient-years, respectively. There was a 2.27-fold (95% CI, 1.1-4.7; P = .03) increased risk of MI 1 to 5 days after exacerbation (defined by prescription of both steroids and antibiotics). This relative risk diminished progressively with time and was not significantly different from the baseline MI risk at any other postexacerbation time interval. One in 2,513 exacerbations was associated with MI within 1 to 5 days. There was a 1.26-fold (95% CI, 1.0-1.6; P = .05) increased risk of stroke 1 to 49 days after exacerbation.

CONCLUSION: The results suggest that exacerbations of COPD increase the risk of MI and stroke. This may have implications for therapy in both stable and exacerbated COPD.

Asthma and cigarette smoking: a review of the empirical literature.

J Asthma. 2010 May;47(4):345-61. McLeish AC, Zvolensky MJ. Department of Psychology, University of Cincinnati, Cincinnati, Ohio 45221-0376, USA.

The purpose of this review paper is to present and evaluate the empirical literature on the association between asthma and cigarette smoking. The authors conducted a literature search utilizing electronic search engines (i.e., PsycINFO and MEDLINE) to examine databases using the following key word algorithms: smoking OR nicotine OR tobacco AND asthma. Only articles that focused on active tobacco smoking and analyzed groups with asthma patients only were examined in the present review.

Overall, empirical evidence suggests that

(1) smoking is more prevalent among individuals with asthma than those without;

(2) smoking is a risk candidate for the development of asthma;

(3) smoking is associated with decreased asthma control and increased risk of mortality and asthma attacks and exacerbations;

(4) smokers with and without asthma may have different risk factors for smoking onset as well as different smoking motives and outcome expectancies; and

(5) smoking cessation is associated with improvements in lung functioning and asthma symptoms.

Future work in this domain of study will lead to clinically relevant health care advances as well as the development of theoretically driven, methodologically diverse lines of research exploring asthma-smoking comorbidity issues.

Asthma patients who smoke have signs of chronic airflow limitation before age 45.

J Asthma. 2010 May;47(4):362-6. Harmsen L, Gottlieb V, Makowska Rasmussen L, Backer V. Respiratory and Allergy Research Unit, Department of Respiratory Medicine L, Copenhagen University Hospital Bispebjerg, Denmark.

BACKGROUND: The frequency of smokers among asthma patients often mirrors the frequency of smokers among healthy individuals. Smoking has been shown to increase the lung function decline in adult asthma patients and change the composition of the bronchial inflammation.

OBJECTIVE: To examine the consequences of smoking in a large cohort of young asthma patients.

METHODS: Seven hundred ninety-three asthma patients, aged 14 to 44, were examined using lung function measurements, bronchial provocations, clinical interviews, and questionnaires.

RESULTS: Forty-five percent of participants were smokers; smokers had significantly lower forced expiratory volume in one second (FEV(1)), FEV(1) in percent of predicted value (FEV(1)% pred), and FEV(1)/forced vital capacity (FVC) values compared with nonsmokers, and there was a dose-response relationship between tobacco exposure and these lung function measures. Smoking seemingly affected the FEV(1) growth already in adolescence, and before the age of 45, significantly more smokers than nonsmokers had signs of airflow limitation, with FEV(1)/FVC ratios below 0.70. Smokers had more asthma symptoms despite receiving inhaled corticosteroid (ICS) treatment as frequently as did nonsmokers.

CONCLUSION: The additive effect of smoking on lung function decline in asthma patients is detectable at early ages and leads to signs of airflow limitation before the age of 45 years.

Exercise is associated with improved asthma control in adults.

Eur Respir J. 2010 Jun 7. Dogra S, Kuk JL, Baker J, Jamnik V. Health and Performance Laboratory Lifespan, Health and Performance Laboratory.

Asthma control levels are suboptimal. The influence of regular exercise on asthma control is unclear. We assessed the effects of a 12-week supervised exercise intervention followed by 12-weeks of self-administered exercise on adults with partly controlled asthma (n=21) compared to matched controls (n=15). Assessments were conducted at baseline and week 12 for both the exercise and control group and again at week 24 for the exercise group. There was a significant treatment effect in the exercise group for asthma control as measured by the Asthma Control Questionnaire (ACQ) from baseline to week 12 compared to control. A clinically significant improvement (0.5 increase) was observed for asthma quality of life and ACQ in the exercise group from baseline to week 12. There was a significant improvement in aerobic fitness from baseline to week 24 in the exercise group.

In conclusion, a 12-week supervised exercise intervention led to improvements in asthma control and quality of life in partially controlled asthmatics motivated to exercise. These improvements were maintained, while aerobic fitness and perceived asthma control significantly improved over an additional 12 weeks of self-administered exercise. These findings indicate that a structured exercise intervention can improve asthma control

Particle size matters: diagnostics and treatment of small airways involvement in asthma.

Eur Respir J. 2010 Jul 1 Cohen J, Postma DS, Douma WR, Vonk JM, De Boer AH, Ten Hacken NH. University Medical Center Groningen, University of Groningen PO Box 30001, 9700 RB Groningen the Netherlands.

Small airways are an important site of inflammation and obstruction in asthma, which contributes to the severity of airway hyperresponsiveness (AHR) that is usually measured by nebulisation of large-particle stimuli. We investigated whether small and large particle sizes of aerosolized adenosine-'5-monophospate (AMP) provide similar severity of AHR. Additionally, effects of small-particle ICS ciclesonide and large-particle ICS fluticasone on AHR to large- and small-particle size AMP were assessed. After a 4-week run-in period using open-label fluticasone 100 mug b.i.d., 37 mild-to-moderate asthmatics underwent provocations with standard size (3.7 micron), large-particle (9.9 micron) and small-particle (1.06 micron) AMP. Subjects received 4-week ciclesonide 160 mug s.i.d. or fluticasone 100 mug b.i.d. (double-blind, double-dummy) followed by large- and small-particle AMP provocation. Small-particle AMP induced a 20% fall in FEV1 (PC20) at a significantly higher dose than large-particle AMP. Ciclesonide and fluticasone had comparable effects on AMP provocations. Not all subjects reached a PC20 at the highest AMP dose. In those who did, ciclesonide improved small-particle PC20AMP by 1.74 doubling doses (DD) (p=0.03), whereas fluticasone did not. Conversely, fluticasone improved large-particle PC20AMP significantly (1.32DD, p=0.03), whereas ciclesonide did not. Small-particle AMP provocation appears a promising tool to assess changes in small airways inflammation.

Future adjustments are necessary taking into account the very small-particle size used, with large exhaled fractions. In asthmatics reaching a PC20 with small- and large-particle AMP provocations, ciclesonide improves hyperresponsiveness with small-particle size AMP, and fluticasone with large-particle size. This warrants further research to target provocations and treatment to specific airway sizes.

Problematic severe asthma in children, not one problem but many: a GA2LEN initiative.

Eur Respir J. 2010 Jul;36(1):196-201. Hedlin G, Bush A, Lødrup Carlsen K, Wennergren G, De Benedictis FM, Melén E, Paton J, Wilson N, Carlsen KH; Problematic Severe Asthma in Childhood Initiative group. Baraldi E et al. Collaborators (23) Astrid Lindgren Children's Hospital, Q2:05, Karolinska University Hospital, 17176 Stockholm, Sweden.

Although most children with asthma are easy to treat with low doses of safe medications, many remain symptomatic despite every therapeutic effort. The nomenclature regarding this group is confusing, and studies are difficult to compare due to the proliferation of terms describing poorly defined clinical entities.

In this review of severe asthma in children, the term problematic severe asthma is used to describe children with any combination of chronic symptoms, acute severe exacerbations and persistent airflow limitation despite the prescription of multiple therapies.

The approach to problematic severe asthma may vary with the age of the child, but, in general, three steps need to be taken in order to separate difficult-to-treat from severe therapy-resistant asthma. First, confirmation that the problem is really due to asthma requires a complete diagnostic re-evaluation. Secondly, the paediatrician needs to systematically exclude comorbidity, as well as personal or family psychosocial disorders. The third step is to re-evaluate medication adherence, inhaler technique and the child's environment.

There is a clear need for a common international approach, since there is currently no uniform agreement regarding how best to approach children with problematic severe asthma. An essential first step is proper attention to basic care.

Preventing Diabetic Foot Ulcer Recurrence in High-Risk Patients
Use of temperature monitoring as a self-assessment tool

Diabetes Care 2007;30 14-20 Lawrence A. Lavery, Kevin R. Higgins, Dan R. Lanctot, George P. Constantinides, Ruben G. Zamorano, Kyriacos A. Athanasiou, David G. Armstrong, C. Mauli Agrawal OBJECTIVE—The purpose of this study was to evaluate the effectiveness of a temperature monitoring instrument to reduce the incidence of foot ulcers in individuals with diabetes who have a high risk for lower extremity complications.

RESEARCH DESIGN AND METHODS—In this physician-blinded, randomized, 15-month, multicenter trial, 173 subjects with a previous history of diabetic foot ulceration were assigned to standard therapy, structured foot examination, or enhanced therapy groups. Each group received therapeutic footwear, diabetic foot education, and regular foot care. Subjects in the structured foot examination group performed a structured foot inspection daily and recorded their findings in a logbook. If standard therapy or structured foot examinations identified any foot abnormalities, subjects were instructed to contact the study nurse immediately. Subjects in the enhanced therapy group used an infrared skin thermometer to measure temperatures on six foot sites each day. Temperature differences >4°F (>2.2°C) between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized.

RESULTS—The enhanced therapy group had fewer foot ulcers than the standard therapy and structured foot examination groups (enhanced therapy 8.5 vs. standard therapy 29.3%, P = 0.0046 and enhanced therapy vs. structured foot examination 30.4%, P = 0.0029). Patients in the standard therapy and structured foot examination groups were 4.37 and 4.71 times more likely to develop ulcers than patients in the enhanced therapy group.

CONCLUSIONS—Infrared temperature home monitoring, in serving as an "early warning sign," appears to be a simple and useful adjunct in the prevention of diabetic foot ulcerations.

Association of Obstructive Sleep Apnea Risk with Asthma Control in Adults.

Chest. 2010 May 21 Teodorescu M, Polomis DA, Hall SV, Teodorescu MC, Gangnon RE, Peterson AG, Xie A, Sorkness CA, Jarjour NN. Medical Service, William S. Middleton Memorial Veteran's Hospital;

BACKGROUND: Unrecognized obstructive sleep apnea (OSA) may lead to poor asthma control despite optimal therapy. Our objective was to evaluate the relationship between OSA risk and asthma control in adults.

METHODS: Asthma patients at routine tertiary care clinic visits completed the validated Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ) and Asthma Control Questionnaire (ACQ). ACQ >/=1.5 defined not well controlled asthma, and SA-SDQ >/=36 for men and >/=32 for women defined high OSA risk. Logistic regression was used to model associations of high OSA risk with not well controlled asthma (ACQ full and short versions).

RESULTS: Among 472 subjects with asthma, the mean ACQ (full version) score was 0.87+/-0.90 and 80 subjects (17%) were not well controlled. Mean SA-SDQ score was 27+/-7, and 109 subjects (23%) met the definition of high OSA risk. High OSA risk was associated on average with 2.87 times higher odds for not well controlled asthma (ACQ full version) (95% confidence interval [1.54-5.32], p=0.0009), after adjusting for obesity and other factors known to worsen asthma control. Similar independent associations were seen when using the short ACQ versions.

CONCLUSIONS: High OSA risk is significantly associated with not well controlled asthma, independent of known asthma aggravators and regardless of the ACQ version used. Patients who have difficulty achieving adequate asthma control should be screened for OSA.

First trimester maternal tobacco smoking habits and fetal growth.

Thorax. 2010 Mar;65(3):235-40. Prabhu N et al. Academic Child Health, University of Aberdeen, Aberdeen AB25 2ZG, UK.

RATIONALE: Maternal smoking in pregnancy is associated with reduced birth weight and childhood lung function. This study determined when maternal smoking first influences fetal growth and how this relates to childhood respiratory outcomes.

METHODS: A longitudinal cohort of 1924 pregnant women was recruited. Fetal ultrasound measurements at 11 weeks (crown-rump length, CRL) and at 20 weeks gestation (femur length, FL, and biparietal diameter, BPD) and birth measurements were recorded. Childhood respiratory symptoms and spirometry were ascertained.

RESULTS: Of the 1924 original study participants, fetal size was determined in 903 in the first trimester, 1544 in the second trimester and at term in 1737 infants. Maternal smoking when first pregnant was reported in 593 (31%) and was not associated with reduced CRL. There was an inverse exposure-response relationship between cigarette consumption and FL (mean reduction in lowest compared with highest tertile 0.91 cm, p=0.033). Birth weight and length of those born to mothers who did (n=331) and did not (n=56) reduce cigarette consumption were similar and reduced compared with 186 infants whose mothers quit during the first trimester (p < or = 0.020). Children of mothers who continued smoking had increased wheeze at age 2 years (OR 1.58, p=0.017) and GP visits with wheeze at age 5 years (OR 2.18, p=0.030) and mean reduction in forced expiratory volume in 1 s of 62 ml (p=0.014) compared with controls.

CONCLUSIONS: Maternal smoking is associated with reduced fetal measurements in the second and third trimesters but not in the first trimester. Mothers who do not quit smoking during the first trimester deliver smaller infants who go on to have adverse respiratory outcomes in childhood.

Effect of maternal moderate to severe asthma on perinatal outcomes.

Respir Med. 2010 Apr 14 Firoozi F, Lemière C, Ducharme FM, Beauchesne MF, Perreault S, Bérard A, Ferreira E, Forget A, Blais L. Université de Montréal, Québec, Canada.

BACKGROUND/OBJECTIVES: It has been reported that adverse fetal outcomes are more prevalent in pregnant women with asthma than they are in women without asthma. In our study, we investigated the effect that the severity of asthma during pregnancy has on the risk of a small for gestational age (SGA) infant, low birth weight (LBW), and preterm birth.

METHODS: A population-based cohort of 13,007 pregnancies from asthmatic women was reconstructed through the linking of three of Quebec's (Canada) administrative databases covering the period between 1990 and 2002. A two-stage sampling cohort design was used to collect additional information on the selected women's life-style habits via a mailed questionnaire. Asthma severity during pregnancy was measured with a validated database index. A logistic regression model was used to obtain the adjusted odds ratios of SGA, LBW and preterm birth as a function of the level of asthma severity.

RESULTS: The proportions of women with mild, moderate and severe asthma were 82.5%, 12.5% and 5.0%, respectively. We sent 3,168 questionnaires to selected women, with a 40.2% (n=1274) response rate. Final estimates showed that the risk of SGA was significantly higher among severe (OR:1.48, 95%CI: 1.15-1.91) and moderate asthmatic women (OR: 1.30, 95%CI:1.10-1.55) than mild asthmatic women. No significant associations were found between asthma severity, preterm birth and LBW.

CONCLUSIONS: Mothers with severe and moderate asthma during pregnancy have a higher risk of SGA babies than those with mild asthma

A randomized controlled trial to evaluate the effectiveness of a distance asthma learning program for pediatricians.

J Asthma. 2010 Apr;47(3):245-50. Le TT, Rait MA, Jarlsberg LG, Eid NS, Cabana MD. Department of Pediatrics, University of Louisville, Louisville, Kentucky, USA.

OBJECTIVES: To assess provider acceptability of a distance learning program for pediatric asthma and pilot test its effects on physician knowledge, attitudes and treatment practices. DESIGN: Randomized controlled trial.

SETTING: Louisville and the surrounding central Kentucky region. PARTICIPANTS: Twenty-four pediatricians in clinical practice. Interventions. A distance learning program for pediatric asthma consisting of Web- or CD-ROM-based multimedia learning modules and two teleconference calls.

OUTCOME MEASURES: Learner satisfaction and change in physician asthma knowledge, attitudes, and treatment behavior at 1 to 4 months (short term) and 6 to 8 months (long term).

RESULTS: Pediatricians had graduated from medical school a mean of 11.6 years before baseline (SD +/-8.9); 56% were female. On all learner satisfaction items, the average score was a 4.0 or greater on a 5-point scale, indicating a favorable response from the participants. Participants in the education group reported increased familiarity with asthma guideline for prescribing daily-inhaled corticosteroids compared to control physicians (p = .03) at short-term follow-up. Participants also expressed increased confidence in selecting a medicine for patients requiring a low-dose inhaled steroid (p = .03). However, these differences were not seen at long-term follow-up. Compared to the control group, there was no significant increase in the proportion of patients receiving inhaled steroids for persistent asthma at short- or long-term follow-up.

CONCLUSIONS: Pediatricians utilizing an asthma distance learning program expressed a high degree of learner satisfaction. The program was associated with a temporary increase in familiarity and confidence in implementing components of the asthma guidelines.

Children with nocturnal asthma wheeze intermittently during sleep.

J Asthma. 2010 Apr;47(3):290-4. Boner AL, Piacentini GL, Peroni DG, Irving CS, Goldstein D, Gavriely N, Godfrey S. Department of Pediatrics, University of Verona, Verona, Italy.

Nocturnal asthma indicates poor overall control of asthma and adversely affects the quality of life of the patient. The purpose of the present study was to compare the objective measurement of nocturnal wheeze with clinical state, recall of symptoms, and changes in lung function. Nine asthmatic children aged 9 to 16 years were followed with an asthma diary and diurnal measurement of peak flow for a week before the nocturnal study; all but two were apparently well controlled. Breath sounds were recorded and analyzed continuously overnight to quantify wheeze using a phonopneumography sensor attached over the trachea. The analytical system (PulmoTrack) utilized an algorithm to detect wheeze and reject interference. The wheeze rate (Tw/Ttot = duration of wheeze/duration of recording) was calculated minute by minute throughout the night. Recordings lasted over 8 hours and all but two children had wheeze lasting for a total time of between 11 and 87 minutes. The pattern of wheezing was very variable during sleep, with episodes of wheeze separated by periods of quiet breathing. There was no relationship between subjective perception of nocturnal asthma, forced expiratory volume in 1 s (FEV(1)) next morning, and the objective measurement of wheeze. Total overnight wheeze was significantly related to the total diary symptom score and to the (small) diurnal variability of peak expiratory flow (PEF). Four of the seven children with asthma who were apparently well controlled had considerable amounts of wheeze during the night that was episodic in nature and unrelated to conventional measures of lung function or nocturnal symptoms.

The Child Asthma Link Line: a coalition-initiated, telephone-based, care coordination intervention for childhood asthma.

J Asthma. 2010 Apr;47(3):303-9. Coughey K, Klein G, West C, Diamond JJ, Santana A, McCarville E, Rosenthal MP. Department of Research and Evaluation, Public Health Management Corporation, Philadelphia, Pennsylvania, USA.

BACKGROUND: Childhood asthma is a complex chronic disease that poses significant challenges regarding management, and there is evidence of disparities in care. Many medical, psychosocial, and health system factors contribute to recognized poor control of this most prevalent illness among children, with resultant excessive use of emergency departments and hospitalizations for care. Recent national guidelines emphasize the need for community-based initiatives to address these critical issues. To address health system fragmentation and impact asthma outcomes, the Philadelphia Allies Against Asthma coalition developed and implemented the Child Asthma Link Line, a telephone-based care coordination and system integration program, which has been in operation since 2001. This study evaluates the effectiveness of the Child Asthma Link Line integration model to improve asthma management by measuring utilization markers of morbidity.

METHODS: Medicaid Managed Care Organization claims data for 59 children who received the Link Line intervention in 2003 are compared to a matched sample of 236 children who did not receive the Link Line intervention. Children in the two study groups are ages 3 through 12 years and matched on 2003 emergency department visits, age, gender, and race/ethnicity. Primary outcome variables analyzed in this study are emergency department visits, hospitalizations, and office visit claims from the follow-up year (2004).

RESULTS: Link Line intervention children were significantly less likely to have follow-up hospitalizations than matched sample children (p = .02). Children enrolled in the Link Line were also more likely to attend outpatient office visits in the follow-up year (p = .045). In addition, Link Line children with multiple emergency department visits in 2003 were significantly less likely to have an emergency department visit in 2004 (p = .046).

CONCLUSION: This coalition-developed, telephone-based, system-level intervention had a significant impact on childhood asthma morbidity as measured by utilization endpoints of follow-up hospitalizations and emergency department visits. Telephone-based care coordination and service integration may be a viable and economic way to impact childhood asthma and other chronic diseases.

Blood pressure and vascular calcification

Hypertension. 2010 Apr;55(4):990-7. Jensky NE, Criqui MH, Wright MC, Wassel CL, Brody SA, Allison MA Departments of Family and Preventive Medicine, University of California San Diego, La Jolla, Calif 92037, USA.

The aim of this study was to determine the associations between the presence and extent of calcified atherosclerosis in multiple vascular beds and systolic blood pressure, diastolic blood pressure, pulse pressure, mean arterial pressure, isolated systolic hypertension, and hypertension. A total of 9510 patients (42.5% women) underwent electron beam computed tomography scanning as part of a routine health maintenance screening. At the same visit, blood pressure was measured with the participant in the seated position using a mercury sphygmomanometer. Mean age was 58+/-11.4 years, and body mass index was 27.1+/-4.5. The prevalences of any calcification in the carotids, coronaries, subclavians, thoracic aorta, abdominal aorta, and iliacs were 31.9%, 57.2%, 31.7%, 37.0%, 54.3%, and 48.8%, respectively. In separate multivariable logistic models containing traditional cardiovascular disease risk factors, pulse pressure and systolic blood pressure were significantly associated with the presence of calcification in all of the vascular beds except the iliacs and subclavians, respectively, with pulse pressure having stronger magnitudes of the associations for most of the vascular beds. Age-stratified analyses indicated that these associations were stronger in those >60 years of age compared with subjects <60 years of age, and sex-stratified analyses demonstrated that men had a greater association compared with women. Also, the magnitudes of the associations for isolated systolic hypertension were, in general, larger than those for hypertension.

Pulse pressure and isolated systolic hypertension are robust and important correlates for calcified atherosclerosis in different vascular beds. Isolated systolic hypertension may be clinically relevant in diagnosing or preventing calcified atherosclerosis.

Short-term Associations between Ambient Air Pollutants and Pediatric Asthma Emergency Department Visits.

Am J Respir Crit Care Med. 2010 Apr 8 Strickland MJ, Darrow LA, Klein M, Flanders WD, Sarnat JA, Waller LA, Sarnat SE, Mulholland JA, Tolbert PE Department of Environmental and Occupational Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States.

RATIONALE: Certain outdoor air pollutants cause asthma exacerbations in children. To advance understanding of these relationships, further characterization of the dose-response and pollutant lag effects are needed, as are investigations of pollutant species beyond the commonly measured criteria pollutants.

OBJECTIVES: Investigate short-term associations between ambient air pollutant concentrations and emergency department visits for pediatric asthma.

METHODS: Daily counts of emergency department visits for asthma or wheeze among children age 5â17 were collected from 41 Metropolitan Atlanta hospitals during 1993â2004 (n = 91,386 visits). Ambient concentrations of gaseous pollutants and speciated particulate matter were available from stationary monitors during this time period. Rate ratios for the warm season (MayâOctober) and cold season (NovemberâApril) were estimated using Poisson generalized linear models in the framework of a case-crossover analysis.

MEASUREMENTS AND MAIN RESULTS: Both ozone and primary pollutants from traffic sources were associated with emergency department visits for asthma or wheeze; evidence for independent effects of ozone and primary pollutants from traffic sources were observed in multipollutant models. These associations tended to be of the highest magnitude for concentrations on the day of the emergency department visit and were present at relatively low ambient concentrations.

CONCLUSIONS: Even at relatively low ambient concentrations, ozone and primary pollutants from traffic sources independently contributed to the burden of emergency department visits for pediatric asthma.

Validation of an electronic version of the Mini Asthma Quality of Life Questionnaire.

Respir Med. 2010 Mar 10. Olajos-Clow J, Minard J, Szpiro K , Juniper EF, Turcotte S, Jiang X, Jenkins B, Lougheed MD Clinical Research Centre, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario, Canada K7L 2V7; Queen's University, Kingston, ON, Canada.

BACKGROUND: The Mini Asthma Quality of Life Questionnaire (MiniAQLQ) is a validated disease-specific quality of life (QOL) paper (p) questionnaire. Electronic (e) versions enable inclusion of asthma QOL in electronic medical records and research databases.

PURPOSE: To validate an e-version of the MiniAQLQ, compare time required for completion of e- and p-versions, and determine which version participants prefer.

METHODS: Adults with stable asthma were randomized to complete either the e- or p-MiniAQLQ, followed by a 2-h rest period before completing the other version. Agreement between versions was measured using the intraclass correlation coefficient (ICC) and Bland-Altman analysis.

RESULTS: Two participants with incomplete p-MiniAQLQ responses were excluded. Forty participants (85% female; age 47.7 ± 14.9 years; asthma duration 22.6 ± 16.1 years; FEV(1) 87.1 ± 21.6% predicted) with both AQLQ scores <6.0 completed the study. Agreement between e- and p-versions for the overall score was acceptable (ICC=0.95) with no bias (difference (Delta) p-e=0.1; P=0.21). ICCs for the symptom, activity limitation, emotional function and environmental stimuli domains were 0.94, 0.89, 0.90, and 0.91 respectively. A small but significant bias (Delta=0.3; P=0.004) was noted in the activity limitation domain. Completion time was significantly longer for the e-version (3.8 ± 1.9min versus 2.7 ± 1.1min; P<0.0001). The majority of patients (57.5%) preferred the e-MiniAQLQ; 35% had no preference.

CONCLUSION: This e-version of the MiniAQLQ is valid and was preferred by most participants despite taking slightly longer to complete. Generalizabilty may be limited in younger (12-17) and older (>65) adults

Predictors of Uncontrolled Asthma in Adult and Pediatric Patients: Analysis of the Asthma Control Characteristics and Prevalence Survey Studies (ACCESS).

J Asthma. 2010 Mar 8. Stanford RH, Gilsenan AW, Ziemiecki R, Zhou X, Lincourt WR, Ortega H. 1Department of Health Outcomes, GlaxoSmithKline, Research Triangle Park, North Carolina, USA.

Background; Despite the availability of effective asthma treatments and evidence-based management guidelines focusing on asthma control, many patients have asthma that is inadequately controlled. The objective of this analysis was to identify risk factors for uncontrolled asthma among adult and pediatric patients.

Methods; Two cross-sectional surveys assessing asthma control status were conducted between January 25 and May 2, 2008, among adult and pediatric patients with asthma. Participants completed a self-administered questionnaire including demographics, medical history, and current asthma medication use. In addition, participants completed either the Asthma Control Test (ACT) or Childhood ACT (C-ACT). Uncontrolled asthma was defined as a score of </=19 on the ACT or C-ACT. Multiple logistic regression was used to identify factors related to uncontrolled asthma.

Results; A sample of 64 primary care provider sites (35 for adults and 29 for pediatric patients) across the United States enrolled. One study enrolled 2238 adults (aged >/=18 years) and the other 2429 children (aged 4-17 years) with asthma. The patients were visiting their health care provider for a scheduled appointment for any reason. The overall prevalence of uncontrolled asthma was 58% and 46% in adult and pediatric patients, respectively. Multivariate analysis identified predictors of uncontrolled asthma in both adults and children including self-reported asthma severity, lack of adherence, and recent history of cold, flu, or sinus infection. The predictors of uncontrolled asthma seen only in adults were less education, insurance status, current smoker, body mass index (BMI) >30 kg/m(2), and history of gastroesophageal symptoms. The predictors of uncontrolled asthma seen only in children were female aged 12-17 years, caregiver unemployment, and history of asthma exacerbation.

Conclusions; A high proportion of patients with asthma seen in primary care settings are not well controlled. Recognition of specific predictors can signal who may be at higher risk of uncontrolled asthma and provide the opportunity for early interventions.

High prevalence of undiagnosed airflow limitation in patients with cardiovascular disease.

Chest. 2010 Feb;137(2):333-40. Soriano JB, Rigo F, Guerrero D, Yañez A, Forteza JF, Frontera G, Togores B, Agustí A. Fundació Caubet-CIMERA Illes Balears, CIMERA, Bunyola, Spain.

BACKGROUND: The prevalence of airflow limitation (AL) in patients with cardiovascular disease (CVD) is unknown, and whether AL is adequately diagnosed and treated in these patients has not been investigated before, to our knowledge.

METHODS: We compared clinical and spirometric data in three groups of individuals. Two of them were participants in the follow-up of an ongoing population-based study according to the presence or absence of CVD. The third group included patients with coronary artery disease (CAD) confirmed by coronariography regularly visited at a tertiary referral university hospital. AL was defined according to the Global Initiative for Obstructive Lung Disease guidelines.

RESULTS: We studied 450 population participants without CVD, 52 population participants with CVD, and 119 hospital patients with CAD. The prevalence of AL in these three groups was 17.5% (95% CI, 14.0-21.0), 19.2% (95% CI, 8.1-30.7), and 33.6% (95% CI, 25.0-42.2), respectively (P < .05). Underdiagnosis of AL ranged from 60% in population participants with CVD up to 87.2% in hospital patients with CAD. Sixty percent of those with spirometrically confirmed AL (in all three groups) did not receive any respiratory treatment.

CONCLUSIONS: AL is frequent in individuals with CVD, particularly in those with CAD attended in the hospital, is largely underdiagnosed and therefore is highly undertreated.

The occupational contribution to severe exacerbation of asthma.

Eur Respir J. 2010 Mar 29. Henneberger PK et al Morgantown, WV, United States.

The goal was to identify occupational risk factors for severe exacerbation of asthma and estimate the extent that occupation contributes to these events.

The 966 participants were working adults with current asthma who participated in the follow-up phase of the European Community Respiratory Health Survey. Severe exacerbation of asthma was defined as self-reported unplanned care for asthma in the past 12 months. Occupations held in the same period were combined with a general-population job-exposure matrix to assess occupational exposures.

Seventy-four participants reported having had at least one severe exacerbation event, for a one-year cumulative incidence of 7.7%. From regression models that controlled for confounders, the relative risk (RR) was statistically significant for low (RR=1.7, 95% CI 1.1-2.6) and high (RR=3.6, 95% CI 2.2-5.8) biological dust exposure, high mineral dust exposure (RR=1.8, 95% CI 1.02-3.2), and high gas and fumes exposure (RR=2.5, 95% CI 1.2-5.5). The summary category of high dust, gas, or fumes exposure had RR=3.1 (95% CI 1.9-5.1). Based on this RR, the population attributable risk was 14.7% among workers with current asthma.

These results suggest occupation contributes to approximately 1 in 7 cases of severe exacerbation of asthma in a working population, and various agents play a role.

Effects of pulmonary rehabilitation in patients with restrictive lung diseases.

Chest. 2010 Feb;137(2):273-9. Salhi B, Troosters T, Behaegel M, Joos G, Derom E. Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.

BACKGROUND: Pulmonary rehabilitation programs improve exercise tolerance, muscle strength, and dyspnea in patients with COPD. The aim of the study was to assess prospectively the effectiveness and feasibility of pulmonary rehabilitation in patients with restrictive lung diseases.

METHODS: In a prospective, nonrandomized, noncontrolled study, patients with an established diagnosis of restrictive lung disease (RLD) participated in a 24-week outpatient multidisciplinary rehabilitation program. Pulmonary function, exercise capacity, muscle force, and dyspnea were measured at inclusion, after 12 and 24 weeks of rehabilitation. Primary outcome was the change in 6-min walk distance (6MWD) after 12 weeks of rehabilitation.

RESULTS: Twenty-nine patients out of 31 patients (57 +/- 17 years of age; 21 men; FEV(1): 1.4 +/- 0.7 L) completed the 12-week rehabilitation program and 26 patients the 24-week rehabilitation program. At inclusion, exercise tolerance (maximal oxygen consumption [V(O(2))max]: 63% +/- 27% predicted; 6MWD: 390 +/- 140 m) and quadriceps force ([QF] 61% +/- 21% predicted) were reduced, and dyspnea, assessed using the Chronic Respiratory Disease Questionnaire (CRDQ), was increased (CRDQ item dyspnea [CRDQd]: 16 +/- 6 points). Exercise capacity, muscle force, and CRDQd improved significantly after 12 weeks (6MWD: 445 +/- 142 m; V(O(2))max: 69% +/- 30% predicted; QF: 73% +/- 25% predicted; CRDQd: 20 +/- 6 points) (P < .05). Further improvements were noted after 24 weeks (6MWD: 463 +/- 146 m; CRDQd: 22 +/- 6 points).

CONCLUSIONS: Patients with RLD respond well after 12 weeks of pulmonary rehabilitation, and even better results were seen after 24 weeks. Clinically significant improvements were obtained in the majority of the patients after 24 weeks.

Acute Care Costs of patients admitted for management of COPD exacerbations: contribution of disease severity, infection, and chronic heart failure.

Intern Med J. 2010 Feb 18. Hutchinson A, Brand C, Irving L, Roberts C, Thompson P, Campbell D. Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital.

Background: In 2003 COPD accounted for 46% of the burden of chronic respiratory disease in the Australian community. In the 65 to 74 year age group, COPD was the 6(th) leading cause of disability for males and the 7(th) for females.

Objective: To measure the influence of disease severity, COPD phenotype and co-morbidities on acute health service utilisation and direct acute care costs in patients admitted with COPD.

Methods: Prospective cohort study of 80 patients admitted to the Royal Melbourne Hospital in 2001-2002 for an exacerbation of COPD. Patients were followed for 12-months and data collected on acute care utilisation. Direct hospital costs were derived using Transition II, an activity-based costing system. Individual patient's costs were then modelled to ascertain which patient factors, influenced total direct hospital costs.

Results: Direct costs were calculated for 225 episodes of care, the median cost per admission was AU$3,124 (IQR $1,393 to $5,045). The median direct cost of acute care management per patient per year was AU$7,273 [IQR $3,957-$14,448]. In a multivariate analysis using linear regression modelling, factors predictive of higher annual costs were increasing age (p = 0.041), use of domiciliary oxygen (p = 0.008) and the presence of CHF (p = 0.006).

Conclusion: This model has identified a number of patient factors that predict higher acute care costs and awareness of these can be used for service planning to meet the needs of patients admitted with COPD.

Home-based pulmonary rehabilitation in chronic obstructive pulmonary disease patients.

Curr Opin Pulm Med. 2010 Mar;16(2):134-43. Vieira DS, Maltais F, Bourbeau J. Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada.

PURPOSE OF REVIEW: Home-based pulmonary rehabilitation programs have been proposed as an alternative to hospital-based programs for patients with chronic obstructive pulmonary disease (COPD). We undertook a systematic review of randomized studies on home-based pulmonary rehabilitation in patients with COPD which report health-related quality of life and/or exercise capacity, in order to assess the benefits of this intervention.

MAIN FINDINGS: From 888 identified references, 12 met the inclusion criteria. Overall, the methodological quality of the studies was average to poor. Eight studies compared home-based rehabilitation to standard care, three compared home-based rehabilitation to hospital-based programs and one included both comparisons. Most of the studies showed improvement in health-related quality of life (statistically and clinically significant) and exercise capacity following home-based rehabilitation as compared with standard care (no pulmonary rehabilitation). Studies that compared home-based pulmonary rehabilitation with hospital-based outpatient programs have not been able to show statistically and clinically significant differences for health-related quality of life and exercise capacity. Adverse events, usually mild, were reported in only two studies.

SUMMARY: Self-monitored, home-based rehabilitation may be an alternative to outpatient rehabilitation. These findings can help expand the recognition, application and accessibility of pulmonary rehabilitation for patients with COPD.

Ambient air pollution and respiratory health effects in mail carriers.

Environ Res. 2010 Jan 2. Karakatsani A, Kapitsimadis F, Pipikou M, Chalbot MC, Kavouras IG, Orphanidou D, Papiris S, Katsouyanni K. 2nd Department of Pulmonary Medicine, "ATTIKON" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

Mail carriers represent an occupational group suffering from respiratory symptoms and lung function impairment. Although environmental conditions may play role, information on the effects of air pollution exposure in this population is lacking.

The present study was conducted in Athens, Greece, in order to investigate the adverse effects of long-term air pollution exposure on respiratory outcomes in mail carriers. A total of 226 mail carriers and 73 office employees were enroled. Information on respiratory symptoms, medical, occupational, residential and smoking history was obtained through a questionnaire. Flow-volume curves were performed in the workplace using a portable spirometer. Individualised personal exposure assessment has been applied based on long-term residential and occupational subject history linked with geographical air pollution distribution. Furthermore, personal measurements were obtained for forty-one mail carriers using NO(2) and O(3) passive samplers, assuming that current air pollution exposure is sufficiently representative of long-term, previous exposure to make a plausible link with current health status.

The analysis based on exposures estimated on the basis of residential and work addresses showed that the most exposed to PM(10) postal workers have rhinitis at a higher rate (OR=1.67, 95% CI: 1.01-2.75). In mail carriers there is indication that those exposed to higher concentrations of Omicron(3) or PM(10) have a greater possibility to present rhinitis (OR=1.63, 95% CI: 0.93-2.88 and OR=1.70, 95% CI: 0.96-3.03, respectively). The effect of O(3) on rhinitis became even more apparent in the analysis based on exposures assessed by personal measurements (OR=6.74, 95% CI: 1.24-36.55). Exposure to NO(2) was significantly associated with decrements in lung function. For office employees the exposure to air pollutants was not associated to any adverse respiratory outcome.

Our findings suggest that air pollution is a contributing factor for the occurrence of rhinitis and lung function impairment in mail carriers.

High BMI is related to higher incidence of asthma, while a fish and fruit diet is related to a lower- Results from a long-term follow-up study of three age groups in Sweden.

Respir Med. 2010 Feb 17. Uddenfeldt M, Janson C, Lampa E, Leander M, Norbäck D, Larsson L, Rask-Andersen A. Department of Medical Sciences, Occupational and Environmental Medicine, Uppsala University, Uppsala, Sweden; Centre for Clinical Research, Uppsala University/County Council of Gävleborg, Sweden.

The causes of the worldwide increase in asthma seen during the last decades remain largely unexplained, but lifestyle and diet are suggested to play important roles. In this follow up of a large-scale population sample in Sweden, we wanted to identify modifiable risk factors for the cumulative incidence over a 13-year follow-up period. In 1990, a self-administered questionnaire was completed by 12,560 individuals from three age groups (16, 30-39 and 60-69 years of age) in two counties of Sweden. In 2003, the eligible subjects (n = 11,282) were sent a new postal questionnaire. In total 8150 (response rate 73%) answered the questionnaire. The prevalence of asthma in 2003 had increased in all ages. In the young adults, the asthma prevalence rose from 11.3% in 1990 to 25.0% in 2003. Adult asthma onset was identified in 791 of the participants. Smoking [RR (95% CI) = 1.37 (1.12-1.68)], BMI [1.49 (1.25-1.77 per inter quartile range)], and nocturnal gastro-oesophageal reflux (GOR) [2.16 (1.72-2.72)] were significant independent risk factors for the cumulative incidence of asthma. The impact of risk factors differed between the age groups where BMI and GOR had a significantly higher impact in the middle aged and the elderly (p < 0.05). High consumption of fruit and fish was protective especially in the elderly [0.52 (0.35-0.77)]. No significant difference was found in the impact of risk factors between men and women.

Weight loss, smoking cessation and a diet rich in fruit and fish may be of importance in preventing onset of adult asthma.

Factors associated with the control of severe asthma.

J Asthma. 2010 Mar;47(2):124-30. Hermosa JL, Sánchez CB, Rubio MC, Mínguez MM, Walther JL. Department of Neumology, Hospital Clinico San Carlos, Madrid, Spain.

Introduction. Control is a priority treatment objective in asthma, and classification based on control is recommended in the follow-up of asthmatic patients. Different factors affect this control, and there are several regional differences, both in terms of prevalence and in terms of management and degree of control.

Objective. To evaluate the factors associated with control of severe asthma in routine clinical practice.

Material and Methods. This was a prospective, cross-sectional, observational study of patients with severe asthma who were receiving treatment with a fixed combination of a corticosteroid (at least 800 mug/day of budesonide or equivalent) and an inhaled beta(2)-adrenergic agonist in respiratory medicine and allergology clinics throughout Spain. The authors collected demographic and socioeconomic data, as well as clinical data on asthma. The patients also completed a self-administered validated questionnaire-the Asthma Control Questionnaire (ACQ)-about the control of their asthma.

Results. The authors included 1471 patients, of whom 1224 (83%) were valid for the final analysis. Women accounted for 61%. Mean age was 51 +/- 16 years. The mean number of exacerbations during the previous year was 2.0 +/- 2.0. The global score on the ACQ was 1.8 +/- 1.1 (0 = no symptoms; 6 = maximum number of symptoms). Only 20.4% of patients were well controlled (ACQ < 0.75), and 55.7% of patients were poorly controlled (ACQ > 1.5). The multivariate analysis revealed that the variable with the greatest effect on control of asthma was the number of exacerbations during the previous year: when the number of exacerbations increased from 0 to 1 or more, the ACQ score increased by 0.56 points. Employed patients had a mean of 0.23 points less (better control) than unemployed and retired patients. Control of asthma was also significantly affected by adherence to treatment, patient knowledge of the disease, body mass index, gender, and number of visits to a physician in the previous 3 months.

Conclusions. Many patients with severe asthma have poor control of their disease. The number of exacerbations is the variable with the greatest effect on control of asthma. Knowledge of the disease and adherence to treatment are associated with better control.

Asthma knowledge and asthma management behavior in urban elementary school teachers.

J Asthma. 2010 Mar;47(2):185-91. Bruzzese JM, Unikel LH, Evans D, Bornstein L, Surrence K, Mellins RB. Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, New York, USA.

Background. Although schools are an important setting for asthma care in youth, teachers' asthma knowledge and symptom management is poor. This study investigated the knowledge, prevention and management behaviors, and communication regarding asthma of teachers of low-income, ethnic minority students. It was hypothesized that relative to colleagues whose students did not have active asthma (i.e., did not have symptoms during the day), teachers of students with active asthma would have better asthma knowledge and that more would take asthma prevention steps and communicate with parents and school nurses.

Methods. Drawing from 25 elementary schools in New York City, 320 pre-Kindergarten through 5th grade classroom teachers with at least one student with asthma completed measures assessing their asthma knowledge, steps taken to manage asthma, communication with the school nurse or parents, information they received about asthma, and whether or not they had at least one student in their class experience asthma symptoms. t test and chi-square were used to test hypotheses.

Results. Asthma knowledge varied among teachers. Most could identify potential triggers, yet few knew that medication taken prior to exercise could prevent symptoms and that students with asthma need not avoid exercise. Communication between teachers and school nurses and between teachers and parents was lacking. Relative to colleagues whose students did not have active asthma, teachers whose students had active asthma had better asthma knowledge, more took steps to prevent students from having asthma symptoms, communicated with parents, and more initiated communication with the nurse.

Conclusions. Teachers' knowledge about asthma and asthma management is limited, especially among those whose students did not have active asthma. Teachers respond reactively to students who have symptoms in class by increasing prevention steps and communications with parents and the school nurse. A more proactive approach to managing asthma in schools is warranted.

Barriers to patient-clinician collaboration in asthma management: the patient experience.

J Asthma. 2010 Mar;47(2):192-7. Newcomb PA, McGrath KW, Covington JK, Lazarus SC, Janson SL. 1University of Texas at Arlington, School of Nursing, Arlington, Texas, USA.

Objective. To describe what adult patients with asthma report about their experiences with their own self-management behavior and working with their clinicians to control asthma.

Methods. The study sample consisted of 104 patients with persistent asthma participating in a clinical trial on asthma monitoring. All subjects were seen by primary care clinicians of a large, academic medical center. This qualitative post hoc analysis examined the views of adults with asthma about their asthma-related health care. Patients attended monthly visits as part of their study participation, during which data were derived from semistructured interviews. All patients included in this analysis participated in the study for 1 year. At the end of study participation, patients were asked to complete an evaluation of their clinician's communication behavior. All study clinicians were also asked to complete a self-evaluation of their own communication behavior.

Results. Five major themes of barriers to successful self-management were identified, including personal constraints, social constraints, communication failures, medication issues, and health care system barriers to collaboration with their clinicians. Patients most frequently reported lack of communication surrounding issues relating to day-to-day management of asthma (31%) and home management of asthma (24%). Clinicians generally rated themselves well for consistency in showing nonverbal attentiveness (89%) and maintaining interactive conversations (93%). However, only 30% of clinicians reported consistency in helping patients make decisions about asthma management and only 33% of clinicians reported consistency in tailoring medication schedules to the patient's routines.

Conclusion. These findings emphasize the difficulties of establishing and maintaining a therapeutic partnership between patients and clinicians. The results underscore the need for system-wide interventions that promote the success of a therapeutic patient-clinician relationship in order to achieve long-term success in chronic disease management.

Repeated instruction on inhalation technique improves adherence to the therapeutic regimen in asthma.

J Asthma. 2010 Mar;47(2):202-8. Takemura M, Kobayashi M, Kimura K, Mitsui K, Masui H, Koyama M, Itotani R, Ishitoko M, Suzuki S, Aihara K, Matsumoto M, Oguma T, Ueda T, Kagioka H, Fukui M.

Background: Adherence to inhalation therapy is a critical determinant of the success of asthma management. Reasons for nonadherence have been well studied, but reasons for good adherence are poorly understood. Understanding the mechanisms of adherence to inhalation therapy is important in developing strategies to promote adherence. The objective of this study was to assess the factors and mechanisms that contribute to and the clinical outcomes relating to adherence to inhalation therapy.

Methods: The factors and outcomes related to adherence to inhalation therapy were examined cross-sectionally in 176 adults with asthma using a self-reported adherence questionnaire that consisted of four items dealing with the use of inhaled controller medications. A 5-point Likert scale was used for the responses to each item. Adherence was assessed based on the overall mean adherence score.

Results: Of the 176 patients who were potential participants, 146 (83%) responded with usable information. Significant factors associated with the overall mean adherence score were older age (r = .18, p = .032) and receiving repeated instruction on inhalation techniques (p = .0016). Of the 146 respondents, 25 (17.1%) patients were given repeated verbal instruction or demonstrations of inhalation technique by a respiratory physician. On logistic regression analysis, good adherence to inhalation therapy was significantly related to the receiving of repeated instruction on inhalation technique, with an odds ratio of 2.90 (95% confidence interval 1.07-7.88; p = .037). Furthermore, less intentional nonadherent behavior was reported in patients with repeated instruction on inhalation technique compared to those without it. A significant correlation was found between the overall mean adherence score and the frequency of asthma exacerbations (r = -.19, p = .021), emergency room visits (r = -.19, p = .042), and the health-related quality of life score (St. George's Respiratory Questionnaire: Total, r = -.22, p = .024; Symptoms, r = -.21, p = .022; Impacts, r = -.20, p = .035).

Conclusions: Repeated instruction on inhalation techniques may contribute to adherence to inhalation therapy through decreasing intentional nonadherence. Furthermore, good adherence to the therapeutic regimen may offer good asthma-related outcomes.

Early life factors associated with incidence of physician-diagnosed asthma in preschool children: results from the Canadian Early Childhood Development cohort study.

J Asthma. 2010 Feb;47(1):7-13. Midodzi WK, Rowe BH, Majaesic CM, Saunders LD, Senthilselvan A. Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Edmonton, Alberta, Canada T6G7T4.

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.

Decreasing frequency of asthma education in primary care.

J Asthma. 2010 Feb;47(1):21-5. Hersh AL, Orrell-Valente JK, Maselli JH, Olson LM, Cabana MD. Division of General Pediatrics, Department of Pediatrics, University of California, San Francisco, California, USA.

BACKGROUND: Provision of asthma education is associated with decreased hospitalizations and emergency department visits for patients with asthma. Our objective was to describe national trends in the provision of asthma education by primary care physicians in office settings.

METHODS: We used the National Ambulatory Medical Care Survey, a nationally representative dataset of patient visits to office-based physicians. We identified visits to primary care physicians for patients where asthma was a reason for the visit (asthma-related visits) or who had a diagnosis of asthma, but asthma was not a specific reason for the visit (asthma-unrelated visits) and estimated the percentage of visits where asthma education was provided. Data were available for asthma-related visits from 2001-2006 and from 2005-2006 only for asthma-unrelated visits. We examined time trends in asthma education and used multivariable logistic regression to identify independent patient and system-related factors that were predictors of asthma education.

RESULTS: The percentage of asthma-related visits where asthma education was provided declined during the study period, from 50% in 2001-2002 to 38% in 2005-2006 (p = 0.03). Asthma education was provided less frequently during asthma-unrelated visits compared to asthma-related visits (12% vs. 38%, p<0.0001). Independent predictors of providing asthma education included age < or = 18 years, receipt of a controller medication, incorporation of an allied health professional during the visit, longer visit duration and Northeast region.

CONCLUSIONS: Asthma education is underused by primary care physicians and rates have declined from 2001-2006. Interventions designed to promote awareness and greater use of asthma education are needed.

Relationship between patient, caregiver, and asthma characteristics, responsibility for management, and indicators of asthma control within an urban clinic.

J Asthma. 2010 Feb;47(1):41-5. Munzenberger P, Secord E, Thomas R. Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan 48201, USA.

Successful asthma management in children requires an appropriate division of responsibility for management tasks between patient and their family. Non-adherence may result without appropriate assignment or acceptance of responsibility for these tasks. This study explored the relationship between selected child, caregiver, family, and asthma characteristics and responsibility for self-management activities. Child and caregiver perceived responsibility for selected tasks were determined and described via means and mean summary scores. Child, caregiver, family, and asthma characteristics were determined via interview and chart review and described by means or proportions. Pearson's correlation coefficient (r) examined any relationship between these characteristics and perceived levels of responsibility. Multiple regression examined whether the affect of child, caregiver, family, and asthma characteristics influenced perceived levels of responsibility for asthma management. One-hundred and four child and caregiver pairs were enrolled.

Mean caregiver scores for all tasks suggest responsibility for each most of the time. The mean child scores for all tasks suggest an unwillingness to assume responsibility most or all of the time. Regression analysis indicated that patient age (r(2) = 0.344), number of hospital admissions (r(2) = 0.052), and PEF (r(2) = 0.106) had the best predictive strength for the patient summary score. Only patient age (r = 0.486) was a significant predictor for the caregiver summary score.

We conclude that children and caregivers perceive differently responsibility for asthma management tasks and patient age had the best predictive strength for both patient and caregiver responsibility.

A deep breath bronchoconstricts obese asthmatics.

J Asthma. 2010 Feb;47(1):55-60. Holguin F, Cribbs S, Fitzpatrick AM, Ingram RH Jr, Jackson AC. Asthma Institute, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.

BACKGROUND: Asthma is characterized by the loss of a deep breath (DB)-induced bronchodilation and bronchoprotection. Obesity causes lung restriction and increases airway resistance, which may further worsen the capacity of a DB to induce bronchodilation; however, whether increasing BMI impairs the bronchodilatory response to a DB in asthmatics is unknown.

METHODS: The population consisted of 99 subjects, 87 with moderate to severe persistent asthma and 12 obese control subjects. Using transfer impedance we derived airway resistance (Raw). Participants breathed for 1 minute and took a slow DB followed by passive exhalation to functional residual capacity (FRC) and tidal breathing for another minute.

RESULTS: After a DB, obese asthmatics had the largest percent increase in Raw (median 9.8% interquartile range [IQR] 3.1-15.1), compared with overweight (6.5% IQR -1.3, 12.1) and lean (0.7% IQR -3, 7.9) asthmatics and obese controls (2.5% IQR -.6, 11) (p for trend = 0.008). The association between the percent increase in Raw after a DB and BMI as a continuous variable was significant (p = 0.02).

CONCLUSIONS: In obese, moderate to severe and poorly controlled asthmatics, a DB results in increased Raw. This phenomenon was not observed in leaner asthmatics of similar severity or in obese control subjects.

Psychological distress and maladaptive coping styles in patients with severe versus moderate asthma.

Chest. 2010 Jan 22. Lavoie KL, Bouthillier D, Bacon SL, Lemière C, Martin J, Hamid Q, Ludwig M, Olivenstein R, Ernst P. 1Department of Psychology, University of Quebec at Montreal (UQAM), P.O. Box 8888, Succursale Center-Ville, Montreal, Quebec, H3C 3P8, Canada.

BACKGROUND: Though several biological factors have been suggested to play a role in the development and persistence of severe asthma, those associated with psychological factors remain poorly understood. This study assessed levels of psychological distress and a range of disease-relevant emotional and behavioural coping styles in patients with severe versus moderate asthma.

METHODS: 84 patients (50% female, M age 46 yrs) with severe (n=42) and moderate (n=42) asthma were recruited. Severe asthma was defined according to ATS criteria. Patients underwent demographic and medical history interviews, pulmonary function and allergy testing. Patients also completed questionnaires measuring asthma symptoms and the Millon Behavioural Medicine Diagnostic Inventory (MBMDI), which assesses psychological distress and emotional/behavioural coping factors that influence disease progression and treatment.

RESULTS: After adjustment for covariates and applying a correction factor that reduced the significant p-level to <.01, patients with severe vs. moderate asthma reported experiencing more psychological distress including worse cognitive dysfunction [F=6.72, p<.01]) and marginally worse anxiety-tension [F=4.02, p<.05]. They also reported worse emotional coping (higher illness apprehension [F=9.57, p<.01], pain sensitivity [F=10.65, p<.01], future pessimism [F=8.53, P<.01], and interventional fragility [F=7.18, p<.01]), and marginally worse behavioral coping (more functional deficits [F=5.48, p<.05] and problematic compliance [F=4.32, p<.05]).

CONCLUSION: Patients with severe asthma have more psychological distress and difficulty coping with their disease both emotionally and behaviorally relative to moderate asthmatics. Future treatment studies should focus on helping severe asthma patients manage distress and cope more effectively with their illness, which may improve outcomes in these high-risk patients

Infant swimming in chlorinated pools and the risks of bronchiolitis, asthma and allergy.

Eur Respir J. 2010 Jan 14. Voisin C, Sardella A, Marcucci F, Bernard A. Catholic University of Louvain, Belgium.

Recent studies suggest that swimming in chlorinated pools during infancy may increase the risks of lower respiratory tract infection.

To assess the influence of swimming in chlorinated pools on the risks of bronchiolitis and its late consequences. We examined 430 children (47% of girls, mean age 5.7 years) in 30 kindergarten schools. Parents completed a questionnaire about the child's health history, swimming practice and potential confounders.

Attendance at indoor or outdoor chlorinated pools ever before the age of two years was associated with an increased risk of bronchiolitis (OR, 1.68, 95% CI, 1.08-2.68, p=0.03), which was exposure-dependent for both types of pools (p for trend <0.01). Associations persisted and were even strengthened by the exclusion of other risk factors. Among children with no parental antecedents of atopic diseases or no day care attendance, ORs for bronchiolitis amounted to 4.45 (1.82-10.9) (p=0.001) and 4.44 (1.88-10.5) (p=0.007) after more than 20 hours spent in chlorinated pools during infancy. Infant swimmers who developed bronchiolitis had also higher risks of asthma and respiratory allergies later in childhood.

Swimming pool attendance during infancy is associated with a higher risk of bronchiolitis with ensuing increased risks of asthma and allergic sensitization.

Detection and home management of worsening asthma symptoms.

Ann Allergy Asthma Immunol. 2009 Dec;103(6):469-73. Garbutt J, Highstein G, Nelson KA, Rivera-Spoljaric K, Strunk R. Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri 63110, USA.

BACKGROUND: Asthma guidelines recommend early home treatment of exacerbations. However, home treatment is often suboptimal and delayed.

OBJECTIVES: To describe antecedent symptoms and signs of asthma exacerbations noticed by parents and to learn when and how parents intensify asthma treatment.

METHODS: Parents of children 2 to 12 years old with asthma exacerbations that required urgent care in the past 12 months completed telephone questionnaires. Where multiple responses were possible, percentages may sum to more than 100%.

RESULTS: One hundred one parents were enrolled and interviewed; 94% were the children's mothers. Seventy percent of the children were black, and 64% had Medicaid insurance. Parents reported multiple antecedent symptoms and signs (median number per child, 3; range, 1-6), including respiratory symptoms (79%), allergy or cold symptoms (43%), behavioral changes (24%), and other nonspecific symptoms (29%). Twenty-three parents reported late respiratory symptoms, such as gasping for breath and using accessory muscles to breath, as the earliest antecedent signs. Treatment was most often intensified when the parent noticed cough (55%), shortness of breath (54%), and wheeze (25%) and included adding albuterol (92%), an oral corticosteroid (17%), an inhaled corticosteroid (8%), or other nonasthma medications (16%).

CONCLUSIONS: Although parents described antecedent symptoms and signs of impending asthma exacerbations that they consistently noticed in their children, many waited for lower respiratory signs to be present before intensifying treatment. Oral corticosteroids were used infrequently. Interventions to improve the ability of parents and children to accurately recognize worsening symptoms and initiate timely, effective treatment are needed.

Decision Support for Teletraining of COPD Patients.

Methods Inf Med.;49(1). Song B, Wolf KH, Gietzelt M, Al Scharaa O, Tegtbur U, Haux R, Marschollek M. Bianying Song, Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Mühlenpfordtstrasse 23, 38106 Braunschweig, Germany,

Background: Supervised physical training has been shown to promote rehabilitation of patients affected by chronic obstructive pulmonary disease (COPD). Currently, due to limited resources, not all COPD patients can be trained by an expert supervisor.

Objectives: The objective of our research is to construct a decision support system (DSS) which observes and controls physical ergometer training sessions of COPD patients. Methods: A systematic literature review and expert interviews were carried out to build up the knowledge base for the DSS.

Results: Nine production rules were established and standardized by Drools and Arden Syntax. The developed software autonomously controls training sessions on a bicycle ergometer on the basis of vital signs data. Thus it offers a new way for the rehabilitation of COPD patients.

Conclusion: Evaluation with nine healthy subjects in a laboratory environment has confirmed its correct function, but the effects of its use for COPD patients' rehabilitation and their quality of life have to be investigated in a further study.

Patient compliance with assessing and monitoring of asthma.

J Asthma. 2009 Dec;46(10):1027-31. Jiang H, Han J, Zhu Z, Xu W, Zheng J, Zhu Y. Department of Pneumology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, P.R. China.

BACKGROUND: The current asthma guidelines encourage use of a diary for assessing and monitoring symptoms and airway function. However, patient compliance and acceptability are usually poor owing to the burden of frequent and prolonged assessment.

OBJECTIVE: We investigated whether better patient compliance could be ensured if a study was more relevant to patient convenience and had less impact on their daily life.

METHODS: A total of 106 patients with symptomatic asthma underwent a fixed-time thrice-daily assessment schedule for a period lasting 2 weeks, and they were assigned to a doctor visit after the assessment. Symptoms and medication use were recorded in a booklet (paper diary) and airway function measured by a portable spirometer (electronic diary).

RESULTS: Of 4,452 expected entries, the paper diary yielded 3,186 compliant entries and the electronic diary yielded 3,557 compliant entries; 71% of patients completed at least 30 compliant entries in the paper diary and 79% in the electronic diary. Use of an electronic device was associated with better compliance compared with paper technique (80.0% vs. 71.7%, p < 0.0001). Patient compliance decreased in the second week compared with the first week of diary keeping for both types of diaries (paper diary: 68.6% vs. 74.8%, p < 0.0001; electronic diary: 76.7% vs. 83.4%, p < 0.0001). The morning compliance was the least good, the afternoon better, and the evening best (paper diary: 68.2% vs. 71.0% vs. 75.9%, p < 0.0001; electronic diary: 77.2% vs. 79.0% vs. 83.9%, p < 0.0001). Among demographics and clinical factors, higher anxiety levels were linked to lower patient compliance.

CONCLUSION: Good patient compliance and acceptability can be achieved when a study takes into account patient convenience, uses user friendly electronic devices, and is less disruptive to patients' daily life.

Different definitions in childhood asthma: how dependable is the dependent variable?

Eur Respir J. 2009 Dec 23. van Wonderen KE, van der Mark LB, Mohrs J, Bindels PJ, van Aalderen WM, Ter Riet G. Academic Medical Center, Amsterdam, the Netherlands.

There is abundant literature on how to select and statistically deal with predictors in prediction models. Less attention has been paid to the choice of the outcome. We assessed the impact of different asthma definitions on prevalence estimates and on prediction model's performances.We searched Pubmed and extracted data of definitions used to diagnose childhood asthma - between 6 and 18 years - in cohort studies. Next, using data from an ongoing cohort study (n=186), we constructed and compared four prediction models which all predict asthma at age six, using a fixed set of predictors and four different definitions in turn. We defined an area of clinical indecision (posterior probability between 25% and 60%) and calculated the number of children who remained inside this area.122 papers yielded 60 different definitions. Prevalence estimates varied between 15.1% and 51.1% depending on the asthma definition used. The percentage of children whose posterior asthma probability was in the area of clinical indecision varied from 14.9% to 65.3%.

Variation in definitions and its effect on the performance of prediction models may be another source of otherwise inexplicable variation in daily clinical decision making. More uniformity of operational asthma definitions seems needed.

Shared Treatment Decision-making Improves Adherence and Outcomes in Poorly Controlled Asthma.

Am J Respir Crit Care Med. 2009 Dec 17. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, Vollmer WM, Boat Study Group. Palo Alto Medical Foundation Research Institute, Palo Alto, California, United States.

RATIONALE: Poor adherence to asthma controller medications results in poor treatment outcomes.

OBJECTIVES: To compare controller medication adherence and clinical outcomes in 612 adults with poorly controlled asthma randomized to one of two different treatment decision-making models or to usual care.

METHODS: In shared decision making (SDM), non-physician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making (CDM), treatment was prescribed without specifically eliciting patient goals/preferences. The otherwise identical intervention protocols both provided asthma education and involved two in-person and three brief phone encounters.

MEASUREMENTS AND MAIN RESULTS: Refill adherence was measured using continuous medication acquisition indices (CMA) â the total daysâ supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister-equivalents (CE). Follow-up Year 1: Compared to usual care, SDM resulted in significantly better controller adherence (CMA, 0.67 vs. 0.46; P<0.0001), LABA adherence (CMA, 0.51 vs. 0.40; P=0.0225); higher cumulative controller medication dose (CE, 10.9 vs. 5.2; P<0.0001); significantly better clinical outcomes (asthma-related quality of life, health care utilization, rescue medication use, asthma control, and lung function); and in Year 2, significantly lower rescue medication use, the sole clinical outcome available for that year. Compared to CDM, SDM resulted in significantly better controller adherence (CMA, 0.67 vs. 0.59; PP=0.03), LABA adherence (CMA, 0.51 vs. 0.41; P=0.0143); higher cumulative controller dose (10.9 vs. 9.1; P=0.005), and quantitatively, but not significantly, better outcomes on all clinical measures.

CONCLUSIONS: Negotiating patients' treatment decisions significantly improves adherence to asthma pharmacotherapy and clinical outcomes

Rhinitis in subjects with work-exacerbated asthma.

Respir Med. 2009 Nov 27. Vandenplas O, Van Brussel P, D'Alpaos V, Wattiez M, Jamart J, Thimpont J. Department of Chest Medicine, Mont-Godinne Hospital; Université Catholique de Louvain, B-5530 Yvoir, Belgium; Fonds des Maladies Professionnelles, Brussels, Belgium.

OBJECTIVES: This study aimed at characterizing the nature, severity, and timing of nasal and ocular symptoms in subjects with work-exacerbated asthma (WEA).

METHODS: Among the 363 subjects referred to a tertiary-care hospital for the investigation of work-related asthma symptoms, 105 subjects who demonstrated non-specific bronchial hyperresponsiveness to histamine, but a negative response to a specific inhalation challenge with the suspected occupational agent(s) were considered as having WEA. Their characteristics were compared with those of 172 subjects with occupational asthma (OA), ascertained by a positive response to a specific inhalation challenge.

RESULTS: A high proportion of subjects with WEA (83%) and OA (90%) reported at least one nasal symptom at work. Sneezing/itching and rhinorrhea were more frequent in subjects with OA (78% and 70%, respectively) than in those with WEA (61%, p = 0.004 and 57%, p = 0.038, respectively), while post-nasal discharge was more common in WEA (30%) than in OA (18%, p = 0.019). Nasal symptoms were less severe in WEA (median [25th-75th percentiles] global severity score: 4 [2-6]) as compared to OA (5 [4-7], p < 0.001). Nasal symptoms preceded less frequently those of asthma in subjects with WEA (17%) than in subjects with OA (43%, p = 0.001).

CONCLUSIONS: Nasal symptoms are highly prevalent in subjects with WEA, although their clinical pattern differs from that found in OA. Further investigations of the health and socio-economic impacts of upper airways symptoms in WEA are required to improve the understanding and management of this common condition.

Frequent nocturnal awakening in early life is associated with nonatopic asthma in children.

Eur Respir J. 2009 Dec;34(6):1288-95. Kozyrskyj AL, Kendall GE, Zubrick SR, Newnham JP, Sly PD. Dept of Paediatrics, University of Alberta, Edmonton, AB, Canada.

Sleep deprivation has become a common phenomenon of the Western world and is associated with a variety of medical problems in children. This retrospective longitudinal analysis of a community-based birth cohort was undertaken to determine whether frequent nocturnal awakening during early life was associated with the development of childhood asthma. 2,398 children born to mothers recruited from the antenatal clinics of a single hospital in Perth, Australia during 1989-1991 were followed up at years 1, 2, 3, 6, 8, 10 and 14. Parent-completed questionnaires were analysed. The odds ratio for asthma at age 6 and 14 yrs in children with frequent nocturnal awakening during the first 3 yrs after birth was determined from multiple logistic regression. Following adjustment for asthma risk factors, co-sleeping and family stress, persistent nocturnal awakening was associated with nonatopic asthma at age 6 and 14 yrs (at age 14 yrs: OR 2.18, 95% CI 1.15-4.13) but not with atopic asthma. We found an increased risk of nonatopic asthma in children following frequent nocturnal awakening during the first 3 yrs of life.

These hypothesis-generating data suggest the need for further systematic study of the effects of disordered sleep in early life on the development of asthma.

Comparison of home and ambulatory blood pressure measurement in the diagnosis of masked hypertension.

J Hypertens. 2010 Jan 8. Hänninen MR , Niiranen TJ , Puukka PJ , Jula AM Population Studies Unit, Department of Chronic Disease Prevention, National Institute for Health and Welfare, Turku, Finland.

INTRODUCTION: The best method to diagnose masked hypertension is controversial. The objective of the present study was to compare home blood pressure (HBP) and ambulatory blood pressure (ABP) measurement in the evaluation of masked hypertension.

METHODS: Two hundred and sixty-one individuals from the general population underwent office BP (duplicate measurements on four visits), HBP (duplicate measurements on seven days) and 24-h ABP measurement, and risk factor evaluation. Target organ damage was assessed by echocardiography and 24-h urinary albumin measurement. Masked hypertension was defined as normal office BP (<140/90 mmHg) with elevated out-of-office BP (HBP >/=135/85 mmHg, daytime ABP >/=140/85 mmHg or both).

RESULTS: HBP and ABP detected 10.6 and 11.4% of masked hypertension, respectively. Only 59% of patients diagnosed as masked hypertensive with ABP measurement also had masked hypertension on HBP measurement. Masked hypertensive patients had higher BMI, waist-to-hip ratio and serum insulin levels than normotensive individuals. They also had greater waist-to-hip ratio than sustained hypertensive individuals. Target organ damage in masked hypertension was between that of normotension and that of sustained hypertension. Office normotensive individuals with elevated HBP tended to have higher rates of cardiovascular risk factors and target organ damage than patients with elevated ABP.

CONCLUSION: HBP and ABP detect a similar, but not an identical, group of masked hypertensive individuals. Their agreement in the diagnosis of masked hypertension is only moderate. Our results suggest that HBP measurement can be used to diagnose masked hypertension, but this diagnosis is not analogous with that made with ABP measurement.

A daily SMS reminder increases adherence to asthma treatment: A three-month follow-up study.

Respir Med. 2009 Oct 23. Strandbygaard U, Thomsen SF, Backer V. Department of Respiratory Medicine, Bispebjerg Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen NV, Denmark.

BACKGROUND: Poor adherence to asthma treatment is a well-recognised challenge and is associated with increased morbidity, mortality and consumption of health care resources. This study examined the impact of receiving a daily text message reminder on one's cell phone on adherence to asthma treatment.

METHODS: A total of 26 subjects aged 18-45 years, with a clinical history of asthma and a positive methacholine challenge test (PD(20)</=4mumol) were randomised to receive, or to not receive, a daily short message service (SMS) reminder on their cell phone to take their anti-asthmatic medication. Inhaled corticosteroids to last for eight weeks and a prescription for four additional weeks were given to the subjects. The primary outcome was adherence to asthma treatment. Secondary outcomes were reimbursement of asthma medication, and change in exhaled nitric oxide levels, lung function, and airway responsiveness.

RESULTS: The absolute difference in mean adherence rate between the two groups after 12 weeks was 17.8%, 95% CI (3.2-32.3%), p=0.019. No significant differences were observed between the two randomisation groups for the secondary outcomes.

CONCLUSION: Daily text message reminders are already after a short period of observation associated with increased adherence to anti-asthmatic medication.

Prevalence of asthma among adult females and males in the United States: results from the National Health and Nutrition Examination Survey (NHANES), 2001-2004.

J Asthma. 2009 Oct;46(8):759-66. McHugh MK, Symanski E, Pompeii LA, Delclos GL. Division of Environmental and Occupational Health Sciences, University of Texas School of Public Health, Houston, Texas 77030, USA.

BACKGROUND: The prevalence of asthma has increased over the last three decades with females exhibiting a higher prevalence of asthma than males. The objective of this study was to obtain gender-specific estimates of the prevalence of current and ever asthma and describe the relationships between risk factors and asthma by gender in US men and women ages 20 to 85.

METHODS: Data for this study came from two cycles (2001-2002 and 2003-2004) of National Health and Nutrition Examination Survey (NHANES) and included 9,243 eligible adults: 4,589 females and 4,654 males. Multiple logistic regression was used to investigate gender-specific associations between race/ethnicity, body mass index (BMI), sociodemographic characteristics, and smoking habits for current asthma and ever asthma.

RESULTS: The prevalence of current asthma was 8.8% for women and 5.8% for men, while the prevalence of ever having been diagnosed with asthma was higher (13.7% and 10.4% for women and men, respectively). Current asthma was less prevalent in Mexican American women (1.9%) and men (0.9%) born in Mexico as compared to Mexican Americans born in the U.S. (8.7% and 5.2% for women and men, respectively) or for any other ethnic group. Approximately 20% of extremely obese women and men had ever been diagnosed with asthma; among this group, 15% reported they had current asthma. Results from multiple logistic regression models indicate that extreme obesity and living in poverty were strongly associated with current and ever asthma for both women and men, as was former smoking and ever asthma for men.

CONCLUSION: As compared to previous NHANES reports, our results indicate that the prevalence of asthma among U.S. adults continues to increase. Further, our findings of marked differences among subgroups of the population suggest asthma-related disparities for impoverished persons and greater prevalence of asthma among obese and extremely obese US adults.

Delivery of asthma and allergy care in Europe.

J Asthma. 2009 Oct;46(8):767-72. Roberts N, Papageorgiou P, Partridge MR. Allergy Department, National & Kapodistrian University of Athens, Greece.

BACKGROUND: There is no comprehensive information available concerning the way in which care is provided for those with allergic conditions in Europe.

OBJECTIVE: To determine who cares for those with asthma, allergic dermatitis, and rhinitis in Europe and to determine the involvement of primary care and other healthcare professionals and the use of patient education and guidelines.

METHODS: A questionnaire survey of colleagues in 43 institutions in 33 European countries with results being related to published sources of information regarding prevalence of allergic diseases in different countries and published data regarding availability of doctors and expenditure on healthcare.

RESULTS: A total of 33 of 43 institutions completed the survey (76.7%) with information being obtained from 26 of the 33 countries surveyed (78.7%). There are wide differences in the use of different healthcare professionals in different countries, with those for asthma, for example, being most likely to be cared for by an allergologist in some countries and by a primary care physician in many others. There was much greater awareness of guidelines for asthma and little reported usage of guidelines in the management of those with allergic skin diseases, and while self-management education was offered most to those with asthma, there was a wide variation in the usage of group education.

CONCLUSIONS: Many of the differences revealed by this survey cannot be explained by the availability of different healthcare professionals nor by differences in healthcare expenditure, and such differences need further evaluation to determine their effect on outcomes and the economics of healthcare so that we may determine that which is optimal.

Predictors of asthma-related pediatric emergency department visits and hospitalizations.

J Asthma. 2009 Oct;46(8):829-34. Tolomeo C, Savrin C, Heinzer M, Bazzy-Asaad A. Pediatric Respiratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA.

OBJECTIVE: Asthma is a leading cause of emergency department visits and hospitalizations for children in the United States. As part of a larger study, the purpose of this analysis was to determine which variables were most effective at predicting subsequent pediatric asthma-related emergency department visits and hospitalizations.

METHODS: A retrospective, descriptive study was conducted. Subjects consisted of a convenience sample of 298 children admitted to a New England Children's Hospital in 2006 with a primary diagnosis of asthma. Data from two hospital databases were collected for 12 months before and 12 months after the 2006 admission. Basic descriptive statistics were followed by chi-square tests to determine which variables were associated with emergency department visits and hospitalizations. Logistic regression analysis was used to determine which variables were significant predictors of asthma-related emergency department visits and hospitalizations.

RESULTS: Sixty-percent of all subjects were male. Ninety subjects experienced a total of 145 emergency department visits and 54 experienced a total of 70 hospitalizations. A previous emergency department visit was a significant predictor of both subsequent emergency department visits and subsequent hospitalizations. Age was also an independent risk factor for subsequent hospitalizations. In this sample, the risk of a hospitalization increased with each year increase in age.

CONCLUSION: These findings support the importance of early identification of children with asthma so that appropriate asthma management can be instituted before an emergency department visit occurs. Furthermore, results suggest involving school-age and preadolescent children in the care of their asthma so that they can be equipped and encouraged to self-manage their own asthma.

Health-related quality of life in college students with and without childhood-onset asthma.

J Asthma. 2009 Oct;46(8):835-40. Fedele DA, Mullins LL, Eddington AR, Ryan JL, Junghans AN, Hullmann SE. Department of Psychology, Oklahoma State University, Stillwater, Oklahoma 74078, USA.

OBJECTIVE: The current study investigated whether differences existed in health-related quality of life between individuals who self-identified as having childhood-onset asthma and individuals without a chronic illness. Additionally, the relationship between perceived illness intrusiveness and illness uncertainty to health-related quality of life was explored.

METHODS: College undergraduates at least 18 years of age who self-identified as having childhood asthma were randomly matched by age and gender to healthy control participants. Participants completed a demographic form, the Mishel Uncertainty in Illness Scale-Community Form, the Illness Intrusiveness Scale, and the SF-36 Health Survey, a measure of health-related quality of life.

RESULTS: Participants with asthma had significantly lower scores on the total and mental health-related quality of life scales than did healthy control subjects. There were no significant differences between self-identified participants with asthma and matched healthy control subjects on physical health-related quality of life scales. Illness intrusiveness was not related to either the physical (e.g., physical functioning, general health) or mental health-related quality of life. Higher levels of illness uncertainty were significantly related to higher levels of mental health-related quality of life (e.g., vitality, mental health). In addition, participants with asthma scored significantly lower than healthy controls on the social functioning and role-emotional subscales.

CONCLUSION: The current study adds to the extant literature by examining the relationships between illness intrusiveness, illness uncertainty, and health-related quality of life among a young adult population. College students with asthma appear to be at risk for diminished quality of life compared to a healthy comparison group. Further examination of various domains of health-related quality of life among older adolescents and young adults with childhood asthma is needed.

Asthma and Serious Psychological Distress: Prevalence and Risk Factors among U.S. Adults, 2001-2007.

Chest. 2009 Oct 16. Oraka E, King ME, Callahan DB. Centers for Disease Control and Prevention, National Center for Environmental Health, Air Pollution and Respiratory Branch, Atlanta, Georgia (Mr. Oraka and Drs. King and Callahan); Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee (Mr. Oraka).

BACKGROUND: For millions of adults, effective control of asthma requires a regimen of care that may be compromised by psychological factors such as anxiety and depression. This study estimated the prevalence and risk factors for serious psychological distress (SPD) and explored their relationship to health-related quality of life (HRQOL) among adults with asthma in the United States.

METHODS: We analyzed data from 186,738 adult respondents from the 2001-2007 U.S. National Health Interview Survey. We calculated weighted average prevalence estimates of current asthma and SPD by demographic characteristics and health-related factors. We used logistic regression analysis to calculate odds ratios for factors that may have predicted asthma, SPD, and HRQOL.

RESULTS: >From 2001 to 2007, the average annual prevalence of current asthma was 7.0% and the average prevalence of SPD was 3.0%. Among adults with asthma, the prevalence of SPD was 7.5% (95% CI, 7.0-8.1%). A negative association between HRQOL and SPD was found for all adults, independent of asthma status. A similar pattern of risk factors predicted SPD and the co-occurrence of SPD and asthma, although adults with asthma who reported lower socioeconomic status, a history of smoking or alcohol use, and more comorbid chronic conditions had significantly higher odds of SPD.

CONCLUSION: This research suggests the importance of mental health screening for persons with asthma and the need for clinical and community-based interventions to target modifiable lifestyle factors that contribute to psychological distress and make asthma worse.

Perception of asthma as a factor in career choice among young adults with asthma

Can Respir J. 2009 Nov-Dec;16(6):e69-75. Bhinder S, Cicutto L, Abdel-Qadir HM, Tarlo SM. University of Toronto, Toronto, Canada.

BACKGROUND/AIM: Asthma is a common chronic condition that can be aggravated by workplace exposures. Young adults with asthma should know how their future occupation might affect their asthma, and potentially, their quality of life. The aim of the present study was to assess the awareness of young adults to occupational risks for asthma and high-risk occupations, as well as their perception of the role of asthma in career choice.

METHODS: Young adults 16 to 22 years of age with reported physiciandiagnosed asthma were recruited to complete a questionnaire eliciting information regarding asthma control, career choice and awareness of occupational exposure risks.

RESULTS: A small majority of the study cohort (56.4%) could identify occupations that cause or exacerbate asthma, and 34.7% indicated that asthma was an important factor in their career plans. Family physicians were most responsible for asthma management (80.2%), but young adults were more likely to discuss asthma and career plans with their parents (43.6%) or friends (29.7%) than with their family physician (13.9%; P<0.001).

CONCLUSION: Young adults with asthma have suboptimal awareness of potential work-related asthma risks. Family physicians most commonly provide asthma care to these young adults. However, few young adults are talking to their family physicians about career choices and asthma. This observation represents an area of asthma care that needs to be explored in young adults with asthma.

Patient compliance with assessing and monitoring of asthma

Background. The current asthma guidelines encourage use of a diary for assessing and monitoring symptoms and airway function. However, patient compliance and acceptability are usually poor owing to the burden of frequent and prolonged assessment.

Objective. We investigated whether better patient compliance could be ensured if a study was more relevant to patient convenience and had less impact on their daily life.

Methods. A total of 106 patients with symptomatic asthma underwent a fixed-time thrice-daily assessment schedule for a period lasting 2 weeks, and they were assigned to a doctor visit after the assessment. Symptoms and medication use were recorded in a booklet (paper diary) and airway function measured by a portable spirometer (electronic diary).

Results. Of 4,452 expected entries, the paper diary yielded 3,186 compliant entries and the electronic diary yielded 3,557 compliant entries; 71% of patients completed at least 30 compliant entries in the paper diary and 79% in the electronic diary. Use of an electronic device was associated with better compliance compared with paper technique (80.0% vs. 71.7%, p < 0.0001). Patient compliance decreased in the second week compared with the first week of diary keeping for both types of diaries (paper diary: 68.6% vs. 74.8%, p < 0.0001; electronic diary: 76.7% vs. 83.4%, p < 0.0001). The morning compliance was the least good, the afternoon better, and the evening best (paper diary: 68.2% vs. 71.0% vs. 75.9%, p < 0.0001; electronic diary: 77.2% vs. 79.0% vs. 83.9%, p < 0.0001). Among demographics and clinical factors, higher anxiety levels were linked to lower patient compliance.

Conclusion. Good patient compliance and acceptability can be achieved when a study takes into account patient convenience, uses user friendly electronic devices, and is less disruptive to patients' daily life.

Asthma control test and peak expiratory flow rate: independent pediatric asthma management tools.

J Asthma. 2009 Dec;46(10):1042-4. Chan M, Sitaraman S, Dosanjh A. Department of Pediatrics, University of California School of Medicine, La Jolla, California, USA.

Background: Management of asthma reflects the complexity of the pathogenesis. According to current National Heart Lung Blood Institute (NHLBI) guidelines, asthma control can be assessed using the validated asthma control test, measures of airway function, and overall assessment of risk and quality of life. We hypothesized that the asthma control test and measures of airway function are independent tools in asthma management. We also studied whether the presence of nasal symptoms is correlated to these measures.

Methods: Serial visits (n = 45) to a pediatric respiratory clinic in an underserved area of San Diego County with a predominantly Hispanic population were reviewed. Patients were included if they were able to perform airway function tests and had more than one provider visit. Patients with other major diseases were excluded. We determined whether uncontrolled asthmatics, defined as an Asthma Control test (ACT) score of 19 or less, had lower % predicted peak expiratory flow Measurements as a group compared to those with higher scores. In addition, the individual ACT and airway function results were analyzed. Patients with and without nasal symptoms at the time of presentation were sub-analyzed to determine differences in ACT and peak flow measurements.

Results: Based on n = 45 physician visits, the mean ACT score was 21 +/- 3.3 (range 12-25) and the mean peak expiratory flow rate (PEFR) was 87.4% +/- 11 (range 65-109%). Patients with ACT scores < / = to 19 or lower (< / = 90%) PEFRs were determined not to have more nasal symptoms. The measures of ACT and peak expiratory flow were independent and not correlated.

Conclusions. Our study indicates that ACT and PEFR are distinct parameters used to manage patients in a pediatric outreach asthma clinic.

Traffic-Related Air Pollution and the Development of Asthma and Allergies During The First 8 Years of Life.

Am J Respir Crit Care Med. 2009 Dec 3. Gehring U, Wijga AH, Brauer M, Fischer P, de Jongste JC, Kerkhof M, Oldenwening M, Smit HA, Brunekreef B. Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands.

RATIONALE: The role of air pollution exposure in the development of asthma, allergies, and related symptoms remains unclear due in part to the limited number of prospective cohort studies with sufficiently long follow-ups addressing this problem.

OBJECTIVES: We studied the association between traffic-related air pollution and the development of asthma, allergy, and related symptoms in a prospective birth cohort study with a unique 8-year follow-up.

METHODS: Annual questionnaire reports of asthma, hay fever, and related symptoms during the first 8 years of life were analyzed for 3,863 children. At age eight, measurements of allergic sensitization and bronchial hyperresponsiveness (BHR) were performed for subpopulations (n=1,700 and 936, respectively). Individual exposures to nitrogen dioxide (NO2), particulate matter (PM2.5), and soot at the birth address were estimated by land-use regression models. Associations between exposure to traffic-related air pollution and repeated measures of health outcomes were assessed by repeated-measures logistic regression analysis. Effects are presented for an interquartile range increase in exposure after adjusting for covariates.

MEASUREMENTS AND MAIN RESULTS: Annual prevalence was 3-6% for asthma and 12-23% for asthma symptoms. Annual incidence of asthma was 6% at age one, and 1-2% at later ages. PM2.5 levels were associated with a significant increase in incidence of asthma [odds ratio (95% confidence interval) 1.28 (1.10-1.49)], prevalence of asthma [1.26 (1.04-1.51)] , and prevalence of asthma symptoms [1.15 (1.02-1.28)]. Findings were similar for NO2 and soot. Associations were stronger for children who did not move since birth. Positive associations with hay fever were found in non-movers only. No associations were found with atopic eczema, allergic sensitization, and BHR.

CONCLUSIONS: Exposure to traffic-related air pollution may cause asthma in children.

Associated factors in children with chronic cough.

Chest. 2009 Sep;136(3):811-5. Khoshoo V, Edell D, Mohnot S, Haydel R Jr, Saturno E, Kobernick A. Pediatric Specialty Center, West Jefferson Medical Center, Marrero, LA 70072, USA.

BACKGROUND: Children presenting with chronic cough are common to the primary care physicians, but data on the etiology are scant.

METHODS: We evaluated 40 children (age range, 5 to 12 years) with chronic cough (> 8 weeks duration) with no obvious cause who were referred by their primary care physicians. All patients underwent an extensive multispecialty workup that included pulmonary, GI, allergy, immunology, and otorhinolaryngology testing. Response to treatment was quantified pretreatment and 8 weeks after treatment by using a visual analog scale.

RESULTS: Positive diagnostic test results were noted for gastroesophageal reflux disease (27.5%), allergy (22.5%), asthma (12.5%), infection (5%), aspiration (2.5%), and multiple etiologies (20%). Appropriate treatment for these factors resulted in a significant improvement in cough.

CONCLUSION: Reflux, allergy, and asthma accounted for > 80% of the likely etiologic factors of chronic cough in children and responded to appropriate treatment.

Airway Epithelial Changes in Smoking but not in Ex-Smoking Asthmatics.

Am J Respir Crit Care Med. 2009 Oct 1. Broekema M, Ten Hacken NH, Volbeda F, Lodewijk ME, Hylkema MN, Postma DS, Timens W. Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.

RATIONALE: Smoking has detrimental effects on asthma outcome defined by increased cough, wheezing, sputum production and frequency of asthma attacks. This ultimately results in accelerated lung function decline. At present, the underlying pathological process of smoke-induced deterioration of asthma is unknown.

OBJECTIVE: To compare bronchial inflammation and remodeling in never-, ex- and current smoking asthma patients.

METHODS: 147 asthma patients, 66 never-smokers, 46 ex-smokers and 35 current smokers were investigated.

MEASUREMENTS: Lung function, exhaled nitric oxide levels and symptom questionnaires were assessed and induced sputum and bronchial biopsies were obtained for determination of airway inflammation and remodeling.

MAIN RESULTS: Smoking asthmatics had lower FEV1 and alveolar and bronchial nitric oxide levels than never-smokers. In addition, smokers had more goblet cells and mucus-positive epithelium, increased epithelial thickness and a higher proliferation rate of intact and basal epithelium than ex- and never-smokers. Additionally, smokers had higher numbers of mast cells and lower numbers of eosinophils than never-smokers. Ex-smokers had similar goblet cell numbers and mucus-positive epithelium, and similar epithelial thickness, epithelial proliferation rate and mast cell numbers as never-smokers.

CONCLUSIONS: Smoking asthma patients have epithelial changes that associate with increased asthma symptoms such as shortness of breath and phlegm production. The fact that epithelial characteristics in ex-smokers are similar to those in never-smokers suggests that the smoke-induced changes can be reversed by smoking cessation.

The impact of uncontrolled asthma on absenteeism and health-related quality of life.

J Asthma. 2009 Nov;46(9):861-6. Dean BB, Calimlim BM, Kindermann SL, Khandker RK, Tinkelman D. Cerner LifeSciences, Beverly Hills, 9100 Wilshire Blvd., Suite 655-E, Beverly Hills, CA 90212, USA.

OBJECTIVE: To evaluate the impact of uncontrolled asthma on the absenteeism and health-related quality of life (HRQOL) of adults and children with asthma and the caregivers of pediatric patients.

PATIENTS AND METHODS: Patient information was obtained from datasets maintained by National Jewish Health for this cross-sectional study. Participants in the study were 12 years of age or older. Participants younger than 18 years had their information provided by caregivers. Caregivers also provided 6 months of absenteeism and QOL data. Participants were classified as having uncontrolled asthma based on a treatment and symptom guideline-based algorithm. Absenteeism was assessed from the self-reported number of work or school days missed due to asthma during the previous 6 months. HRQOL among adults was measured using the validated Marks Asthma Quality of Life Questionnaire (Marks-AQLQ) and among caregivers using the validated Pediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ). To account for the positive skew in absenteeism data, a zero-inflated Poisson regression model was used to compare group differences. HRQOL was analyzed for adults and caregivers using the Wilcoxon-Mann-Whitney test.

RESULTS: A total of 15,149 patients met the inclusion criteria for the study and were included in the analysis. Adults with uncontrolled asthma and caregivers of children with uncontrolled asthma reported significantly higher absenteeism than their controlled counterparts: 43% vs 24% adults reported missing days of work, with a median 6 days vs 3 days missed; 31% vs 16% of caregivers reported missing days of work, with 4 days vs 2 days missed; and caregivers reported that more than 70% vs 45% pediatric patients missed school, with a median of 6 days vs 4 days missed (uncontrolled vs controlled asthma, respectively). Adult uncontrolled asthmatics and caregivers of uncontrolled pediatric patients had significantly lower HRQOL as indicated by the Marks-AQLQ (scores 1.5 points higher, p < 0.001) and PACQLQ (scores < 0.5 points lower, p < 0.001), respectively.

CONCLUSIONS: Uncontrolled asthma has far-reaching impact on the productivity and quality of life of asthma patients and their caregivers. Proper assessment, treatment, and disease management to improve asthma control may reduce the impact of uncontrolled asthma on asthmatic adults, children, and the caretakers of pediatric asthmatic patients

Effectiveness of asthma education with and without a self-management plan in hospitalized children.

J Asthma. 2009 Nov;46(9):906-10. Espinoza-Palma T, Zamorano A, Arancibia F, Bustos MF, Silva MJ, Cardenas C, De La Barra P, Puente V, Cerda J, Castro-Rodriguez JA, Prado F. Department of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Cristobal Colón 3770 depto 75, Las condes, Santiago, Chile.

Background: Formal education in primary care can reduce asthma exacerbations. However, there are few studies in hospitalized children, with none originating in Latin America.

Methods: A prospective randomized study was designed to evaluate whether a full education with self-management plan (ESM) was more effective than an education without self-management plan (E) in reducing asthma hospitalization. Children (5 to 15 years of age) who were hospitalized for an asthma attack were divided in two groups. Children in the E group received general instructions based on a booklet. Those in the ESM group received the same booklet plus a self-management guide and a puzzle game that reinforces the lessons learned in the booklet. Patients were interviewed every 3 months, by telephone, for one year. Interviewers recording the number of hospitalizations, exacerbations, and emergency visits for asthma and oral steroid burst uses.

Results: From 88 children who met the inclusion criteria, 77 (86%) completed one year of follow-up (41 from E and 36 from ESM group). Overall, after one year, the hospitalization decreased by 66% and the inhaled corticosteroids therapy increased from 36% to 79%. At the end of the study, there was no difference in exacerbations, emergency visits, oral steroid burst uses, or hospitalizations between the two groups.

Conclusions: Asthma education with or without a self-management plan during asthma hospitalization were effective in reducing exacerbations, emergency visits, oral steroid burst uses, and future rehospitalizations. This evidence supports the importance of providing a complete asthma education plan in any patient who is admitted for asthma exacerbation.

Do asthma patients prefer to monitor symptoms or peak flow?

J Asthma. 2009 Nov;46(9):940-3. Harver A, Humphries CT, Kotses H. Department of Public Health Sciences, The University of North Carolina at Charlotte, 9201 University City Blvd., Charlotte, NC 28223-0001, USA.

We administered a 65-item survey to patients to assess preference of symptoms and peak flow to detect worsening asthma and to collect information about asthma triggers, asthma knowledge sources, and barriers to peak flow meter use. It was completed by 139 asthma patients. Survey responses were comparable for adult and pediatric patients and for those who owned peak flow meters and those who did not. But patients who owned a peak flow meter reported more severe asthma than others. On average, the patients preferred symptoms to peak flow for assessing worsening asthma. It is likely that the preference for symptom over peak flow monitoring was effort related: Patients preferred symptom monitoring because it was the easier of the two to conduct.

Close correlation between anxiety, depression, and asthma control.

Respir Med. 2009 Sep 2. Di Marco F, Verga M, Santus P, Giovannelli F, Busatto P, Neri M, Girbino G, Bonini S, Centanni S. Clinica di Malattie dell'Apparato Respiratorio, Ospedale San Paolo, Università degli Studi di Milano, Milano, Italy.

BACKGROUND: We investigated the correlation between patients' characteristics, including anxiety and depression, and the level of asthma control evaluated by asthma control test (ACT), a self-administered validated questionnaire.

METHODS: This is a cross-sectional study on asthmatic outpatients of three Italian hospitals. Demographic data, spirometry, anxiety and depression scores as well as the level of asthma control from 315 patients were collected.

RESULTS: Patients with poorly controlled asthma were more frequently women, older, with a worse pulmonary function, obese, more anxious and/or more depressed. Four different independent factors associated with poor asthma control evaluated by ACT have been found: FEV(1)<60% (odds ratio, OR: 6.52), anxiety (OR: 3.76), age >/=65years (OR: 2.69), and depression (OR: 2.45). The presence of anxiety and depression was associated with a higher healthcare utilization. Finally, we found a high level of agreement between ACT and multidimensional GINA approach in evaluating asthma control, with a concordance in 239 patients (81% of the population).

CONCLUSION: There is a close correlation between anxiety and depression, and a poor asthma. A better understanding of this association may have major clinical implications, mainly in patients with poor controlled asthma in whom the presence of anxiety and depression should be investigated.

Multicenter study of cigarette smoking among patients presenting to the emergency department with acute asthma.

Ann Allergy Asthma Immunol. 2009 Aug;103(2):121-7. Patel SN, Tsai CL, Boudreaux ED, Kilgannon JH, Sullivan AF, Blumenthal D, Camargo CA Jr. Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Cooper University Hospital, Camden 08103, USA.

BACKGROUND: Many studies have focused on smoking and chronic asthma severity. However, research on the relationship between smoking and acute asthma severity in an acute care setting is sparse.

OBJECTIVES: To determine the smoking prevalence among emergency department (ED) patients with acute asthma and to investigate the relationships between smoking and acute asthma severity.

METHODS: A 63-site medical record review study of ED patients, ages 14 to 54 years, with a principal diagnosis of acute asthma was performed. Patients with chronic obstructive pulmonary disease were excluded. Measurements for acute asthma severity included sociodemographic factors, asthma medical history, ED presentation, clinical course, medications administered, and return visit within 48 hours.

RESULTS: A total of 4,052 patient medical records were reviewed. A total of 1,332 patients (33%; 95% confidence interval, 31%-34%) were documented as smokers. No statistically significant differences were found between smokers and nonsmokers in vital signs, oxygen saturation, peak expiratory flow, and administration of asthma medications. By contrast, smokers were more likely than nonsmokers to receive antibiotics in the ED (12% vs 9%, P < .001) or at discharge (23% vs 14%, P < .001). A multivariate analysis confirmed that smoking status was independently associated with antibiotic administration (odds ratio, 1.6; 95% confidence interval, 1.3-1.8).

CONCLUSIONS: One-third of ED patients with acute asthma smoked cigarettes. Smokers and nonsmokers did not differ in their acute asthma severity. Asthmatic smokers, however, were more likely to receive antibiotics, even when adjusting for other possible confounders.

What defines airflow obstruction in asthma?

Eur Respir J. 2009 Sep;34(3):568-73 Cerveri I, Corsico AG, Accordini S, Cervio G, Ansaldo E, Grosso A, Niniano R, Tsana Tegomo E, Antó JM, Künzli N, Janson C, Sunyer J, Svanes C, Heinrich J, Schouten JP, Wjst M, Pozzi E, de Marco R. IRCCS San Matteo Hospital Foundation, University of Pavia, Italy.

Asthma guidelines from the Global Initiative for Asthma (GINA) and from the National Heart, Lung, and Blood Institute provide conflicting definitions of airflow obstruction, suggesting a fixed forced expiratory volume in 1 s (FEV(1))/forced vital capacity (FVC) cut-off point and the lower limit of normality (LLN), respectively. The LLN was recommended by the recent American Thoracic Society/European Respiratory Society guidelines on lung function testing. The problem in using fixed cut-off points is that they are set regardless of age and sex in an attempt to simplify diagnosis at the expense of misclassification. The sensitivity and specificity of fixed FEV(1)/FVC ratios of 0.70, 0.75 and 0.80 versus the LLN were evaluated in 815 subjects (aged 20-44 yrs) with a diagnosis of asthma within the framework of the European Community Respiratory Health Survey. In males, the 0.70 ratio showed 76.5% sensitivity and 100.0% specificity, the 0.75 ratio 100.0% sensitivity and 92.4% specificity, and the 0.80 ratio 100.0% sensitivity but 58.1% specificity. In females, the 0.70 ratio showed 57.3% sensitivity and 100.0% specificity, the 0.75 ratio 91.5% sensitivity and 95.9% specificity, and the 0.80 ratio 100.0% sensitivity but 72.9% specificity. The fixed cut-off points cause a lot of misidentification of airflow obstruction in young adults, with overestimation with the 0.80 ratio and underestimation with the 0.70 ratio.

In conclusion, the GINA guidelines should change their criteria for defining airflow obstruction.

Barriers to asthma management among urban families: caregiver and child perspectives

J Asthma. 2009 Sep;46(7):731-9. Laster N, Holsey CN, Shendell DG, McCarty FA, Celano M. Morehouse School of Medicine, Atlanta, Georgia, USA.

OBJECTIVE: Asthma is one of the most common chronic diseases of childhood. Those particularly affected are young, poor, African American children. Moreover, rates of emergency department visits, hospitalizations, and mortality are substantially higher for black children. Despite the ample published research on asthma prevalence and asthma management interventions, there is little research available on barriers to asthma care among urban, low-income families as perceived by children with asthma and their caregivers.

METHODS: This qualitative study analyzed data from five focus groups conducted with 28 participants in metropolitan Atlanta.

RESULTS: This study found caregiver and child health beliefs and perceptions concerning the use of daily controller medications to be a significant barrier to asthma care and proper self-management at home and at school. Barriers to environmental control consisted mostly of financial constraints, which made residential environmental remediation activities difficult to implement. Psychological distress was prevalent among both children and caregivers, which demonstrated the burden associated with managing a chronic illness.

CONCLUSION: Families in urban, low-income communities require asthma management interventions tailored to their specific characteristics, barriers, and challenges. Our findings can be used to inform and enhance asthma management interventions for urban families with children with asthma.

The strategy for predicting future exacerbation of asthma using a combination of the Asthma Control Test and lung function test.

J Asthma. 2009 Sep;46(7):677-82 Sato R, Tomita K, Sano H, Ichihashi H, Yamagata S, Sano A, Yamagata T, Miyara T, Iwanaga T, Muraki M, Tohda Y. Department of Respiratory Medicine and Allergology, Kinki University School of Medicine, Osaka-Sayama, Osaka, Japan.

BACKGROUND: Various factors have been reported to be useful for predicting future exacerbations.

OBJECTIVE: This study was intended to determine a usefulness of a combination of a patient-based questionnaire, such as the Asthma Control Test (ACT) score with objective assessments, such as forced expiratory volume in 1 second (FEV(1)) and/or exhaled nitric oxide (FE(NO)), for predicting future exacerbations in adult asthmatics.

METHODS: We therefore enrolled 78 subjects with mild to moderate asthma, who were clinically stable for 3 months who all had been regularly receiving inhaled steroid treatment. All subjects underwent a routine assessment of asthma control including the ACT score, spirometry, and FE(NO), and then were followed up until a severe exacerbation occurred. The predictors of an increased risk of severe exacerbation were identified and validated using decision trees based on a classification and regression tree (CART) analysis. The properties of the developed models were the evaluated with the area under the ROC curve (AUC) (95% confidence interval [CI]).

RESULTS: The CART analysis automatically selected the variables and cut-off points, the ACT score <or=23 and FEV(1) <or= 91.8%, with the greatest capacity for discriminating future exacerbations within one year or not. When the probability was calculated by the likelihood ratio of a positive test (LP), the ACT score <or=23 was identified with a 60.3% probability, calculated by 1.82 of LP, whereas the combined ACT score <or=23 and the percentage of predicted FEV(1) <or= 91.8% were identified with an 85.0% probability, calculated by an LP score of 5.43, for predicting future exacerbation.

CONCLUSION: These results demonstrated that combining the ACT score and percentage of predicted FEV(1), but not FE(NO,) can sufficiently stratify the risk for future exacerbations within one year.

Measuring asthma control is the first step to patient management: a literature review.

J Asthma. 2009 Sep;46(7):659-64. Halbert RJ, Tinkelman DG, Globe DR, Lin SL. Department of Community Health Sciences, UCLA School of Public Health, Los Angeles, California 90066, USA. halbert@ucla.edu

Asthma control is recognized as a critical aspect of the evaluation and management of the disease. Here we evaluate and compare existing instruments for measuring asthma control in an attempt to evaluate their clinical utility. Based on a literature review, we identified validated instruments used to assess asthma control in adults. We examined the specific measurement properties and the strengths and weaknesses of each instrument, and evaluated a single instrument, the Asthma Control Questionnaire (ACQ), more closely as an example, evaluating its applicability in the clinical setting. Our review identified five validated instruments designed to measure asthma control: the Asthma Control Questionnaire (ACQ), Asthma Control Scoring System (ACSS), Asthma Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), and the Lara Asthma Symptom Scale (LASS). None of the instruments covered all relevant control characteristics, but most were aligned with guideline definitions of control. All instruments demonstrated validity and responsiveness, with some measure of reliability. All instruments were short and easily administered, easy to interpret, and all had evidence to support their use in clinical decision making.

Association between obesity and asthma in US children and adolescents

J Asthma. 2009 Sep;46(7):642-6 Ahmad N, Biswas S, Bae S, Meador KE, Huang R, Singh KP. Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA.

BACKGROUND: To explore the association between obesity and asthma in US children and adolescents with adjustment of other structural and behavioral factors.

METHOD: Prevalence and associated risk factors of asthma were explored in 102,273 children and adolescents in the National Survey of Children's Health (2003-2004). Subgroup analysis was performed for subjects of 0-6 year-old, 7-12 year-old, and 13-17 year-old. Crude and adjusted odds ratios for the potential risk factors were examined in univariate and multivariate logistic regressions.

RESULTS: The overall prevalence of obesity was 24.5% and that of asthma was 12.5%. The adjusted odds ratio of asthma with obesity remains significantly bigger than 1 for children in the 7-12 and the 13-17 year-old age-groups. Gender and race were significantly associated with asthma in all age groups. The two parent family structure showed significant protectiveness against asthma with children in the 0-6 year-old age group. Poverty was positively associated with asthma in the 7-12 years old age group. Having a smoker in the household increased the odds of asthma by 29% and 23.5% in the 0-6 and 13-17 year-old age-groups, respectively. Higher education level of the parents and access to healthcare showed positive association with asthma in the 13-17 year-old age group.

CONCLUSION: Gender and race were significantly associated with asthma. In the 13-17 year-old age-groups, obesity, household education level, healthcare coverage, and household smoking were positively associated with asthma. Further studies should characterize how the family structure and household education level influence childhood asthma in 0-6 and 13-17 year-old age-groups respectively.

Home blood pressure monitoring in blood pressure control among haemodialysis patients: an open randomized clinical trial.

Nephrol Dial Transplant. 2009 Jul 8. da Silva GV, de Barros S, Abensur H, Ortega KC, Mion D Jr; Cochrane Renal Group Prospective Trial Register: CRG060800146. 1Nephrology Division, Hypertension Unit, University of São Paulo School of Medicine.

BACKGROUND: It is not known if the adjustment of antihypertensive therapy based on home blood pressure monitoring (HBPM) can improve blood pressure (BP) control among haemodialysis patients.

METHODS: This is an open randomized clinical trial. Hypertensive patients on haemodialysis were randomized to have the antihypertensive therapy adjusted based on predialysis BP measurements or HBPM. Before and after 6 months of follow-up, patients were submitted to ambulatory blood pressure monitoring (ABPM) for 24 h, HBPM during 1 week and echocardiogram.

RESULTS: A total of 34 and 31 patients completed the study in the HBPM and predialysis BP groups, respectively. At the end of study, the systolic (SBP) and diastolic (DBP) blood pressure during the interdialytic period measured by ABPM were significantly lower in the HBPM group in relation to the predialysis BP group (mean 24-h BP: 135 +/- 12 mmHg/76 +/- 7 mmHg versus 147 +/- 15 mmHg/79 +/- 8 mmHg; P < 0.05). In the HBPM analysis, the HBPM group showed a significant reduction only in SBP compared to the predialysis BP group (weekly mean: 144 +/- 21 mmHg versus 154 +/- 22 mmHg; P < 0.05). There were no differences between the HBPM and predialysis BP groups in relation to the left ventricular mass index at the end of the study (108 +/- 35 g/m(2) versus 110 +/- 33 g/m(2); P > 0.05).

CONCLUSIONS: Decision making based on HBPM among haemodialysis patients has led to a better BP control during the interdialytic period in comparison with predialysis BP measurements. HBPM may be a useful adjuvant instrument for blood pressure control among haemodialysis patients.

Effects of Alcohol and Sleep Restriction on Simulated Driving Performance in Untreated Patients With Obstructive Sleep Apnea

Annals of Internal Medicine 151(7):447-455, 6 October 2009 Andrew Vakulin, BSc (Hons); Stuart D. Baulk, PhD; Peter G. Catcheside, PhD; Nick A. Antic, MBBS, PhD; Cameron J. van den Heuvel, PhD; Jillian Dorrian, PhD; and R. Doug McEvoy, MD

Background: Because of previous sleep disturbance and sleep hypoxia, patients with obstructive sleep apnea (OSA) might be more vulnerable to the effects of alcohol and sleep restriction than healthy persons.

Objective: To compare the effects of sleep restriction and alcohol on driving simulator performance in patients with OSA and age-matched control participants.

Design: Driving simulator assessments in 2 groups under 3 different conditions presented in random order.

Setting: Adelaide Institute for Sleep Health, Sleep Laboratory, Adelaide, Australia.

Participants: 38 untreated patients with OSA and 20 control participants.

Measurements: Steering deviation, crashes, and braking reaction time.

Intervention: Unrestricted sleep, sleep restricted to a maximum of 4 hours, and ingestion of an amount of 40% vodka calculated to achieve a blood alcohol level of 0.05 g/dL.

Results: Patients with OSA demonstrated increased steering deviation compared with control participants (mean, 50.5 cm [95% CI, 46.1 to 54.9 cm] in the OSA group and 38.4 cm [CI, 32.4 to 44.4 cm] in the control group; P < 0.01) and significantly greater steering deterioration over time (group by time interaction, P = 0.02). The increase in steering deviation after sleep restriction and alcohol was approximately 40% greater in patients with OSA than in control participants (group by condition interaction, P = 0.04). Patients with OSA crashed more frequently than control participants (1 vs. 24 participants; odds ratio [OR], 25.4; P = 0.03) and crashed more frequently after sleep restriction (OR, 4.0; P < 0.01) and alcohol consumption (OR, 2.3; P = 0.02) than after normal sleep. In patients with OSA, prolonged eye closure (>2 seconds) and microsleeps (> 2 seconds of theta activity on electroencephalography) were significant crash predictors (OR, 19.2 and 7.2, respectively; P < 0.01). Braking reaction time was slower after sleep restriction than after normal sleep (mean, 1.39 [SD, 0.06] seconds vs. 1.22 [SD, 0.04] seconds; P < 0.01) but not after alcohol consumption. No group differences were found.

Limitation: Simulated driving was assessed rather than on-road driving.

Conclusion: Patients with OSA are more vulnerable than healthy persons to the effects of alcohol consumption and sleep restriction on various driving performance variables.

Obesity, Waist Size, and Prevalence of Current Asthma in the California Teachers Study Cohort.

Thorax. 2009 Aug 25. Von Behren J, Lipsett M, Horn-Ross PL, Delfino RJ, Gillilan F, McConnell R, Bernstein L, Clarke CA, Reynolds P. Northern California Cancer Center, United States.

Obesity is a risk factor for asthma, particularly in women, but few cohort studies have evaluated abdominal obesity, which reflects metabolic differences in visceral fat known to influence systemic inflammation. We examined the relationships of asthma prevalence with measures of abdominal obesity and adult weight gain, in addition to body mass index (BMI), in a large cohort of female teachers. We calculated prevalence odds ratios (ORs) for current asthma using multivariable linear modeling, adjusting for age, smoking, and race/ethnicity. Of the 88,304 women in the analyses, 13% (11,500) were obese (BMI >/= 30 kg/m2) at baseline; 1,334 were extremely obese (BMI >/= 40). Compared to those of normal weight, the adjusted OR for adult-onset asthma increased from 1.40 (95% confidence interval (CI): 1.31, 1.49) for overweight women to 3.30 (95% CI: 2.85, 3.82) for extremely obese women. Large waist circumference (> 88 cm) was associated with increased asthma prevalence even among women with a normal BMI (OR = 1.37, 95% CI: 1.18, 1.59). Among obese women, the OR for asthma was greater among those who were also abdominally obese compared to women whose waist was </=88 cm (2.36 vs. 1.57). Obese and overweight women were at greater risk of severe asthma episodes, measured by urgent medical visits and hospitalizations.

This study confirms the association between excess weight and asthma severity and prevalence, and showed that a large waist was associated with increased asthma prevalence even among women considered to have normal body weight.

Proactive integrated care improves quality of life in patients with COPD.

Eur Respir J. 2009 May;33(5):1031-8. Koff PB, Jones RH, Cashman JM, Voelkel NF, Vandivier RW. University of Colorado Hospital, Aurora, CO 80045, USA.

Self-management strategies improve a variety of health-related outcomes for patients with chronic obstructive pulmonary disease (COPD). These strategies, however, are primarily designed to improve chronic disease management and have not focused on early detection and early treatment of exacerbations. In COPD, the majority of exacerbations go unreported and treatment is frequently delayed, resulting in worsened outcomes. Therefore, a randomised clinical trial was designed to determine whether integration of self-management education with proactive remote disease monitoring would improve health-related outcomes. A total of 40 Global Initiative for Chronic Obstructive Lung Disease stage 3 or 4 COPD patients were randomised to receive proactive integrated care (PIC) or usual care (UC) over a 3-month period. The primary and secondary outcomes were change in quality of life, measured by the St George's Respiratory Questionnaire (SGRQ), and change in healthcare costs. PIC dramatically improved SGRQ by 10.3 units, compared to 0.6 units in the UC group. Healthcare costs declined in the PIC group by US$1,401, compared with an increase of US$1,709 in the UC group, but this was not statistically significant. PIC uncovered nine exacerbations, seven of which were unreported. Therefore, proactive integrated care has the potential to improve outcomes in chronic obstructive pulmonary disease patients through effects of self-management, as well as early detection and treatment of exacerbations.

Carbon monoxide pollution is associated with decreased lung function in asthmatic adults.

Eur Respir J. 2009 Aug 13. Canova C, Torresan S, Simonato L, Scapellato ML, Tessari R, Visentin A, Lotti M, Maestrelli P. University of Padova, Padova, Italy.

The aim of this study was to test the effects of exposure to air pollutants on lung function in a panel of 19 adult asthmatics living in Padova followed for five 30-day periods during two consecutive years (1492 morning and 1434 evening analyzed measures). Peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) were measured by a pocket electronic meter. Daily levels of air pollutants and meteorological variables were collected at city outdoor monitoring sites. We observed inverse statistically significant associations between morning and evening PEF and CO (p=0.01-0.03) without clear differences between lags (0-3 days). An increment of 1 mg.m(-3) of CO was associated to a PEF variation which ranged from -2.6% to -2.8%. All effect estimates on PEF for CO remained significant and even increased after controlling for PM10, NO2 and SO2 in single and multi-pollutant models. A similar trend was observed for FEV1, but the associations were not statistically significant. A not statistically significant inverse relationship between evening PEF and SO2 was also detected. PEF and FEV1 were not related to PM10 and NO2 concentrations.

Our results indicate that in this panel of adult asthmatics the worsening of lung function is associated with the exposure to gaseous pollutants and it occurs at levels of CO and SO2 lower than current European standards.

The overlap syndrome of asthma and COPD: what are its features and how important is it?

Thorax. 2009 Aug;64(8):728-35. Gibson PG, Simpson JL. Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Mail Centre, Newcastle, NSW 2310, Australia.

There is a need to re-evaluate the concept of asthma and chronic obstructive pulmonary disease (COPD) as separate conditions, and to consider situations when they may coexist, or when one condition may evolve into the other. Epidemiological studies show that in older people with obstructive airway disease, as many as half or more may have overlapping diagnoses of asthma and COPD (overlap syndrome). These people are typically excluded from current therapy trials, which limit the generalisability of these trials, and this presents a problem for evidence-based guidelines for obstructive airway diseases. Studying overlap syndrome may shed light on the mechanisms of COPD development. Overlap syndrome is recognised by the coexistence of increased variability of airflow in a patient with incompletely reversible airway obstruction. Patients typically have inflammatory features that resemble COPD, with increased airway neutrophilia, as well as features of airway wall remodelling. Overlap syndrome can develop when there is accelerated decline in lung function, or incomplete lung growth, or both. The risk factors for these events are shared, such that increasing age, bronchial hyper-responsiveness, tobacco smoke exposure, asthma and lower respiratory infections/exacerbations are significant risk factors for both incomplete lung growth and accelerated loss of lung function. Studying these events may offer new insights into the mechanisms and treatment of obstructive airway diseases.

Validating the Framingham Hypertension Risk Score. Results From the Whitehall II Study.

Hypertension. 2009 Jul 13. Kivimäki M, Batty GD, Singh-Manoux A, Ferrie JE, Tabak AG, Jokela M, Marmot MG, Davey Smith G, Shipley MJ. Department of Epidemiology and Public Health, University College London, London, United Kingdom; Institut National de la Sante' et de la Recherche Me'dicale, Paris, France; Medical Research Council Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom; Semmelweis University Faculty of Medicine, 1st Department of Medicine, Budapest, Hungary; Finnish Institute of Occupational Health and Department of Psychology, University of Helsinki, Helsinki, Finland; Medical Research Council Centre for Causal Analyses in Translational Epidemiology, Department of Social Medicine, University of Bristol, Bristol, United Kingdom.

A promising hypertension risk prediction score using data from the US Framingham Offspring Study has been developed, but this score has not been tested in other cohorts. We examined the predictive performance of the Framingham hypertension risk score in a European population, the Whitehall II Study. Participants were 6704 London-based civil servants aged 35 to 68 years, 31% women, free from prevalent hypertension, diabetes mellitus, and coronary heart disease. Standard clinical examinations of blood pressure, weight and height, current cigarette smoking, and parental history of hypertension were undertaken every 5 years for a total of 4 times. We recorded a total of 2043 incident (new-onset) cases of hypertension in three 5-year baseline follow-up data cycles. Both discrimination (C statistic: 0.80) and calibration (Hosmer-Lemeshow chi(2): 11.5) of the Framingham hypertension risk score were good. Agreement between the predicted and observed hypertension incidences was excellent across the risk score distribution. The overall predicted:observed ratio was 1.08, slightly better among individuals >50 years of age (0.99 in men and 1.02 in women) than in younger participants (1.16 in men and 1.18 in women). Reclassification with a modified score on the basis of our study population did not improve the prediction (net reclassification improvement: -0.5%; 95% CI: -2.5% to 1.5%).

These data suggest that the Framingham hypertension risk score provides a valid tool with which to estimate near-term risk of developing hypertension.

Effect of Modest Salt Reduction on Blood Pressure, Urinary Albumin, and Pulse Wave Velocity in White, Black, and Asian Mild Hypertensives.

Hypertension. 2009 Jul 20. He FJ, Marciniak M, Visagie E, Markandu ND, Anand V, Dalton RN, Macgregor GA. Blood Pressure Unit, Cardiac and Vascular Sciences, St. George's, University of London, UK; and the WellChild Laboratory, King's College London, Evelina Children's Hospital, UK.

A reduction in salt intake lowers blood pressure. However, most previous trials were in whites with few in blacks and Asians. Salt reduction may also reduce other cardiovascular risk factors (eg, urinary albumin excretion, arterial stiffness). However, few well-controlled trials have studied these effects. We carried out a randomized double-blind crossover trial of salt restriction with slow sodium or placebo, each for 6 weeks, in 71 whites, 69 blacks, and 29 Asians with untreated mildly raised blood pressure. From slow sodium to placebo, urinary sodium was reduced from 165+/-58 (+/-SD) to 110+/-49 mmol/24 hours (9.7 to 6.5 g/d salt). With this reduction in salt intake, there was a significant decrease in blood pressure from 146+/-13/91+/-8 to 141+/-12/88+/-9 mm Hg (P<0.001), urinary albumin from 10.2 (IQR: 6.8 to 18.9) to 9.1 (6.6 to 14.0) mg/24 hours (P<0.001), albumin/creatinine ratio from 0.81 (0.47 to 1.43) to 0.66 (0.44 to 1.22) mg/mmol (P<0.001), and carotid-femoral pulse wave velocity from 11.5+/-2.3 to 11.1+/-1.9 m/s (P<0.01). Subgroup analysis showed that the reductions in blood pressure and urinary albumin/creatinine ratio were significant in all groups, and the decrease in pulse wave velocity was significant in blacks only.

These results demonstrate that a modest reduction in salt intake, approximately the amount of the current public health recommendations, causes significant falls in blood pressure in all 3 ethnic groups. Furthermore, it reduces urinary albumin and improves large artery compliance. Although both could be attributable to the falls in blood pressure, they may carry additional benefits on reducing cardiovascular disease above that obtained from the blood pressure falls alone.

Approach to the diagnosis and management of suspected exercise-induced bronchoconstriction by primary care physicians.

BMC Pulm Med. 2009 Jun 15;9:29. Hull JH, Hull PJ, Parsons JP, Dickinson JW, Ansley L. School of Psychology & Sport Sciences, Northumbria University, Newcastle, UK.

BACKGROUND: Exercise-related respiratory symptoms in the diagnosis of exercise-induced bronchoconstriction (EIB) have poor predictive value. The aim of this study was to evaluate how athletes presenting with these symptoms are diagnosed and managed in primary care.

METHODS: An electronic survey was distributed to a random selection of family practitioners in England. The survey was designed to assess the frequency with which family practitioners encounter adults with exercise-related respiratory symptoms and how they would approach diagnostic work-up and management. The survey also evaluated awareness of and access to diagnostic tests in this setting and general knowledge of prescribing asthma treatments to competitive athletes.

RESULTS: 257 family practitioners completed the online survey. One-third of respondents indicated they encountered individuals with this problem at a frequency of more than one case per month. Over two-thirds of family practitioners chose investigation as an initial management strategy, while one-quarter would initiate treatment based on clinical information alone. PEFR pre- and post-exercise was the most commonly selected test for investigation (44%), followed by resting spirometry pre- and post-bronchodilator (35%). Short-acting beta2-agonists were the most frequently selected choice of treatment indicated by respondents (90%).

CONCLUSION: Family practitioners encounter individuals with exercise-related respiratory symptoms commonly and although objective testing is often employed in diagnostic work-up, the tests most frequently utilised are not the most accurate for diagnosis of EIB. This diagnostic approach may be dictated by the reported lack of access to more precise testing methods, or may reflect a lack of dissemination or awareness of current evidence. Overall the findings have implications both for the management and hence welfare of athletes presenting with this problem to family practitioners and also for the competitive athletes requiring therapeutic use exemption.

The role of physical activity and body mass index in the health care use of adults with asthma.

Ann Allergy Asthma Immunol. 2009 Jun;102(6):462-8 Dogra S, Baker J, Ardern CI. Lifespan Health and Performance Laboratory, York University, Toronto, Ontario, Canada.

BACKGROUND: Health care use in patients with asthma is affected by many factors, including sex and ethnicity. The role of physical activity (PA) and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) in this relationship is unknown.

OBJECTIVE: To determine the role of PA and BMI in the health care use of patients with asthma.

METHODS: A sample of adults with asthma (n=6,835) and without asthma (n=78,051) from cycle 3.1 of the Canadian Community Health Survey was identified. Health care use was self-reported as overnight hospital stays (yes or no), length of overnight hospital stay (<4 or > or =4 nights), and physician consultations (<3 or > or =3). Self-reported physical activities were used to derive total energy expenditure and to classify participants as active (>3.0 kcal/kg of body weight per day), moderately active (1.5-3.0 kcal/kg of body weight per day), and inactive (<1.5 kcal/kg of body weight per day). The BMI was categorized as normal weight (18.5-24.9), overweight (25.0-29.9), and obese (30.0-59.9).

RESULTS: Adjusted logistic regression models revealed that patients with asthma were more likely to have an overnight hospital stay (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.95-2.60), 4 or more overnight hospital stays (OR, 1.48; 95% CI, 1.12-1.96), and 3 or more physician consultations (OR, 2.43; 95% CI, 2.18-2.71) compared with patients without asthma (OR, 1.00). Inactive patients with asthma were more likely to have an overnight hospital stay (OR, 1.68; 95% CI, 1.31-2.16) and 3 or more physician consultations (OR, 1.23; 95% CI, 1.04-1.46) than active patients with asthma (OR, 1.00). Inactive/obese patients with asthma were 2.35 (95% CI, 1.69-3.27) times more likely to have an overnight hospital stay and 2.76 (95% CI, 2.11-3.60) times more likely to have 3 or more physician consultations than active/normal weight patients with asthma (OR, 1.00).

CONCLUSIONS: Higher PA levels are associated with lower health care use in individuals with and without asthma. In those with asthma, PA was a more important factor in overnight hospital stays than BMI, whereas both BMI and PA were important determinants of physician consultations.

An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice.

Am J Respir Crit Care Med. 2009 Jul 1;180(1):59-99. Reddel HK, Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, Casale TB, Chanez P, Enright PL, Gibson PG, de Jongste JC, Kerstjens HA, Lazarus SC, Levy ML, O'Byrne PM, Partridge MR, Pavord ID, Sears MR, Sterk PJ, Stoloff SW, Sullivan SD, Szefler SJ, Thomas MD, Wenzel SE; American Thoracic Society/European Respiratory Society Task Force on Asthma Control and Exacerbations.

BACKGROUND: The assessment of asthma control is pivotal to the evaluation of treatment response in individuals and in clinical trials. Previously, asthma control, severity, and exacerbations were defined and assessed in many different ways. PURPOSE: The Task Force was established to provide recommendations about standardization of outcomes relating to asthma control, severity, and exacerbations in clinical trials and clinical practice, for adults and children aged 6 years or older.

METHODS: A narrative literature review was conducted to evaluate the measurement properties and strengths/weaknesses of outcome measures relevant to asthma control and exacerbations. The review focused on diary variables, physiologic measurements, composite scores, biomarkers, quality of life questionnaires, and indirect measures.

RESULTS: The Task Force developed new definitions for asthma control, severity, and exacerbations, based on current treatment principles and clinical and research relevance. In view of current knowledge about the multiple domains of asthma and asthma control, no single outcome measure can adequately assess asthma control. Its assessment in clinical trials and in clinical practice should include components relevant to both of the goals of asthma treatment, namely achievement of best possible clinical control and reduction of future risk of adverse outcomes. Recommendations are provided for the assessment of asthma control in clinical trials and clinical practice, both at baseline and in the assessment of treatment response.

CONCLUSIONS: The Task Force recommendations provide a basis for a multicomponent assessment of asthma by clinicians, researchers, and other relevant groups in the design, conduct, and evaluation of clinical trials, and in clinical practice.

Asthma patients' perception of their ability to influence disease control and management

Ann Allergy Asthma Immunol. 2009 May;102(5):378-84. Laforest L, El Hasnaoui A, Pribil C, Ritleng C, Schwalm MS, Van Ganse E. CHU Lyon, Unité de Pharmacoépidémiologie, Service de Neurologie, Hôpital Pierre Wertheimer, Bron, France.

BACKGROUND: Patients' perception of their ability to influence their asthma symptoms has not been sufficiently addressed.

OBJECTIVE: To study the relationship between patients' perceived ability to self-care, as approached by internal locus of control (LOC) orientation, and concomitant level of asthma control.

METHODS: A cross-sectional study was conducted from May 19, 2004, through July 7, 2005. Asthma patients receiving inhaled corticosteroids and supervised in primary care were identified. Asthma control was measured with the Asthma Control Test. Patients reported their LOC orientation on a 100-mm visual analog scale (0%, "I have absolutely no influence on asthma change," to 100%, "this change only depends on me"). Asthma therapy was obtained from a prescription database. The risk of an internal LOC of less than 50% was studied.

RESULTS: Among the 163 patients with documented LOC (mean age, 52 years; 58% female), 72 (44.2%) had an internal LOC of less than 50%. Asthma control was inadequate for 65 of the 157 patients with available data on the global score of the Asthma Control Test (41.4%). Patients with inadequately controlled asthma had a higher risk of a LOC of less than 50% (odds ratio, 2.68; 95% confidence interval, 1.23-5.81). A 3-fold increased risk also appeared for patients older than 65 years compared with those younger than 45 years. Conversely, no association was identified with sex, asthma severity markers, or therapy.

CONCLUSIONS: Asthma control was related to internal LOC orientation (ie, perceived ability to self-care). Improved self-care efficiency is a target for adequate disease management.

Adherence to diagnostic guidelines and quality indicators in asthma and COPD in Swedish primary care.

Pharmacoepidemiol Drug Saf. 2009 May;18(5):393-400. Weidinger P, Nilsson JL, Lindblad U. Department of Clinical Sciences, Lund University, Malmö, Sweden.

PURPOSE: To study the clinical evaluation and treatment of patients with asthma and COPD in primary care in Sweden, with a focus on adherence to recommended guidelines and quality indicators.

METHODS: All visits at health care centres in Skaraborg, Sweden, are documented in computerized medical records constituting the Skaraborg Primary Care Database (SPCD). In a register-based retrospective observational study, all patients diagnosed with asthma or COPD during 2000-2005 (n = 12,328) were identified. In a 5% random sample (n = 623), information on performed investigations at initial visits and at follow-up during 2004-2005 was collected. Compliance with procedures as recommended by national guidelines was used for quality assessment.

RESULTS: Among 499 patients with asthma, 167 (33%) were investigated with spirometry or Peak Expiratory Flow (PEF) during initial visits in agreement with guidelines. Correspondingly, 40 out of 124 patients with COPD (32%) were investigated with spirometry. During follow-up, evaluation in agreement with guidelines was performed in 130 (60%) of patients with asthma and in 35 patients out of 77 (45%) with COPD. Prescribing of ICS reached quality target, still every second patient made an acute visit during follow-up.

CONCLUSION: Adherence to recommended guidelines in asthma/COPD was low. Acute visits were common and despite the prescribing of ICS according to recommendations, patients still seem uncontrolled in their disease. There is a need for quality improvement in the clinical evaluation and treatment of patients with asthma and COPD.

An international prospective general population-based study of respiratory work disability.

Thorax. 2009 Apr;64(4):339-44 Torén K, Zock JP, Kogevinas M, Plana E, Sunyer J, Radon K, Jarvis D, Kromhout H, d'Errico A, Payo F, Antó JM, Blanc PD. Department of Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Box 414, S-405 30 Göteborg, Sweden.

BACKGROUND: Previous cross-sectional studies have shown that job change due to breathing problems at the workplace (respiratory work disability) is common among adults of working age. That research indicated that occupational exposure to gases, dust and fumes was associated with job change due to breathing problems, although causal inferences have been tempered by the cross-sectional nature of previously available data. There is a need for general population-based prospective studies to assess the incidence of respiratory work disability and to delineate better the roles of potential predictors of respiratory work disability.

METHODS: A prospective general population cohort study was performed in 25 centres in 11 European countries and one centre in the USA. A longitudinal analysis was undertaken of the European Community Respiratory Health Survey including all participants employed at any point since the baseline survey, 6659 subjects randomly sampled and 779 subjects comprising all subjects reporting physician-diagnosed asthma. The main outcome measure was new-onset respiratory work disability, defined as a reported job change during follow-up attributed to breathing problems. Exposure to dusts (biological or mineral), gases or fumes during follow-up was recorded using a job-exposure matrix. Cox proportional hazard regression modelling was used to analyse such exposure as a predictor of time until job change due to breathing problems.

RESULTS: The incidence rate of respiratory work disability was 1.2/1000 person-years of observation in the random sample (95% CI 1.0 to 1.5) and 5.7/1000 person-years in the asthma cohort (95% CI 4.1 to 7.8). In the random population sample, as well as in the asthma cohort, high occupational exposure to biological dust, mineral dust or gases or fumes predicted increased risk of respiratory work disability. In the random sample, sex was not associated with increased risk of work disability while, in the asthma cohort, female sex was associated with an increased disability risk (hazard ratio 2.8, 95% CI 1.3 to 5.9).

CONCLUSIONS: Respiratory work disability is common overall. It is associated with workplace exposures that could be controlled through preventive measures.

Dyspnea is related to family functioning in adult asthmatics.

J Asthma. 2009 Apr;46(3):280-3. Furgał M, Nowobilski R, Pulka G, Polczyk R, de Barbaro B, Nizankowska-Mogilnicka E, Szczeklik A. Family Therapy Department, Jagiellonian University School of Medicine, Cracow, Poland.

OBJECTIVE: The aim of the study was to assess links between family relationships and severity of dyspnea identified in asthmatic adults.

MATERIALS: A total of 131 consecutive, non-selected patients with asthma participated in the study: 88 women (67.18%) and 43 men (32.82%). The mean age of the studied patients was 49.87 years, SD = 13.73. The majority of the study population consisted of patients with grade II (37.74%) and IV (34.91%) of the disease in terms of severity (according to the GINA classification, 2006).

STUDY PROTOCOL: All patients underwent functional respiratory tests. The subjective severity of dyspnea was assessed according to the ten-tier Borg scale. To evaluate family functioning values, the Family Assessment Questionnaire (FAQ) was used. Spouses of the asthmatic patients also completed questionnaires.

RESULTS: A significant relationship was identified between the values of the dimension: affective expression (assessment of the family performed by the asthmatic patient) and the severity of dyspnea (p = 0.03, r = -0.24) as well as between values of the dimensions: affective expression and affective involvement (as assessed by the spouse of the patient) and severity of dyspnea (p = 0.01, r = 0.39; p = 0.02, r = 0.34, respectively). The relationship between the severity of dyspnea declared by the patient and the FAQ dimension: Task accomplishment (as assessed by the spouse of the patient) was borderline (statistical significance [p = 0.06]).

CONCLUSIONS: (1) A relationship can be observed between the functioning of the asthmatic patient's family and the severity of the patient's declared dyspnea. Dyspnea constitutes a specific form of emotional communication in the inter-spouse relationships. (2) An analysis of the severity of dyspnea in asthmatic patients should take into account the context of the functioning of the patient's family.

Body mass index-percentile and diagnostic accuracy of childhood asthma.

J Asthma. 2009 Apr;46(3):291-9. Lang JE, Feng H, Lima JJ. Division of Pulmonology, Allergy & Immunology, Nemours Children's Clinic, Jacksonville, FL 32207, USA.

OBJECTIVE: To determine whether high BMI-percentile is associated with misdiagnosis of asthma among children referred to an asthma specialist.

METHODS: We queried the electronic records of children 8 to 18 years of age seen by a Nemours pediatric pulmonologist. All visits during a 6-year period with the chief complaint of asthma, or an asthma-like symptom such as wheeze, cough, or dyspnea, were included. We collected spirometry, blood counts, and immunoglobulin E (IgE) if available. We determined whether the child had referring physician-diagnosed asthma, specialist-diagnosed asthma, or both. Specialist-diagnosed asthmatics who met additional objective "gold-standard" criterion were labeled strict-criterion asthma.

RESULTS: Prevalence of high BMI-percentile was extremely common in all defined asthma groups, even those meeting strict criteria for diagnosis. Referring physician-diagnosed asthmatics did not have higher rates of obesity, and referring physician-diagnosed asthmatics had objective indicators of asthma that were the same as asthmatics diagnosed by a specialist. There was good diagnostic correlation between referring physicians and asthma specialists that was not affected by BMI. Among specialist-diagnosed asthmatics, increased BMI-percentile associated with significantly reduced forced expiratory volume in 1 second (FEV(1)), forced expiratory flow during the middle half of the forced vital capacity (FEF(25 - 75)), and FEV(1)/forced vital capacity (FVC); and significantly increased total blood leukocytes, neutrophils, and platelets compared to leans. For all 2,258 referrals, the estimated odds ratio of receiving a specialist-diagnosis of asthma increased by 0.4% with each increasing BMI percentile.

CONCLUSIONS: Referring physicians do not appear to erroneously diagnose children with asthma due to overweight status. Our data confirm that overweight status is extremely high in children with true asthma and likely increases the risk for true asthma. Although these data cannot discern causality, high BMI-percentile is associated with greater airflow obstruction and elevated markers of systemic inflammation that could contribute to underlying mechanisms of asthma.

Duration of television viewing in early childhood is associated with the subsequent development of asthma.

Thorax. 2009 Mar 13 Sherriff AM, Maitra A, Ness AR, Mattocks C, Riddoch C, Reilly J, Paton J, Henderson J. University of Glasgow, United Kingdom.

OBJECTIVES: To investigate whether duration of television (TV) viewing in young children is associated with subsequent development of asthma. DESIGN: Prospective longitudinal cohort study.

SETTING: Avon Longitudinal Study of Parents and Children (ALSPAC), United Kingdom.

PARTICIPANTS: Children taking part in Avon Longitudinal Study of Parents and Children (ALSPAC) with no wheeze up to 3 (1/2) years with follow up data at 11 (1/2) years.

MAIN OUTCOME MEASURES: Asthma defined as: Doctor diagnosed asthma by 7 (1/2) years with symptoms and/or treatment in last 12 months at 11 (1/2) years. Parental report of hours of children's television viewing per day was ascertained at 39 months.

RESULTS: In children asymptomatic for wheeze to 3(1/2) years with follow up data at 11(1/2) years, asthma prevalence was 6% (185/3065). Increased TV viewing at 3 (1/2) years was associated with increased prevalence of asthma at 11 (1/2) years (p for linear trend=0.0003). Children who watched television for more than 2 hours per day were almost twice as likely to develop asthma by 11 (1/2) years than those watching <2 hours TV per day (Adjusted Odds Ratio (AOR) (95% Confidence Interval) 1.8 (1.2 to 2.6)).

CONCLUSION: Longer duration of TV viewing in children asymptomatic for wheeze at 3(1/2) years was associated with the development of asthma in later childhood.

Association between asthma symptoms and obesity in preschool (4-5 year old) children.

J Asthma. 2009 May;46(4):362-5. Tai A, Volkmer R, Burton A. Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.

OBJECTIVE: There have been many publications looking at the association between asthma and obesity in school aged children and adolescents. There have been few studies looking at the association in preschool children.

METHODS: Questionnaire data on 1509 4- to 5-year-old children were collected in 2006 from the state of South Australia, Australia. The prevalence of asthma symptoms, allergic rhinitis and eczema was ascertained using the International Study of Asthma and Allergy in Childhood (ISAAC) questionnaire. Body mass index was calculated from height and weight data and prevalence of obesity was defined using the International Obesity Task Force (IOTF) definitions.

RESULTS: The prevalence of wheeze in the last 12 months in the preschool population was 23.7%. In the cohort, 199 (13.7%) children were classified as overweight and 83 (5.7%) children were classified as obese. A significant relationship was identified between "wheeze in the last 12 months" (p <.01), "wheeze ever" (p <.001) and "asthma ever" (p <.001) with the trend towards obesity. The relationship was significant for both male and female sex with the exception of "wheeze in the last 12 months" in obese females. (p = 0.09).

CONCLUSION: There is an association between asthma symptoms and obesity in preschool children. The relationship is evident for both male and female sex.

High prevalence of depression amongst mothers of children with asthma

J Asthma. 2009 May;46(4):388-91 Leão LL, Zhang L, Sousa PL, Mendoza-Sassi R, Chadha R, Lovatel R, Lincho CS, Leal RD, Sinzkel E, Nicoletti D, Martiello J. Postgraduate Program on Health and Behavior, Catholic University of Pelotas, Brazil.

OBJECTIVE: To compare the prevalence of depression among mothers of children with asthma and mothers of children without asthma and to investigate the influence of severity and duration of childhood asthma on maternal depression.

METHOD: A cross-sectional study including 80 mothers of children with asthma and 160 mothers of children without asthma who attended the pediatric outpatient clinics of a teaching hospital in Southern Brazil. The main outcome measure was the presence of depression in these mothers, measured by the Beck Depression Inventory.

RESULTS: The prevalence of depression was higher among mothers of asthmatic children compared with mothers of non-asthmatic children (43.8% vs. 17.5%, p < 0.001), with an adjusted prevalence ratio of 2.74 (95% confidence interval [CI] 1.76-4.25). Mothers of children with persistent asthma had a higher prevalence of depression than mothers of children with intermittent asthma (62.8% vs. 21.6%, p < 0.001), with an adjusted prevalence ratio of 2.77 (95% CI: 1.46-5.27). No significant association was observed between duration of childhood asthma and maternal depression.

CONCLUSION: Mothers of children with asthma have a higher prevalence of depression than mothers of children without asthma. The severity but not duration of childhood asthma is associated with maternal depression.

Deaths with asthma in France, 2000-2005: a multiple-cause analysis.

J Asthma. 2009 May;46(4):402-6 Fuhrman C, Jougla E, Uhry Z, Delmas MC. Institut de veille sanitaire, Saint-Maurice Cedex, France.

Mortality from asthma has decreased in many countries since the 1990s. Mortality statistics are usually based only on the underlying cause of death. The objectives of this study were to describe the characteristics of deaths and the trends in asthma-related mortality using multiple-cause analysis. Data were obtained from the French Centre of Epidemiology on Medical Causes of Death. Because ICD-10 was implemented in 2000, the analysis covers the period 2000-2005. In 2004-2005, asthma was the underlying cause of 42% of deaths with certificates mentioning asthma. The age-standardised rates of death from asthma decreased from 2000 through 2005 (-12% and -11%/year in the 1-44 and 45-64 age groups, respectively). The decline for all deaths with asthma was less pronounced (-9%/year in the 1-44 age group and -8%/year in the 45-64). Among adults aged 65 or older, the decrease in asthma-related mortality was higher in men (-12%/year for underlying cause, -9% for multiple-cause) than women (-5% and -3%, respectively). Since 2002, age-standardised rates of asthma-related mortality have been higher in women than men. In people aged 1-44 years, in-hospital deaths have declined between 2000 and 2005 while the proportion of non-hospital deaths increased from 53% to 67%.

Regardless of the definition used, the age-standardised rate of asthma-related deaths decreased from 2000 to 2005, and the faster decline for underlying cause than for multiple-cause mortality argues for a real decline in mortality attributable to asthma. Using multiple cause-of-death analysis provides additional information for asthma mortality surveillance.

Asthma and asthma severity among African American adults in the Jackson Heart Study.

J Asthma. 2009 May;46(4):421-8. Hickson DA, Wilhite RL, Petrini MF, White WB, Burchfiel C. Jackson State University, Jackson Heart Study, Coordinating Center, USA.

The aims of this study were to investigate the baseline prevalence of and risk factors associated with asthma, classify asthma severity, and describe medication use in a population-based sample of African American men and women 21 to 84 years of age from the Jackson Heart Study (JHS). Participants provided responses to respiratory and medical history questions and a medication inventory and underwent spirometry and other clinical examinations. These data were used to examine the extent to which novel and traditional risk factors were associated with asthma. Of the 4,098 participants included in this analysis, 9.4% reported lifetime asthma (5.7% current, 3.7% former), and current asthma was higher in women (6.8%) than in men (3.8%). An additional 9.8% reported an attack of wheeze with shortness of breath or non-doctor confirmed asthma (i.e., "probable" asthma). The mean forced expiratory volume in 1 second (FEV(1))% predicted was lower in those reporting current asthma (women: 83.7 +/- 18.0; men: 75.2 +/- 16.8) compared to those not reporting asthma (women: 95.6 +/- 16.7; men: 91.7 +/- 16.0). Current and probable asthma was associated with lower serum cortisol levels and hypertension medication use, along with traditional risk factors (i.e., lower socio-economic status, higher global stress scores, obesity, and fair to poor perceived general health). Severe asthma was low among participants reporting current (9.8%), former (3.3%), and probable (4.9%) asthma. Asthma medication use was reported by nearly 60% of the participants reporting current asthma. Asthma in African American adults is associated with decreased serum cortisol, hypertension medication use, and considerable lung function impairment compared to those who did not report asthma.

The prevalence of asthma in the JHS is lower than state and national estimates, although the estimates are not directly comparable. Furthermore, asthma is drastically underdiagnosed in this population.

Personality, adherence, asthma control and health-related quality of life in young adult asthmatics.

Respir Med. 2009 Feb 12. Axelsson M, Emilsson M, Brink E, Lundgren J, Torén K, Lötvall J. Department of Internal Medicine, Sahlgrenska Academy, University of Gothenburg, SE-405 30 Gothenburg, Sweden; Department of Nursing, Health and Culture, University West, SE-461 86 Trollhättan, Sweden.

BACKGROUND: Striving for improved adherence and asthma control is of vital concern in today's asthma management. Several influential factors have been identified, but the importance of personality traits has been insufficiently explored. The aim was first to determine whether personality traits in young adult asthmatics are related to asthma control and health-related quality of life (HRQL), and second to examine the influences of personality traits on adherence to regular asthma medication treatment.

METHODS: Young adult asthmatics, 22 years of age (n=268) completed questionnaires. Statistical analyses were performed.

RESULTS: The personality traits Negative Affectivity and Impulsivity correlated negatively with asthma control, whereas in women Hedonic Capacity correlated positively with asthma control. Negative Affectivity, Impulsivity, Hedonic Capacity, Alexithymia and asthma control predicted the mental dimension of HRQL. Asthma control and physical activity predicted the physical dimension of HRQL. Among respondents with regular asthma medication (n=109), Impulsivity correlated negatively with adherence. In men, Antagonism and Alexithymia were associated with low adherence. Additionally, Alexithymia, Hedonic Capacity and Negative Affectivity showed non-linear relationships with adherence, meaning that initially increased scores on these personality traits scales were associated with increased adherence but higher scores did not increase adherence. Respondents who were prescribed a single inhaler combining ICS and LABA reported higher adherence than those with monotherapies.

CONCLUSION: These data suggest that personality can influence how asthma patients adhere to asthma medication treatment, and report their control and HRQL. Tools determining personality traits may be useful in the future in individualizing management of asthma patients.

Control of asthma in children: still unacceptable? A French cross-sectional study.

Respir Med. 2009 Apr 8. de Blic J, Boucot I, Pribil C, Robert J, Huas D, Marguet C. Université Paris Descartes; Hôpital Necker Enfants Malades, Service de Pneumologie et d'Allergologie Pédiatriques, 149 rue de Sèvres, 75015 Paris, France.

BACKGROUND: The goal of asthma management focuses on adequate control of asthma, although little is known about the optimal level of asthma control to be reached. The ELIOS study was conducted in France to address this lack of information.

METHODS: Cross-sectional study of asthmatic children (4-15 years) visiting their medical practitioner. The primary objective was to assess the level of asthma control with a 3-level composite score based on French (ANAES) guidelines criteria (optimal, acceptable, and unacceptable).

RESULTS: Asthma control was assessed in 3431 children and classified as optimal (26%), acceptable (41.3%), and unacceptable (32.7%). When PEFR was studied, asthma control was optimal in 23.0%, acceptable in 35.8% and unacceptable in 41.2% (p<0.001) of children. Unacceptable asthma control was significantly associated with higher BMI (p=0.002), more recent diagnosis of asthma (p=0.008), passive exposure to parental tobacco smoke (p<0.001), number of associated allergic diseases (p<0.001), frequent respiratory tract infections (p<0.001) and low socioeconomic status (p<0.001). Multivariate analysis identified presence of respiratory tract infections (p<0.0001), passive exposure to parental tobacco smoke (p=0.009) and low socioeconomic status (p=0.042) as variables associated with unacceptable asthma control.

CONCLUSIONS: There is room for improvement in France as only 25% of asthmatic children are optimally controlled. Public health strategies should increase awareness among physicians and parents about the importance of using asthma control tools, eliminating exposure to tobacco smoke and treating associated allergic diseases.

Improving asthma care for the elderly: a randomized controlled trial using a simple telephone intervention.

J Asthma. 2009 Feb;46(1):30-5. Patel RR, Saltoun CA, Grammer LC. Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.

BACKGROUND: Several studies suggest that asthma is undertreated in the elderly population.

OBJECTIVE: To determine if the use of a simple telephone intervention can improve asthma care in the elderly.

METHODS: Fifty-two elderly subjects with asthma who required their rescue inhalers more than twice a week and had at least one emergency department or urgent care visit in the previous year were randomized to an intervention or control group. All subjects received two telephone calls over a 12-month period. The intervention group received an asthma-specific questionnaire and the control group received a general health questionnaire. Medication use and health care utilization were evaluated at the beginning and end of a 12-month period.

RESULTS: The study was completed by 23 control and 25 intervention subjects. Baseline data were similar in both groups. After 12 months, 72% (n = 18) of the intervention group were on an inhaled corticosteroid compared with 40% (n = 10) of the control group (p = 0.08). The intervention group had fewer emergency department visits when compared with the control group (p = 0.21). Sixty-four percent (n = 16) of the intervention group had an asthma action plan compared with 26% (n = 6) in the control group (p = 0.01).

CONCLUSION: This study suggests that asthma care in the elderly can be improved using a simple telephone intervention.

CLINICAL IMPLICATIONS: Clinicians need to recognize that under treatment of asthma in the elderly still exists and to use alternative methods such as a simple telephone questionnaire to improve care in this population.

Incremental direct expenditure of treating asthma in the United States.

J Asthma. 2009 Feb;46(1):73-80 Kamble S, Bharmal M. College of Health and Human Services, The University of North Carolina at Charlotte, Charlotte, North Carolina, USA.

OBJECTIVE: There is a wide range in the estimates of cost of asthma that are available in the literature. Given the growing prevalence of asthma and its associated healthcare resource use in the United States (U.S.), it is important to obtain current and precise cost estimates attributable to asthma treatment. The objectives of this study were to estimate the incremental direct expenditures associated with asthma in the U.S.

METHODS: Retrospective analysis was conducted using the 2004 Medical Expenditure Panel Survey (MEPS) data that are representative of the civilian non-institutionalized population of the U.S. Asthma respondents were identified as those with International Classification of Diseases-9-Clinical Modification (ICD-9-CM) diagnosis codes for asthma in 2004 or those who had a self-report of having asthma in 2004. Incremental total expenditures and expenditures for various categories of resource use including physician office visits, emergency room visits, outpatient visits, inpatient visits, medications, and other medical visits associated with asthma were estimated separately in children (age < 18 years) and in adults (age > or = 18 years) using generalized linear regression models. The models were adjusted for covariates including age, gender, race, ethnicity, education, marital status (for age group > or = 18 years), geographic region, insurance status, and comorbidities.

RESULTS: The prevalence of asthma among children and adults in 2004 was estimated at 8.7% (6.4 million persons) and 6.72% (14.8 million persons), respectively. The annual adjusted mean incremental total expenditure associated with asthma was $1,004.6 (SE: $326.1; p = 0.002) per person among children and was $2,077.5 (SE: $544.5; p < 0.0001) per person among adults, after adjusting for covariates. Prescription medications and physician office visits were the major drivers of total expenditures and constituted approximately 38% and 49% of the total incremental expenditures for asthma in children and adults, respectively. Inpatient visit expenditures were high in both age groups but were not significantly different from zero.

CONCLUSION: Given the prevalence of asthma among U.S. children and adults and its associated incremental expenditures, the annual direct medical expenditure attributable to asthma treatment is estimated at approximately $37.2 billion in 2007 U.S. dollars representing a significant portion of healthcare resource use in the U.S.

A population-based clinical study of allergic and non-allergic asthma.

J Asthma. 2009 Feb;46(1):91-4 Knudsen TB, Thomsen SF, Nolte H, Backer V. Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark.

BACKGROUND: The aim of this study was to describe differences between allergic and non-allergic asthma in a large community-based sample of Danish adolescents and adults.

METHODS: A total of 1,186 subjects, 14 to 44 years of age, who in a screening questionnaire had reported a history of airway symptoms suggestive of asthma and/or allergy, or who were taking any medication for these conditions were clinically examined. All participants were interviewed about respiratory symptoms, and furthermore skin test reactivity, lung function, and airway responsiveness were measured.

RESULTS: A total of 489 individuals had clinical asthma of whom 61% had allergic asthma, whereas 39% had non-allergic asthma. Subjects with non-allergic asthma were more likely to be females, OR = 2.24 (1.32-3.72), p = 0.003, and to have cough as the predominant symptom, OR = 1.96, (1.19-3.23), p = 0.008, but were less likely to have AHR, OR = 0.40, (0.24-0.66), p < 0.001, food allergy, OR = 0.28, (0.11-0.73), p = 0.009, and symptoms of rhinitis, OR = 0.08 (0.05-0.14) compared with subjects with allergic asthma. Subjects with non-allergic asthma had had persistent symptoms within the last 4 weeks more often than subjects with allergic asthma (68% vs. 53%), p = 0.001.

CONCLUSIONS: Non-allergic asthma accounts for two in every five cases of asthma in adults and constitutes symptomatically, and in terms of lung function, a more severe form of disease than allergic asthma.

Asthma, Airway Inflammation, and Epithelial Damage in Swimmers and Cold-air Athletes

Eur Respir J. 2009 Jan 7. Bougault V, Turmel J, St-Laurent J, Bertrand M, Boulet LP. Centre de Recherche, Hôpital Laval, Université Laval, Québec, Canada.

Endurance athletes show an increased prevalence of airway hyperresponsiveness. The aim of this study was to evaluate the long-term effects of training on airway responsiveness, inflammation and epithelial damage in swimmers and cold-air athletes.

Sixty-four elite athletes (32 swimmers and 32 cold-air athletes), 32 mild asthmatic subjects and 32 healthy controls had allergy skin prick testing, methacholine challenge and induced sputum analysis.

Sixty-nine percent of swimmers and 28% of cold-air athletes had airway hyperresponsiveness. Sputum neutrophil count correlated with the number of training hours per week in both swimmers and cold-air athletes (r=0.58 and 0.52 respectively). Eosinophil counts were higher in swimmers than in healthy subjects, although lower than in asthmatic subjects, and correlated with airway hyperresponsiveness in swimmers only (r=0.64). Eosinophil count in cold-air athlete was similar to healthy subjects. Bronchial epithelial cell count was not correlated with airway hyperresponsiveness but was significantly increased in swimmers, compared with healthy and asthmatic controls.

In conclusion, we observed significant airway inflammation only in competitive athletes with airway hyperresponsiveness. The majority of elite athletes showed however evidences of bronchial epithelial damage that could possibly contribute to the development of airway hyperresponsiveness.

Comparative Airway Response to High- vs Low-Molecular Weight Agents in Occupational Asthma

Eur Respir J. 2009 Jan 7. Dufour MH, Lemière C, Prince P, Boulet LP. Centre de recherche de, l'Hôpital Laval, Institut Universitaire de cardiologie et de, pneumologie, Hôpital Laval, Québec, Québec, Canada.

Airway responses to occupational agents in sensitized workers may vary, clinically and physiologically. We compared the patterns of change in airway responsiveness, type of response, and fall in expiratory flows following laboratory exposure to high or low molecular weight agents in sensitized workers.

Data on workers who underwent specific inhalation challenges with occupational sensitizers (117 exposed to HMW and 130 to LMW) were collected in their medical charts.

Maximum falls in FEV1 were of similar magnitude for both types of agents. Compared with high molecular weight agents, low molecular weight substances induced more frequently late or dual responses and higher increases in airway responsiveness. After exposure to high molecular weight agents, there was a mean reduction in doubling concentrations of methacholine (+/-SD) of 0.5+/-1.7 for early responses, compared to 2.8+/-1.2 for late responses, and 1.4+/-2.0 for dual responses. Isolated early responses were more frequently found in women, smokers, workers with a higher % predicted FEV1 and higher PC20, and in those with longer asthma duration.

Workers' characteristics, as well as the type of agent they are sensitized to, may help predict the type of response after specific inhalation challenge.

Maternal smoking and environmental tobacco smoke exposure and the risk of allergic diseases in Japanese infants: the Osaka Maternal and Child Health Study.

J Asthma. 2008 Nov;45(9):833-8 Tanaka K, Miyake Y, Sasaki S, Ohya Y, Hirota Y; Osaka Maternal and Child Health Study Group. Matsunaga I, Oda H, Kanzaki H, Kitada M, Horikoshi Y, Ishiko O, Nakai Y, Nishio J, Yamamasu S, Yasuda J, Kawai S, Yanagihara K, Wakuda K, Kawashima T, Narimoto K, Iwasa Y, Orino K, Tsunetoh I, Yoshida J, Iito J, Kaneko T, Kamiya T, Kuribayashi H, Taniguchi T, Takemura H, Morimoto Y. Department of Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.

PURPOSE: It remains controversial whether environmental tobacco smoke increases the risk of allergic diseases. The present prospective cohort study examined whether in utero exposure to maternal smoking and postnatal exposure to environmental tobacco smoke were associated with the development of wheeze, asthma, and atopic eczema in Japanese infants.

METHODS: Study subjects included 763 infants. Data were obtained through the use of questionnaires completed by the mother during pregnancy and at 2 to 9 and 16 to 24 months postdelivery. Information regarding maternal smoking during pregnancy and postnatal exposure to environmental tobacco smoke was collected at 2 to 9 months postdelivery, and information on allergic symptoms was collected when the infant was between 16 to 24 months of age. Cases were defined according to criteria of the International Study of Asthma and Allergies in Childhood for wheeze and atopic eczema. Additionally, doctor-diagnosed asthma and atopic eczema were identified. Adjustment was made for maternal age, family income, maternal and paternal education, parental history of asthma, atopic eczema, allergic rhinitis, indoor domestic pets, baby's older siblings, baby's sex, birth weight, and time of surveys.

RESULTS: The cumulative incidence of wheeze, atopic eczema, doctor-diagnosed asthma, and doctor-diagnosed atopic eczema was 22.1%, 18.6%, 4.3%, and 9.0%, respectively. Maternal smoking during pregnancy was not related to the risk of wheeze, whereas postnatal maternal smoking in the same room as the child increased the risk of wheeze. No significant association was observed between perinatal tobacco smoke exposure and the development of asthma and atopic eczema.

CONCLUSIONS: Our findings suggest that postnatal maternal smoking might be associated with an increased risk of wheeze in Japanese infants.

Food allergy is associated with potentially fatal childhood asthma

J Asthma. 2008 Dec;45(10):862-6 Vogel NM, Katz HT, Lopez R, Lang DM. The Children's Hospital, The Cleveland Clinic Foundation, Center for Pediatric Allergy and Immunology, Cleveland, Ohio 44195, USA.

BACKGROUND: Risk factors for potentially fatal childhood asthma are incompletely understood.

OBJECTIVE: To determine whether self-reported food allergy is significantly associated with potentially fatal childhood asthma.

STUDY DESIGN: Medical records from 72 patients admitted to a pediatric intensive care unit (PICU) for asthmatic exacerbation were reviewed and compared in a case-control design with 2 randomly selected groups of 108 patients admitted to a regular nursing floor for asthma and 108 ambulatory patients with asthma. Factors evaluated included self-reported food allergy, gender, age, poverty area residence, race/ethnicity, inhaled steroid exposure, tobacco exposure, length of hospital stay, psychologic comorbidity, and season of admission.

RESULTS: At least one food allergy was documented for 13% (38/288) of the patients. Egg, peanut, fish/shellfish, milk, and tree nut accounted for 78.6% of all food allergies. Children admitted to the PICU were significantly more likely to report food allergy (p = 0.004) and 3.3 times more likely to report at least one food allergy compared with children admitted to a regular nursing floor, and significantly more likely to report food allergy (p < 0.001) and 7.4 times more likely to report at least one food allergy compared with children seen in the ambulatory setting. Children admitted to either the PICU or the regular nursing floor were significantly more likely be African-American (p < 0.001) and to be younger (p < 0.01) compared with children seen in the ambulatory setting.

CONCLUSIONS: Self-reported food allergy is an independent risk factor for potentially fatal childhood asthma. Asthmatic children or adolescents with food allergy are a target population for more aggressive asthma management.

The relationship between disease control, symptom distress, functioning, and quality of life in adults with asthma

J Asthma. 2008 Dec;45(10):882-6 Oh EG. College of Nursing, Yonsei University, Seodaemun-Gu, Seoul, Republic of Korea.

PURPOSE: The purpose of this study was to evaluate quality of life (QOL) from a multidimensional perspective in relation to asthma control, symptom distress, and functioning in adults with asthma.

METHODS: A cross-sectional, mailing survey design was used. The convenience sample of 172 people diagnosed with asthma participated in this study. QOL, conceptualized as subjective satisfaction with life, was measured by the Quality of Life Index-Pulmonary Version III (QLI-PV III). Functioning was measured with the Living with Asthma Questionnaire (LWAQ). Instruments measuring asthma control and symptom experience have been developed for this study. Multiple regression and path analysis were used to examine the relationships.

RESULTS: The QOL was affected directly by functioning (beta = -0.70). Asthma control and symptom distress were indirectly influencing QOL. Among the predictors, direct paths were found between asthma control and functioning (gamma = 0.20), and between symptom distress and functioning (gamma = 0.57); 51% of the total variation in functioning was explained by symptom distress and asthma control; 48% of the total variation in QOL was explained by functioning.

CONCLUSION: The findings highlight the importance of symptom distress and control of asthma symptoms with respect to functioning and QOL in people with asthma.

Breathing exercises for asthma: a randomised controlled trial.

Thorax. 2008 Dec 3 Thomas M, McKinley RK, Mellor S, Watkin G, Holloway E, Scullion J, Shaw DE, Wardlaw A, Price D, Pavord I. University of Aberdeen, United Kingdom.

BACKGROUND: The effect of breathing modification techniques on asthma symptoms and objective disease control is uncertain.

METHODS: Prospective parallel-group single-blinded randomised controlled trial comparing breathing training with asthma education (to control for non-specific effects of clinician attention). Primary care managed asthmatic subjects with impaired health status were randomised to 3 sessions of either physiotherapist supervised breathing training (n=94) or asthma nurse delivered asthma education (n=89). The main outcome was Asthma Quality of Life Questionnaire (AQLQ) score, with secondary outcomes including spirometry, bronchial hyperresponsiveness, exhaled nitric oxide, induced sputum eosinophil count, and Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression (HAD) and hyperventilation (Nijmegen) questionnaire scores.

RESULTS: 1-month post-intervention, similar improvements in AQLQ scores from baseline occurred in both groups, but at 6 months significant between-group difference favouring breathing training were observed (0.38, 95% confidence interval 0.08 to 0.68 units). At the 6-month assessment, significant between-group differences favouring breathing training were seen in HAD-anxiety (1.1, 0.2 to 1.9), HAD-depression (0.8, 0.1 to 1.4) and Nijmengen (3.2, 1.0 to 5.4) scores, with trends to improved ACQ (0.2, 0.0 to 0.4). No significant between-group differences were seen at 1 month. Breathing training was not associated with significant changes in airways physiology, inflammation or hyperresponsiveness.

CONCLUSION: Breathing training resulted in improvements in asthma-specific health status and other patient-centred measures but not in asthma pathophysiology. Such exercises may help patients whose quality of life is impaired by asthma but are unlikely to reduce the need for anti-inflammatory medication.

Health-related quality of life predicts onset of asthma in a longitudinal population study.

Respir Med. 2008 Nov 27. Leander M, Cronqvist A, Janson C, Uddenfeldt M, Rask-Andersen A. Department of Medical Sciences, Occupational and Environmental Medicine, Uppsala University, Uppsala, Sweden; Ersta Sköndal University College, Department of Health Care Sciences, Stockholm, Sweden.

BACKGROUND: Health-related quality of life (HRQL) has been increasingly used as an outcome measure in asthma, but less is known about the prognostic implication of low health-related quality of life. The purpose of this study was to investigate if a set of quality of life measures could predict onset of asthma.

METHODS: In the baseline study 391 subjects without asthma answered a respiratory questionnaire and the Gothenburg Quality of Life (GQL) instrument in 1990. The GQL questionnaire included two parts: (1) the prevalence of HRQL-related symptoms and (2) well-being scores for physical, mental and social dimensions. The participants were also investigated with spirometry and allergy testing. In 2003, the same respiratory questionnaire that had been used in 1990 was sent. There were 290 responders, of whom 22 subjects had developed asthma.

RESULTS: Participants who had developed asthma by the follow-up had a higher prevalence of sleep disturbances (30% vs. 10%), problems with chest pain (16% vs. 2%), depression (40% vs. 20%) difficulty relaxing (40% vs. 13%) and constipation (25% vs. 2%) at baseline than participants who did not develop asthma (p<0.05). Subjects who developed asthma also scored significantly lower on well-being variables as sleep, energy, mood, patience, memory, appetite, fitness and sense of appreciation outside home. These differences remained after adjusting for age, sex, smoking habits, asthma heredity, socioeconomic groups and building dampness.

CONCLUSION: Participants with low health-related quality of life at baseline were more likely to report having developed asthma 12 years later.

Obesity and exercise habits of asthmatic patients.

Ann Allergy Asthma Immunol. 2008 Nov;101(5):488-94. Westermann H, Choi TN, Briggs WM, Charlson ME, Mancuso CA. Weill Cornell Medical College, New York, New York, USA.

BACKGROUND: National guidelines recommend 20 to 30 minutes of exercise 3 to 5 days a week. However, achieving these goals may be challenging for asthmatic patients whose symptoms are exacerbated by exercise.

OBJECTIVE: To describe relationships among exercise habits, weight, and asthma severity and control in adults with asthma.

METHODS: Self-reported exercise habits were obtained from 258 stable patients by using the Paffenbarger Physical Activity and Exercise Index. Disease status was measured by using the Asthma Control Questionnaire and the Severity of Asthma Scale. Exercise habits were evaluated in multivariate analyses with age, sex, education, body mass index, and asthma control and severity as independent variables.

RESULTS: The mean patient age was 42 years; 75% were women, 62% were college graduates, and 40% were obese. Only 44% of patients did any exercise. In bivariate analysis, patients with well-controlled asthma were more likely to exercise; however, in multivariate analysis, asthma control and severity were not associated, but male sex (P = .01), having more education (P = .04), and not being obese (P < .001) were associated. Asthma control and severity also were not associated with type, duration, or frequency of exercise, but not being obese was associated in multivariate analyses. Only 22% of all patients (49% of those who exercised) met national guidelines for weekly exercise. Not being obese was the only variable associated with meeting guidelines in multivariate analysis (P = .02).

CONCLUSIONS: Compared with the general population, a lower proportion of asthmatic patients did any routine exercise and met national exercise guidelines. Physicians need to manage asthma and obesity to help asthmatic patients meet exercise goals.

Economic burden prior to COPD diagnosis: a matched case-control study in the United States.

Respir Med. 2008 Dec;102(12):1744-52. Akazawa M, Halpern R, Riedel AA, Stanford RH, Dalal A, Blanchette CM. Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

BACKGROUND: In the United States, chronic obstructive pulmonary disease (COPD) diagnosis is often a lengthy process, and consequently results in delays in treatment in early stages. Disease progression and complication may result in increased levels of healthcare service use. To understand the economic burden of COPD prior to diagnosis in the U.S., trends in utilization and costs during the period before initial COPD diagnosis were compared with matched controls.

METHODS: A retrospective case-control study was conducted using medical and pharmacy claims data from a large managed care health plan representing a base population of over 30 million covered lives in the U.S. COPD patients with at least 12 months of continuous enrollment and aged 40 years or older were identified (n=28,968) and matched to up to three random controls (n=81,322) by age, gender, region of plans and index date. Multivariate regression models were used to estimate average incremental service use and cost between COPD patients and controls. Moreover, trends in utilization and costs for the COPD patients were examined over 36 months before diagnosis.

RESULTS: COPD patients used 1.5-1.6 times more inpatient/emergency department (IP/ED) services and office visits compared to control patients. The average incremental annual costs for IP/ED services, office visits, and medical and pharmacy services were estimated at $550, $238, $1438 and $401, respectively, after adjusting for age, gender, region and comorbid conditions. The 36-month trend analysis showed that COPD patients' healthcare utilization and costs increased gradually over time, often with a marked increase in the month before COPD diagnosis.

CONCLUSIONS: COPD patients in the U.S. consumed substantial healthcare services and costs prior to diagnosis. More timely diagnosis and subsequent treatment may avoid costly healthcare utilization and unnecessary mortality and morbidity post-diagnosis.

Validity of Asthma Control Test for Asthma Control Assessment in Chinese Primary Care Settings.

Chest. 2008 Dec 31. Zhou X, Ding FM, Lin JT, Yin KS. From the Department of Respiratory Medicine (Drs. Zhou and Ding), Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, People's Republic of China; the Department of Respiratory Medicine (Dr. Lin), Sino-Japan Friendship Hospital, Beijing, People's Republic of China; and the Department of Respiratory Medicine (Dr. Yin), First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China.

Objective: To evaluate the validity of Asthma Control Test (ACT) for assessing clinical asthma control in Chinese patients in primary care settings.

Methods: This multicenter study involved 403 asthma patients from 15 primary care settings in China, who completed ACT, Asthma Control Questionnaire (ACQ) and spirometry test. According to the rating of asthma control by asthma specialists in line with the Global Initiative for Asthma (GINA) 2006 guidelines, patients were divided into uncontrolled, partly controlled and controlled groups to evaluate the reliability, empirical validity and screening accuracy of ACT. The screening accuracy of ACT and ACQ was analyzed comparatively, and the asthma control levels rated by the patients and the specialists were also compared.

Results: The 5-item ACT had an internal consistency reliability of 0.861 and a correlation coefficient with the specialists' rating of 0.697. The ACT scores showed significant differences between different levels of percent predicted FEV(1) (F=37.59, p < 0.0001) and specialists' ratings of asthma control (F=169.53, p < 0.0001), and also between patients requiring different treatment adjustments (F=111.33, p < 0.0001). The asthma was controlled for an ACT score of 20 or above, partly controlled for a score of 19 and 18, and uncontrolled for a score of 17 or below. ACT showed similar percentages of correctly classified result with ACQ. The patients' self-rated asthma control level was significantly higher than that rated by the specialists (Z=5.93, p < 0.0001).

Conclusions: ACT is reliable, valid and practicable for asthma control assessment in Chinese patients in the primary care settings.

The use of microspirometry in detecting lowered FEV1 values in current or former cigarette smokers.

Prim Care Respir J. 2008 Dec;17(4):232-7. Rytila P, Helin T, Kinnula V. Division of Allergology, Helsinki University Central Hospital, Helsinki, Finland.

AIMS: COPD is an underdiagnosed disease. This study was undertaken to assess the value of microspirometry in detecting reduced FEV1 values in cigarette smokers i.e. subjects at high risk for COPD.

METHODS: A total of 611 smokers or ex-smokers with a smoking history >20 years and no previously-diagnosed lung disease were recruited (389 male, age 27-83 years, mean age 56 years, mean smoking history 35 pack years, 19% ex-smokers).

RESULTS: An FEV1 < 80% predicted on microspirometry was found in 44.6% of cases. The mean FEV1 was 2.8 litres (80.6% predicted, range 26-121%). This correlated well with values obtained from full spirometry (R=0.965, p<0.0001). Detailed questionnaire responses revealed that almost half of the subjects (48.2%) reported chronic cough and sputum production and 39.8% reported breathlessness during exercise.

CONCLUSIONS: Microspirometry finds a considerable number of smokers or ex-smokers with reduced FEV1 values. Microspirometry is quick to perform. All smokers with reduced microspirometry FEV1 values would benefit from smoking cessation, and all patients with reduced FEV1 values need to be considered for full spirometry to confirm if they actually have COPD.

Gender differences in the prevalence of airway hyperresponsiveness and asthma in athletes.

Respir Med. 2008 Nov 20. Langdeau JB, Day A, Turcotte H, Boulet LP. Centre de Recherche de l'Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Qc, Canada.

BACKGROUND: Although athletes have a high prevalence of airway hyperresponsiveness (AHR) and asthma, little is known about possible gender differences in regard to these features. We looked at the comparative prevalence of AHR, physician-diagnosed asthma and respiratory symptoms during exercise in female (F) and male (M) athletes.

METHOD: A retrospective analysis was done on 2 groups of athletes: Group 1 (n=100) taking part in a study on the prevalence of AHR to methacholine (PC(20)<16mg/ml) and Group 2 (n=698), taking part in a provincial survey on the prevalence of physician-diagnosed asthma. Subjects from both groups filled the same questionnaire on respiratory symptoms during exercise (breathlessness, wheezing and chest tightness).

RESULTS: In Group 1, prevalence of AHR was significantly higher in female (60%) compared with male (21.5%, p<0.0001) athletes despite a similar prevalence of physician-diagnosed asthma (F: 17.1%, M: 15.4%, p>0.05). Respiratory symptoms during exercise were more frequently reported in females (37.1%, M: 16.9%, p=0.02); however, when corrected for the PC(20), this difference became non-significant. In Group 2, the prevalence of physician-diagnosed asthma was not different between genders (F: 12.5%, M: 14%, p>0.05) but respiratory symptoms during exercise were more often reported in female (19.4%) than in male (12.2%, p=0.01) athletes.

CONCLUSIONS: This analysis shows a higher prevalence of AHR and exercise-induced respiratory symptoms in female compared to male athletes, but a similar prevalence of physician-diagnosed asthma. This suggested that the increase in respiratory symptoms in female athletes failed to translate into a higher prevalence of physician-diagnosed asthma.

Childhood Asthma and Increased Airway Responsiveness-- A Relationship that Begins in Infancy

Am J Respir Crit Care Med. 2008 Oct 31 Turner SW, Young S, Goldblatt J, Landau LI, Le Souef PN. School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.

INTRODUCTION: Asthma is associated with increased airway responsiveness (AR) but the age when this relationship becomes established is not clear. The present study tested the hypothesis that the association between increased AR and asthma is established after one month of age.

METHODS: As part of a birth cohort study, AR was determined at ages one (early infancy), six (mid infancy) and twelve months (late infancy). At eleven years of age (childhood), AR and the presence of asthma symptoms were determined.

RESULTS: Of the 253 study subjects enrolled, AR was determined in 202 in early infancy, 174 in mid infancy, 147 in late infancy and 176 in childhood. Increased AR in late infancy, but not early or mid infancy, was associated with increased wheeze at age 11 years (p=0.016). Increased AR in infancy persisted into childhood in association with male gender, early respiratory illness and maternal smoking and asthma. Among those 116 assessed in both late infancy and childhood, recent wheeze was present in 35% of children with increased AR at both ages, 13% with increased AR in childhood only, 12% for those with increased AR in late infancy only and 0% for those who did not have increased AR at either age, p=0.005; the proportions of children with diagnosed asthma in the corresponding groups were 27%, 20%, 12% and 0%, p=0.037.

CONCLUSIONS: The association between increased infantile AR and childhood asthma emerges at the end of the first year of life.

The burden of rhinitis in a managed care organization

Ann Allergy Asthma Immunol. 2008 Sep;101(3):240-7 Schatz M, Zeiger RS, Chen W, Yang SJ, Corrao MA, Quinn VP. Department of Allergy, Kaiser Permanente Southern California, San Diego, California 92111, USA.

BACKGROUND: Rhinitis is a common health condition, but the extent of the burden in managed care organizations (MCOs) has not been well described.

OBJECTIVE: To compare medical utilization in a large MCO of patients (1) with vs without rhinitis and (2) with allergic (AR) vs nonallergic (NAR) rhinitis.

METHODS: Patients 4 years and older with 1 or more encounters with an International Classification of Diseases, Ninth Revision, code for rhinitis and patients treated for rhinitis but without a rhinitis encounter (rhinitis treatment-only group) were identified. Patients seen in allergy departments for rhinitis were categorized as having AR or NAR.

RESULTS: Of 1,726,084 patients continuously enrolled for all 4 study years, 29% had 1 or more encounters for rhinitis (15%) or were treated for rhinitis (14%). Compared with patients without rhinitis, those with rhinitis encounters were significantly more likely to have encounters for asthma (odds ratio [OR], 2.7), acute sinusitis (OR, 4.4), chronic sinusitis (OR, 15.2), conjunctivitis (OR, 1.5), acute otitis media (OR, 1.9), chronic otitis media (OR, 4.3), sleep apnea (OR, 3.4), and fatigue (OR, 2.0). Results for rhinitis treatment-only patients (n = 242,565) were generally similar to those for rhinitis encounter patients. NAR was diagnosed in 21% of patients, who were significantly more likely than patients with AR to undergo sinus radiology and nasal surgery; to receive diagnoses of sinusitis, otitis media, sleep apnea, and fatigue; and to receive medications for nonrespiratory conditions (P < .001).

CONCLUSIONS: Rhinitis was common in this large MCO. Patients with rhinitis, especially NAR, had significantly more respiratory and nonrespiratory comorbid conditions than did patients without rhinitis.

Electronic medical records in a sub-specialty practice: one asthma center's experience

J Asthma. 2008 Nov;45(9):849-51 Tolomeo C, Shiffman R, Bazzy-Asaad A. Yale School of Medicine, Pediatric Respiratory Medicine, New Haven, CT 06520-8064, USA.

There are numerous known benefits associated with the use of an electronic medical record (EMR). In October of 2004, a pediatric respiratory medicine practice at a major academic institution began the process of implementing an EMR system. Through this process, another benefit was realized, improved coordination between out-patient and in-patient care in relation to asthma education. The process began with the formation of an implementation team. The team consisted of technical as well as clinical experts from various disciplines. Together the team developed templates, decision support tools and standardized patient care letters. The team also determined workflow and provided training on the EMR system. A major benefit associated with EMR implementation was the increase in the number of children who were hospitalized with an asthma exacerbation and received an asthma action plan upon discharge. Prior to the EMR system, 4% received an asthma action plan upon discharge. After implementation of the EMR system, 58% received an asthma action plan upon discharge.

The prevalence of asthma in an NCAA Division I collegiate athletic program.

J Asthma. 2008 Nov;45(9):845-8. Zoz DF, Parsons JP, Oman JL, Phillips G, Kaeding CC, Best TM, Mastronarde JG. Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH, USA.

PURPOSE: To determine the prevalence of asthma among all varsity athletes in a large National Collegiate Athletic Association (NCAA) Division I program.

METHODS: We retrospectively reviewed the medical records for all varsity athletes at The Ohio State University (OSU). Data were abstracted from patient charts that contained a Medical Health Questionnaire, annual physical examinations, and medical encounters by the OSU Sports Medicine staff. A diagnosis of asthma was defined by self-report of physician diagnosis as recorded in the medical record.

RESULTS: Overall, 130 of 763 (17.0%) athletes had a diagnosis of asthma. Females (67/280 or 23.9%) had a significantly higher prevalence of asthma than males (63/483 or 13.0%) (p value = 0.001). There was no significant difference in the prevalence of asthma between high- and low-ventilation sports. (p value = 0.201).

CONCLUSIONS: The prevalence of asthma among varsity athletes at The Ohio State University is 17.0%, which is significantly higher than the reported prevalence of asthma in the general United States population between 18 to 24 years of age. More females had asthma in our study population than males. These data will allow for future studies and development of focused screening programs of collegiate athletes.

Efficacy of an outdoor air pollution education program in a community at risk for asthma morbidity.

J Asthma. 2008 Nov;45(9):839-44 Dorevitch S, Karandikar A, Washington GF, Walton GP, Anderson R, Nickels L. Division of Epidemiology and Biostatistics, Division of Environmental and Occupational Health Sciences, University of Illinois at Chicago School of Public Health, Chicago, IL 60612, USA.

BACKGROUND: Asthma management guidelines recommend avoiding exposure to indoor and outdoor air pollutants. A limitation of such recommendations is that they do not provide information about how the public should obtain and act on air quality information. Although the Air Quality Index (AQI) provides simplified outdoor air quality forecasts, communities with high rates of asthma morbidity tend to have low rates of internet access due to factors such as low socioeconomic status. Assessments of knowledge about air quality among low-income minority communities are lacking, as are community-based programs to educate the public about using the AQI.

METHODS: An air quality education program and system for disseminating air quality information were developed to promote pollutant avoidance during the reconstruction of a major highway in a low-income minority community on Chicago's South Side. The program, which centered on workshops run by community asthma educators, was evaluated using a pre-test, post-test, and 1-year follow-up questionnaire.

RESULTS: A total of 120 community workshop participants completed at least a portion of the evaluation process. At baseline, knowledge about air quality was limited. Following the workshops, substantial increases were noted in rates of correct answers to questions about health effects of air pollution, the availability of air quality information, and the color code for an AQI category. Approximately 1 year after the workshops were held, few participants could recall elements of the training. Few participants have internet access, and alternative means of distributing air quality information were suggested by study participants.

CONCLUSIONS: Baseline knowledge of air quality information was limited in the community studied. Air quality education workshops conducted by community educators can increase knowledge about outdoor air quality and its impact on health over the short term. Refresher workshops or other efforts to sustain the knowledge increase may be useful. Given the known short-term and long-term effects of air quality on morbidity and mortality, air quality education efforts should be further developed, evaluated, and promoted for the general public, for people with underlying cardiopulmonary disease, and given the documented health disparities within the general population, for low-income and minority communities.

Control of persistent asthma in Spain: associated factors.

J Asthma. 2008 Nov;45(9):740-6 Díez Jde M, Barcina C, Muñoz M, Leal M. Pulmonology Service, Hospital General Universitario Gregorio Maranon, Madrid, Spain.

INTRODUCTION: The main objective of asthma treatment is tailored control for each patient. However, despite the excellent therapeutic arsenal currently available, many patients remain unable to achieve adequate control of this disease.

OBJECTIVE: The main objective this study was to evaluate the degree of control and the determinants of asthma in patients with persistent asthma in Spain in usual clinical practice.

MATERIALS AND METHODS: This was a cross-sectional epidemiological study. The patients enrolled were 18 years of age or over, with a 6-month history of diagnosed persistent asthma, who were followed up by primary care physicians in Spain between the months of June and December 2006. Demographic and socioeconomic data were collected, as were anthropometric data and different clinical variables. The control of asthma was evaluated using the Asthma Control Questionnaire (ACQ).

RESULTS: The study included 6,824 patients, of whom 306 were excluded; therefore the final number of patients analyzed was 6,518 (95.5%). According to severity, 41.4% of patients had mild persistent asthma, 51.2% had moderate persistent asthma, and the remainder severe persistent asthma. The mean score in the ACQ was 1.4 +/- 1.0, distributed as follows: in 28.4% of cases, the score was below 0.75; in 31.6%, it was between 0.75 and 1.5; and in 39.7% it was above 1.5. Multiple regression analysis showed that the factor that most affected the degree of control of the disease was classification by severity. Other associated factors were sex, race, body mass index, smoking, level of education, habitual activity, years since diagnosis of asthma, number of exacerbations and admissions to hospital during the last year, and basic treatment of the disease.

CONCLUSIONS: The number of patients with poorly controlled persistent asthma in Spain is high (71.6%). There are demographic, socioeconomic, anthropometric, and clinical variables that affect the level of control of this disease.

Risk factors for asthma and other allergic diseases in seasonal rhinitis.

J Asthma. 2008 Oct;45(8):710-4 Celikel S, Isik SR, Demir AU, Karakaya G, Kalyoncu AF. Department of Chest Diseases, Adult Allergy Unit, Hacettepe University School of Medicine, Ankara, Turkey.

BACKGROUND: Rhinitis and asthma are common comorbidities. The aim of this study was to determine the risk factors for asthma and other allergic diseases in seasonal rhinitis (SR) patients.

METHODS: Records of 922 patients diagnosed as SR between 1991 and 2005 were evaluated retrospectively. Patients were grouped according to the results of our standard skin prick tests as follows: I-No sensitization: no sensitization to any allergen; II-Mono-pollen sensitization: sensitization to only one pollen allergen; III-Poly-pollen sensitization: sensitization to more than one pollen allergen; IV-Mite sensitization: sensitization to mite with or without any other allergen sensitization.

RESULTS: The mean age of the patients was 29.5 +/- 9.6 and 587 patients (63.2%) were females. Age at onset of SR was median 21 years (16-29 years). Of the 922 patients, 99 had no sensitization, 335 had poly-pollen sensitization, 346 had mono-pollen sensitization, and 142 had mite sensitization. The most prevalent allergens were P. pratense (85.3%) and O. europae (31.5%). No sensitization group as compared to poly-pollen sensitization group had significantly higher prevalence of asthma as a single accompanying disease (14.1%, p < 0.05). Mono-pollen sensitization was significantly associated with lower risk of any accompanying allergic disease (OR: 0.7, 95% CI 0,5-0,9) while no sensitization group (OR: 2.8, 95% CI 1.3-5.9) and mite sensitization were associated with asthma (OR: 2.3, 95% CI 1.2-4.4).

CONCLUSION: SR is a condition that presents with different phenotypes. The group with no sensitization and mite sensitization has the highest prevalence of asthma while SR patients with mono-pollen sensitization are unlikely to have an accompanying allergic disease, including asthma.

Asthma and swimming: a meta-analysis.

J Asthma. 2008 Oct;45(8):639-47 Goodman M, Hays S. Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA

In this meta-analysis, studies on swimming and asthma were divided into four groups: Group I compared frequency of asthma among elite swimmers to that of other athletes; Group II examined the association between asthma and swimming during childhood; Group III evaluated effects of swimming programs on asthma severity and pulmonary function; and Group IV compared immediate respiratory effects of swimming to those of other types of exercise. The summary results were expressed as meta-odds ratios (ORs) for binary endpoints such as presence of asthma, and meta-differences for continuous endpoints such as changes in post-exercise pulmonary function tests (PFTs). All summary measures of effect were calculated using random effects models accompanied by a corresponding 95% confidence interval (CI) and a test for heterogeneity. In the analysis comparing frequency of asthma among elite swimmers to that among other athletes (Group I), meta-ORs ranged from 2.3 to 2.6 with all 95% CIs excluding 1.0. The corresponding meta-ORs reflecting the association between asthma and swimming pool use during childhood (Group II) were in the 0.63-0.82 range and were not statistically significant. In comparison to swimming, running and/or cycling was associated with a statistically significant four-to six-fold increase in exercise induced bronchospasm. Although asthma is more commonly found among elite swimmers than among other high-level athletes, it is premature to draw conclusions about the causal link between swimming and asthma because most studies available to date used cross-sectional design, because the association is not confirmed among non-competitive swimmers, and because asthmatics may be more likely to select swimming as the activity of choice because of their condition.

‘Harmless’ virus may hide and cause asthma

Reuters

Most beat the bug during childhood, but it may come back, researchers say

A usually harmless childhood virus may hide in the lungs and come back to cause wheezing and other symptoms of asthma, U.S. researchers reported on Tuesday.

They found evidence that respiratory syncytial virus or RSV stayed in the lungs of mice and caused the overactive airway symptoms that characterize asthma.

"This research suggests that there's a potential new mechanism for asthma related to viral infections in children that could be associated with RSV," pediatrician Dr. Asuncion Mejias of the University of Texas Southwestern, who led the study, said in a statement.

"These findings could aid in the development of preventive and therapeutic interventions for children with recurrent wheezing due to a virus such as RSV."

Nearly every child is infected with RSV early in life, and the virus usually clears up without serious complications in about a week. But 3 percent to 10 percent of infants with RSV infections develop severe bronchitis and must be treated in the hospital.

Doctors also thought the body quickly cleared itself of those types of viruses. But writing in the Journal of Infectious Diseases, the researchers said it may persist in some children.

They previously showed that RSV infection could raise the likelihood of chronic lung disease in mice.

For this experiment, the UTSW team infected mice with either live RSV or viruses weakened by ultraviolet light or heat.

After 42 days, the researchers found evidence of the virus in every mouse infected with live RSV, but not in the others.

"Whether RSV persists in children remains to be seen, but the fact that the virus persists in mice is amazingly powerful," said Dr. Octavio Ramilo, a pediatrician who also worked on the study. Also, the more virus detected in the lungs of the mice, the more likely they were to have airway hyperreactivity -- or bronchospasms -- and the worse those spasms were.

Mice treated with an antibody -- an immune system protein -- targeted to RSV ended up with less virus in the lungs and developed significantly less airway hyperreactivity and lung inflammation.

"We are currently doing a study in which we are treating kids with a new antibody that is very potent," Mejias said. "The plan is to follow them for a year to see if aggressive treatment against the virus can prevent wheezing."

Occupational Rhinitis In Workers Investigated For Occupational Asthma

Thorax. 2008 Oct 3. Castano R, Gautrin D, Theriault G, Trudeau C, Ghezzo H, Malo JL. Hôpital du Sacré-Cur de Montréal, Canada.

BACKGROUND: The links between asthma and rhinitis are nowadays referred to as the united airways disease (UAD). Current evidence shows that the UAD model seems to be applicable to occupational rhinitis (OR) and occupational asthma (OA).

OBJECTIVE: We aimed to objectively assess, in the context of specific inhalation challenge (SIC) testing, the concomitance of bronchial and nasal reaction in the investigation of OR and OA

METHODS: Forty-three subjects with a history of work-related asthma symptoms underwent SIC for confirmation of OA and investigation of OR. Subjects underwent assessment of changes in bronchial calibre by spirometry and assessment of nasal patency and airway inflammation by acoustic rhinometry and nasal lavage.

RESULTS: A positive nasal challenge was observed in 25 SIC whereas a positive bronchial challenge was observed in 17 SIC. A concomitant positive nasal and bronchial challenge was observed in 13 instances. This association was significant (risk ratio= 1.7; 95% CI=1.0 to 2.4; p=0.04) and more frequent in subjects challenged with high molecular weight (n= 11/22) than low-molecular weight agents (n= 2/21). Among subjects with a positive nasal challenge, nasal lavage showed a significant increase in eosinophils at 30 min post-exposure that correlated with changes in nasal patency.

CONCLUSION: Results provided objective evidence supporting the UAD concept by using OR and OA as a model for demonstrating a concomitant significant physiological reaction of the nose and lungs after challenge. We demonstrated that OR can be assessed by objective means; this condition often coexists with OA but can be present without OA.

Wheezing and bronchial hyper-responsiveness in early childhood as predictors of newly diagnosed asthma in early adulthood: a longitudinal birth-cohort study.

Lancet. 2008 Sep 20;372(9643):1058-64. Stern DA, Morgan WJ, Halonen M, Wright AL, Martinez FD. Arizona Respiratory Center, University of Arizona, Tucson, AZ, USA.

BACKGROUND: Incidence of asthma increases during early adulthood. We aimed to estimate the contributions of sex and early life factors to asthma diagnosed in young adults.

METHODS: 1246 healthy newborn babies were enrolled in the Tucson Children's Respiratory Study. Parental characteristics, early-life wheezing phenotypes, airway function, and bronchial hyper-responsiveness to cold dry air and sensitisation to Alternaria alternata were determined before age 6 years. Physician-diagnosed asthma, both chronic and newly diagnosed, and airway function were recorded at age 22 years.

FINDINGS: Of 1246 babies enrolled, 849 had follow-up data at 22 years. Average incidence of asthma at age 16-22 years was 12.6 per thousand person-years. 49 (27%) of all 181 cases of active asthma at 22 years were newly diagnosed, of which 35 (71%) were women. Asthma remittance by 22 years was higher in men than in women (multinomial odds ratio [M-OR] 2.0, 95% CI 1.2-3.2, p=0.008). Age at diagnosis was linearly associated with the ratio of forced expiratory volume at 1 s to forced vital capacity at age 22 years. Factors independently associated with chronic asthma at 22 years included onset at 6 years (7.4, 3.9-14.0) and persistent wheezing (14.0, 6.8-28.0) in early life, sensitisation to A alternata (3.6, 2.1-6.4), low airway function at age 6 years (2.1, 1.1-3.9), and bronchial hyper-responsiveness at 6 years (4.5, 1.9-10.0). Bronchial hyper-responsiveness (6.9, 2.3-21.0), low airway function at 6 years (2.8, 1.1-6.9), and late-onset (4.6, 1.7-12.0) and persistent wheezing (4.0, 1.2-14.0) predicted newly diagnosed asthma at age 22 years.

INTERPRETATION: Asthma with onset in early adulthood has its origins in early childhood.

Rhinitis and onset of asthma: a longitudinal population-based study.

Lancet. 2008 Sep 20;372(9643):1049-57. Shaaban R, Zureik M, Soussan D, Neukirch C, Heinrich J, Sunyer J, Wjst M, Cerveri I, Pin I, Bousquet J, Jarvis D, Burney PG, Neukirch F, Leynaert B. Unit 700 Epidemiology, National Institute of Health and Medical Research (INSERM), Paris, France.

BACKGROUND: A close relation between asthma and allergic rhinitis has been reported by several epidemiological and clinical studies. However, the nature of this relation remains unclear. We used the follow-up data from the European Community Respiratory Health Survey to investigate the onset of asthma in patients with allergic and non-allergic rhinitis during an 8.8-year period.

METHODS: We did a longitudinal population-based study, which included 29 centres (14 countries) mostly in western Europe. Frequency of asthma was studied in 6461 participants, aged 20-44 years, without asthma at baseline. Incident asthma was defined as reporting ever having had asthma confirmed by a physician between the two surveys. Atopy was defined as a positive skin-prick test to mites, cat, Alternaria, Cladosporium, grass, birch, Parietaria, olive, or ragweed. Participants were classified into four groups at baseline: controls (no atopy, no rhinitis; n=3163), atopy only (atopy, no rhinitis; n=704), non-allergic rhinitis (rhinitis, no atopy; n=1377), and allergic rhinitis (atopy+rhinitis; n=1217). Cox proportional hazards models were used to study asthma onset in the four groups.

FINDINGS: The 8.8-year cumulative incidence of asthma was 2.2% (140 events), and was different in the four groups (1.1% (36), 1.9% (13), 3.1% (42), and 4.0% (49), respectively; p<0.0001). After controlling for country, sex, baseline age, body-mass index, forced expiratory volume in 1 s (FEV(1)), log total IgE, family history of asthma, and smoking, the adjusted relative risk for asthma was 1.63 (95% CI 0.82-3.24) for atopy only, 2.71 (1.64-4.46) for non-allergic rhinitis, and 3.53 (2.11-5.91) for allergic rhinitis. Only allergic rhinitis with sensitisation to mite was associated with increased risk of asthma independently of other allergens (2.79 [1.57-4.96]).

INTERPRETATION: Rhinitis, even in the absence of atopy, is a powerful predictor of adult-onset asthma.

Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years: analysis from Phase Three of the ISAAC programme

Lancet. 2008 Sep 20;372(9643):1039-48 Beasley R, Clayton T, Crane J, von Mutius E, Lai CK, Montefort S, Stewart A; ISAAC Phase Three Study Group. Collaborators (96) Medical Research Institute of New Zealand, Wellington, New Zealand.

BACKGROUND: Exposure to paracetamol during intrauterine life, childhood, and adult life may increase the risk of developing asthma. We studied 6-7-year-old children from Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC) programme to investigate the association between paracetamol consumption and asthma.

METHODS: As part of Phase Three of ISAAC, parents or guardians of children aged 6-7 years completed written questionnaires about symptoms of asthma, rhinoconjunctivitis, and eczema, and several risk factors, including the use of paracetamol for fever in the child's first year of life and the frequency of paracetamol use in the past 12 months. The primary outcome variable was the odds ratio (OR) of asthma symptoms in these children associated with the use of paracetamol for fever in the first year of life, as calculated by logistic regression.

FINDINGS: 205 487 children aged 6-7 years from 73 centres in 31 countries were included in the analysis. In the multivariate analyses, use of paracetamol for fever in the first year of life was associated with an increased risk of asthma symptoms when aged 6-7 years (OR 1.46 [95% CI 1.36-1.56]). Current use of paracetamol was associated with a dose-dependent increased risk of asthma symptoms (1.61 [1.46-1.77] and 3.23 [2.91-3.60] for medium and high use vs no use, respectively). Use of paracetamol was similarly associated with the risk of severe asthma symptoms, with population-attributable risks between 22% and 38%. Paracetamol use, both in the first year of life and in children aged 6-7 years, was also associated with an increased risk of symptoms of rhinoconjunctivitis and eczema.

INTERPRETATION: Use of paracetamol in the first year of life and in later childhood, is associated with risk of asthma, rhinoconjunctivitis, and eczema at age 6 to 7 years. We suggest that exposure to paracetamol might be a risk factor for the development of asthma in childhood.

Body mass index, respiratory function and bronchial hyperreactivity in allergic rhinitis and asthma

Respir Med. 2008 Sep 23. Ciprandi G, Pistorio A, Tosca M, Ferraro MR, Cirillo I. Department of Internal Medicine, University of Genoa, Genoa, Italy; Azienda Ospedaliera Universitaria San Martino, University of Genoa, Genoa, Italy.

BACKGROUND: Several studies have outlined a possible relationship between an increased body mass index (BMI) and respiratory allergic diseases, such as asthma and rhinitis. The aim of the study was to analyse the relationship between BMI and allergic diseases, including allergic rhinitis and asthma, and functional parameters, such as nasal airflow, FEV(1), and non-specific BHR to methacholine, in a cohort of navy army subjects.

METHODS: The study included 100 patients with moderate-severe persistent allergic rhinitis alone, 100 with intermittent allergic asthma alone, and 100 healthy controls. All subjects were evaluated performing skin prick test, spirometry, and bronchostimulation test with methacholine. Rhinomanometry was performed in patients with rhinitis.

RESULTS: BMI values were significantly lower in control subjects with respect to patients with rhinitis (P=0.0002) and with respect to patients with asthma (P<0.0001). BMI was also significantly higher in males with respect to females (P=0.005). A significant relationship has been observed between some categories of BHR and BMI either in patients with rhinitis (P<0.01) or in patients with asthma (P<0.01), whereas there was no association between BMI and functional parameters.

CONCLUSION: This study provides the first evidence of a significant relationship between BMI and allergic rhinitis and between BMI and BHR in both allergic disorders.

Achieving asthma control in practice: Understanding the reasons for poor control.

Respir Med. 2008 Sep 22. Haughney J, Price D, Kaplan A, Chrystyn H, Horne R, May N, Moffat M, Versnel J, Shanahan ER, Hillyer EV, Tunsäter A, Bjermer L. Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, Scotland, UK.

Achieving asthma control remains an elusive goal for the majority of patients worldwide. Ensuring a correct diagnosis of asthma is the first step in assessing poor symptom control; this requires returning to the basics of history taking and physical examination, in conjunction with lung function measurement when appropriate. A number of factors may contribute to sub-optimal asthma control. Concomitant rhinitis, a common co-pathology and contributor to poor control, can often be identified by asking a simple question. Smoking too has been identified as a cause of poor asthma control. Practical barriers such as poor inhaler technique must be addressed. An appreciation of patients' views and concerns about maintenance asthma therapy can help guide discussion to address perceptual barriers to taking maintenance therapy (doubts about personal necessity and concerns about potential adverse effects). Further study into, and a greater consideration of, factors and patient characteristics that could predict individual responses to asthma therapies are needed.

Finally, more clinical trials that enrol patient populations reflecting the real world diversity of patients seen in clinical practice, including wide age ranges, presence of comorbidities, current smoking, and differing ethnic origins, will contribute to better individual patient management.

Predicting worsening asthma control following the common cold.

Eur Respir J. 2008 Sep 3. Walter MJ, Castro M, Kunselman SJ, Chinchilli VM, Reno M, Ramkumar TP, Avila PC, Boushey HA, Ameredes BT, Bleecker ER, Calhoun WJ, Cherniack RM, Craig TJ, Denlinger LC, Israel E, Fahy JV, Jarjour NN, Kraft M, Lazarus SC, Lemanske RF Jr, Martin RJ, Peters SP, Ramsdell JW, Sorkness CA, Sutherland ER, Szefler SJ, Wasserman SI, Wechsler ME; for the National Heart, Lung, and Blood Institute's Asthma Clinical Research Network. Saint Louis, MO.

The asthmatic response to the common cold is highly variable and early characteristics that predict worsening of asthma control following a cold have not been identified.

In this prospective multi-center cohort study of 413 adult subjects with asthma, we used the mini-Asthma Control Questionnaire (mini-ACQ) to quantify changes in asthma control and the Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21) to measure cold severity. Univariate and multivariable models examined demographic, physiologic, serologic, and cold-related characteristics for their relationship to changes in asthma control following a cold.

We observed a clinically significant worsening of asthma control following a cold (increase in mini-ACQ of 0.69+/-0.93). Univariate analysis demonstrated season, center location, cold length, and cold severity measurements all associated with a change in asthma control. Multivariable analysis of the covariates available within the first 2 days of cold onset revealed the day 2 and the cumulative sum of the day 1 and 2 WURSS-21 scores were significant predictors for the subsequent changes in asthma control.

In asthmatic subjects the cold severity measured within the first 2 days can be used to predict subsequent changes in asthma control. This information may help clinicians prevent deterioration in asthma control following a cold.

A new perspective on concepts of asthma severity and control.

Eur Respir J. 2008 Sep;32(3):545-54. Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, Casale TB, Chanez P, Enright PL, Gibson PG, de Jongste JC, Kerstjens HA, Lazarus SC, Levy ML, O'Byrne PM, Partridge MR, Pavord ID, Sears MR, Sterk PJ, Stoloff SW, Szefler SJ, Sullivan SD, Thomas MD, Wenzel SE, Reddel HK. Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin, New Zealand.

Concepts of asthma severity and control are important in the evaluation of patients and their response to treatment but the terminology is not standardised and the terms are often used interchangeably. This review, arising from the work of an American Thoracic Society/European Respiratory Society Task Force, identifies the need for separate concepts of control and severity, describes their evolution in asthma guidelines and provides a framework for understanding the relationship between current concepts of asthma phenotype, severity and control.

"Asthma control" refers to the extent to which the manifestations of asthma have been reduced or removed by treatment. Its assessment should incorporate the dual components of current clinical control (e.g. symptoms, reliever use and lung function) and future risk (e.g. exacerbations and lung function decline). The most clinically useful concept of asthma severity is based on the intensity of treatment required to achieve good asthma control, i.e. severity is assessed during treatment. Severe asthma is defined as the requirement for (not necessarily just prescription or use of) high-intensity treatment. Asthma severity may be influenced by the underlying disease activity and by the patient's phenotype, both of which may be further described using pathological and physiological markers. These markers can also act as surrogate measures for future risk.

Temporal Trends in Asthma Mortality over 30 Years.

J Asthma. 2008 Sep;45(7):611-4. Luis Lopez-Campos J, Cayuela A, Rodriguez S, Vigil E. The Unidad Medico-Quirurgica de Enfermedades Respiratorias, Hospitales Universitarios Virgen del Roci, Seville, Spain.

Background. Bronchial asthma is an important cause of morbidity and mortality worldwide. There is limited availability of updated information on asthma mortality trends. In this context, further investigation of asthma mortality trends is necessary.

Objective. We aimed to assess trends in asthma mortality trends in the Autonomous Community of Andalusia (over 7 million inhabitants), Spain, during the period 1975-2005.

Method. Official population estimates and data on asthma deaths were obtained from official authorities. Crude and age-adjusted death rates for different age and gender groups were calculated. Joinpoint regression analysis was used for trend analysis.

Results. Age-adjusted death rates for asthma have fallen 2.9% for females and 7.7% for males from 1975 to 2005. This trend has not been constant but has varied during the study period. After a non-significant increase from 1975 to 1981 (4.5% for females and 3.8% for males), adjusted asthma mortality rates have been declining 3.7% for females and 9.6% for males (both p values < 0.05) since 1981. Age-group analysis revealed that the downturn in asthma mortality rates occurred in all age groups above 45 years for males and 35 years for females.

Conclusions. During the last decades, significant variation in asthma mortality was found in Andalusia. This variation has not been constant during the study period. Currently, the decreasing trend initiated in 1981 continues.

Household smoking and childhood asthma in the United States: a state-level analysis.

J Asthma. 2008 Sep;45(7):607-10. Goodwin RD, Cowles RA. Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.

Background: The reason for the substantial geographic variation in the prevalence of childhood asthma is not known.

Objective: To investigate the association between exposure to cigarette smoking in the home and childhood asthma at the state-level, toward improving current understanding of geographic variation in childhood asthma rates.

Methods: Data were drawn from the National Children's Health Survey (NCHS, 2003), a representative sample (n = 102, 000) of youth 0 to 17 years of age in the United States. Household smoking and asthma in children were reported by parents. Air quality for each state was obtained from Environmental Protection Act (EPA) reports, and state-level poverty reports were obtained from the US Department of Agriculture.

Results: Household smoking was associated with a statistically significant increase in risk of asthma among children at the state level (p = 0.026). This association did not appear to be influenced by outdoor air quality at the state level or socioeconomic position.

Conclusions: These results are the first to show a link between cigarette smoking in the home and childhood asthma at a state-level in the United States.

Asthma care issues in kindergarten teachers: an evaluation on knowledge, attitudes, and self-efficacy of asthma.

J Asthma. 2008 Sep;45(7):539-44. Hung CC, Huang GS, Lin CH, Gau BS. College of Public Health, National Taiwan University, Institute of Health Policy and Management, Taiwan, Republic of China.

As frequently there is no school nurse in a kindergarten setting, teachers receiving non-medical training take the primary roles of symptom assessment and management of young children with asthma. This article presents the knowledge, attitudes, and self-efficacy of asthma in kindergarten teachers in Taiwan.

A total valid sample of 460 teachers was recruited from 70 kindergartens. Results showed most teachers understood the basic facts about asthma rather than the complex issues; they demonstrated positive attitudes toward having asthmatic children in class. Regarding self-efficacy, teachers lacked confidence in their ability to manage asthma attacks. Teachers' asthma knowledge showed a significant positive correlation with attitude (r = 0.27, p < 0.001) and self-efficacy knowledge (r = 0.23, p < 0.001).

Given the need to help kindergarten teachers take care of children with asthma, the implications of kindergarten teachers' in-service education and training to asthma care are also discussed.

Allergy to kiwi in patients with baker's asthma: identification of potential cross-reactive allergens

Ann Allergy Asthma Immunol. 2008 Aug;101(2):200-5 Palacin A, Quirce S, Sánchez-Monge R, Fernández-Nieto M, Varela J, Sastre J, Salcedo G. Unidad de Bioquímica, Departamento de Biotecnología, E.T.S. Ingenieros Agrónomos, UPM, Madrid, Spain.

BACKGROUND: Baker's asthma is a frequent IgE-mediated occupational disorder mainly provoked by inhalation of cereal flour. Allergy to kiwifruit has being increasingly reported in the past few years. No association between both allergic disorders has been described so far.

METHODS: Twenty patients with occupational asthma caused by wheat flour inhalation were studied. Kiwi allergens Act d 1 and Act d 2 were purified by cation-exchange chromatography. Wheat, rye, and kiwi extracts, purified kiwi allergens, and model plant glycoproteins were analyzed by IgE immunodetection, enzyme-linked immunosorbent assay (ELISA), and inhibition ELISAs.

RESULTS: Kiwifruit ingestion elicited oral allergy syndrome in 7 of the 20 patients (35%) with baker's asthma. Positive specific IgE and skin prick test responses to this fruit were found in all these kiwi allergic patients, and IgE to Act d 1 and Act d 2 was detected in 57% and 43%, respectively, of the corresponding sera. Actinidin Act d 1 and bromelain (harboring cross-reactive carbohydrate determinants) reached above 50% inhibition of the IgE binding to wheat and/or kiwi extracts.

CONCLUSIONS: A potential association between respiratory allergy to cereal flour and allergy to kiwifruit has been disclosed. Cross-reactive carbohydrate determinants and thiol-proteaseshomologous to Act d 1 are responsible for wheat-kiwi crossreactivity in some patients.

Asthma control and future asthma-related morbidity in inner-city asthmatic children.

Ann Allergy Asthma Immunol. 2008 Aug;101(2):144-52 Kwong KY, Morphew T, Scott L, Guterman J, Jones CA. Division of Allergy and Immunology, Department of Pediatrics, Los Angeles County + University of Southern California Medical Center and Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.

BACKGROUND: Asthma guidelines recommend routine evaluation of asthma control, which includes measurements of impairment and risk. It is unclear whether rigorous asthma control changes risk of asthma morbidity.

OBJECTIVE: To examine whether the degree of asthma control in inner-city asthmatic children results in differential risk reduction of future asthma-related morbidity.

METHODS: This retrospective observational study examines 960 inner-city children with asthma who were highly engaged in an asthma-specific disease management program for a minimum of 2 years. Degree of asthma control was determined during the first year of enrollment and was categorized as well controlled (> or = 80% of visits in control), moderately controlled (50%-79% of visits in control), or difficult to control (< 50% of visits in control). Risk and probability of asthma-related morbidity at each visit were determined during the second year of enrollment and included self-reported asthma exacerbations requiring systemic corticosteroid rescue and emergency department visits or hospitalizations.

RESULTS: Increasing the degree of asthma control measured during the first year of enrollment led to statistically significant incremental reductions in risk of acute asthma exacerbations and emergency department visits or hospitalizations during the second year of enrollment.

CONCLUSIONS: Achieving and maintaining asthma control in inner-city children with asthma results in significant reductions in asthma-related morbidity. Systematic assessments of asthma control may be useful for predicting future risk in children with asthma.

Ambient air pollution triggers wheezing symptoms in infants

Thorax. 2008 Aug;63(8):710-6. Andersen ZJ, Loft S, Ketzel M, Stage M, Scheike T, Hermansen MN, Bisgaard H. Department of Biostatistics, Institute of Public Health, Copenhagen University, Øster Farimagsgade 5 Entr. B, P O Box 2099, 1014 Copenhagen K, Denmark.

BACKGROUND: There is limited evidence for the role of air pollution in the development and triggering of wheezing symptoms in young children. A study was undertaken to examine the effect of exposure to air pollution on wheezing symptoms in children under the age of 3 years with genetic susceptibility to asthma

METHODS: Daily recordings of symptoms were obtained for 205 children participating in the birth cohort study Copenhagen Prospective Study on Asthma in Children and living in Copenhagen for the first 3 years of life. Daily air pollution levels for particulate matter <10 microm in diameter (PM(10)) and the concentrations of ultrafine particles, nitrogen dioxide (NO(2)), nitrogen oxide (NO(x)) and carbon monoxide (CO) were available from a central background monitoring station in Copenhagen. The association between incident wheezing symptoms and air pollution on the concurrent and previous 4 days was estimated by a logistic regression model (generalised estimating equation) controlling for temperature, season, gender, age, exposure to smoking and paternal history of asthma.

RESULTS: Significant positive associations were found between concentrations of PM(10), NO(2), NO(x), CO and wheezing symptoms in infants (aged 0-1 year) with a delay of 3-4 days. Only the traffic-related gases (NO(2), NO(x)) showed significant effects throughout the 3 years of life, albeit attenuating after the age of 1 year.

CONCLUSIONS: Air pollution related to traffic is significantly associated with triggering of wheezing symptoms in the first 3 years of life.

The Asthma-Mental Health Nexus in a Population Based Sample of the United States

Chest. 2008 Aug 21. Chun TH, Weitzen SH, Fritz GK. Departments of Emergency Medicine and Pediatrics, The Warren Alpert Medical School of Brown University; Department of Community Health, The Warren Alpert Medical School of Brown University; Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University.

Background: Asthma is one of the most prevalent chronic medical conditions in the United States (U.S.). Asthma's relationship with psychological factors has been known for centuries and recently there has been a resurgence of interest in this topic. This study investigates the relationship between current asthma and poor mental health in a nationally representative sample of the U.S. population.

Methods: This study utilizes data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey (n = 355,710). A multinomial logistic regression model was constructed to assess the relationship between current asthma and poor mental health. The relationship between formerly having asthma and poor mental health was also investigated.

Results: Persons reporting poor mental health have increased risk of currently having asthma compared to persons reporting good mental health. Additionally, this asthma-mental health relationship has a "dose-response" relationship. For every incremental increase in days of poor mental health, there is a corresponding increase in risk of currently having asthma. Previously reported risk factors for asthma, i.e. age, gender, race, marital, smoking, overall health, exercise, obesity, and socio-economic (SES) status were all found to be important covariates of asthma. The relationship between former asthma and poor mental health is less clear.

Conclusions: This large, nationally representative sample confirms the relationship between asthma and mental health symptoms. Any degree of poor mental health appears to increase one's risk for asthma. Future research is needed to determine the causal and/or physiological relationship between asthma and mental health symptoms.

Impact of allergic rhinitis on asthma: effects on bronchodilation testing

Ann Allergy Asthma Immunol. 2008 Jul;101(1):42-6. Ciprandi G, Cirillo I, Pistorio A, La Grutta S, Tosca M. Department of Internal Medicine, Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.

BACKGROUND: A remarkable relationship exists between the upper and lower airways. Bronchial obstruction is a paramount feature of asthma, and its reversibility is considered a main step in asthma diagnosis.

OBJECTIVE: To investigate the degree of bronchodilation and possible risk factors related to it in patients with moderate-severe persistent allergic rhinitis alone.

METHODS: A total of 375 patients with moderate-severe persistent allergic rhinitis and 115 controls were prospectively and consecutively evaluated by means of clinical examination, skin prick testing, spirometry, and bronchodilation testing.

RESULTS: Patients with rhinitis showed a significant increase in forced expiratory volume in 1 second (FEV) after bronchodilation testing compared with basal values and levels in controls (P < .001). Two-thirds of the rhinitic patients had reversibility (> or = 12% basal levels). Patients with reversibility had lower FEV1 levels, longer rhinitis duration, and mite and tree allergies.

CONCLUSIONS: This study highlights the close link between the upper and lower airways and the relevance of performing bronchodilation testing in patients with moderate-severe persistent allergic rhinitis.

Physical training does not increase allergic inflammation in asthmatic children

Eur Respir J. 2008 Aug 6. Moreira A, Delgado L, Haahtela T, Fonseca J, Moreira P, Lopes C, Mota J, Santos P, Rytilä P, Castel-Branco MG. Faculty of Medicine, University of Porto, Porto, Portugal; and Immuno-allergology, Hospital of São João, Porto, Portugal.

We studied the effects of a 3-month physical training program on airway inflammation and clinical outcomes in school-aged children with asthma.Thirty four subjects, 12.7+/-3.4 years, with persistent allergic asthma were randomly allocated into training and control groups. Exercise consisted of twice-weekly 50 minutes sessions for 12 weeks. Inflammation was assessed by exhaled nitric oxide, blood eosinophils, eosinophil cationic protein, C-reactive protein, total and mite specific IgE. Lung volumes and bronchial responsiveness to metacholine were determined. Paediatric Asthma -and Caregiver's- Quality of Life Questionnaires were used to evaluate activity restrictions, symptoms and emotional stress. Efficacy of the training was assessed by accelerometry.After the program, exercise children had double daily minutes in moderate-to-vigorous activities compared to controls. No differences in changes were seen between groups for asthma outcomes. However, total IgE decreased more in the exercise group, as did mite specific IgE.Training did not increase inflammation in children with persistent asthma, and may have decrease both total and allergen specific IgE levels.

We conclude there is no reason to discourage asthmatic children with a controlled disease to exercise.

The course of persistent airflow limitation in subjects with and without asthma.

Respir Med. 2008 Aug 4 Guerra S, Sherrill DL, Kurzius-Spencer M, Venker C, Halonen M, Quan SF, Martinez FD. Arizona Respiratory Center, University of Arizona, Tucson, AZ, USA; Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.

RATIONALE: Most patients who develop persistent airflow limitation do so either as a manifestation of chronic obstructive pulmonary disease that is largely related to smoking or as a consequence of persistent asthma. We sought to compare the natural course of lung function associated with persistent airflow limitation in subjects with and without asthma from early to late adult life.

METHODS: We studied 2552 participants aged 25 or more who had multiple questionnaire and lung function data from the long-term prospective population-based Tucson Epidemiological Study of Airway Obstructive Disease. Persistent airflow limitation was defined as FEV1/FVC ratio consistently <70% in all completed surveys subsequent to the first survey with airflow limitation. Participants were divided into nine groups based on the combination of their physician-confirmed asthma status (never, onset </=25 years, or onset >25 years) and the presence of airflow limitation during the study follow-up (never, inconsistent, or persistent).

RESULTS: Among subjects with an asthma onset </=25 years, blood eosinophilia increased significantly the odds of developing persistent airflow limitation (adjusted ORs: 3.7, 1.4-9.5), whereas cigarette smoking was the strongest risk factor for persistent airflow limitation among non-asthmatics and among subjects with asthma onset after age 25 years. Among subjects with persistent airflow limitation, the natural course of lung function differed between subjects with asthma onset </=25 years and non-asthmatics, with the former having lower FEV1 levels at age 25 (predicted value for a 175-cm tall male of 3400 versus 4090ml, respectively; p<0.001) and the latter having greater FEV1 loss between age 25 and 75 (1590 versus 2140ml; p=0.003).

CONCLUSION: In subjects who have asthma onset before 25 years of age and persistent airflow limitation in adult life, the bulk of the FEV1 deficit is already established before age 25 years.

Weight loss and asthma: a systematic review.

Thorax. 2008 Aug;63(8):671-6. Eneli IU, Skybo T, Camargo CA Jr. Department of Pediatrics, Ohio State University, Center for Healthy Weight and Nutrition, Columbus Children's Hospital, Columbus, Ohio 43205, USA.

Epidemiological studies first demonstrated the association between obesity and asthma and they have begun to provide additional evidence to support causality: a dose-effect relationship, consistency across studies (especially among women) and the correct temporal order (ie, obesity before asthma). To date, relatively few studies have addressed reversibility, an important but less frequently demonstrated epidemiological criterion of causality. Reversibility suggests that if excessive weight is a risk factor for asthma, then reducing body weight should decrease the prevalence of asthma, or at least decrease asthma related symptoms or health care utilisation. We performed a systematic review on weight loss and asthma, based on searches between January 1966 and January 2007 of both PubMed and the Cochrane Clinical Trial Database. Of the 15 relevant studies, asthma was the primary outcome in only five. Only one study was conducted in children. Regardless of the type of intervention (surgical vs medical), all 15 studies noted an improvement in at least one asthma outcome after weight loss. The improvement was noted across studies that differed in sample age, gender or country of origin. The heterogeneity of the interventions and outcomes precluded quantitative synthesis. We briefly review the role of specific factors (eg, gastro-oesophageal reflux) in the weight loss-asthma association, and potential directions for future research.

How Gastric Reflux May Trigger Asthma

ScienceDaily (July 23, 2008)

Researchers at Duke University Medical Center appear to have solved at least a piece of a puzzle that has mystified physicians for years: why so many patients with asthma also suffer from GERD, or gastroesophageal reflux disease.

Clinicians first noted a relationship between the two diseases in the mid-1970s. Since then, studies have shown that anywhere from 50 to 90 percent of patients with asthma experience some aspect of GERD. But can GERD cause asthma, or, is it the other way around? Perhaps there is some shared mechanism at the root of both disorders causing them to arise together. Physicians could make a case for each scenario, but until now, the exact nature of the relationship was not clear.

Working in laboratory experiments with mice, Dr. Shu Lin, an assistant professor of surgery and immunology at Duke, discovered that inhaling tiny amounts of stomach fluid that back up into the esophagus -- a hallmark of GERD -- produces changes in the immune system that can drive the development of asthma.

In the experiments, researchers inserted miniscule amounts of gastric fluid into the lungs of mice (mimicking the human process of micro-aspiration, or breathing in tiny amounts) over a period of eight weeks. They compared these animals' immune systems with those of mice that were exposed to allergens but not the gastric fluid.

The immune systems of the two sets of mice responded very differently. Those that had the gastric fluid in their lungs developed what researchers call a T-helper type 2 response, a type of immune system reaction characteristic of asthma. The other mice responded in a more balanced manner, mounting an immune reaction consisting of both T-helper type 1 and T-helper type 2 responses.

"This is the first experimental evidence in a controlled, laboratory setting linking these two very common conditions in humans," says Lin, the senior author of the study published online in the European Journal of Clinical Investigation. "These data suggest that chronic micro-aspiration of gastric fluid can drive the immune system toward an asthmatic response."

"This does not mean that everyone with GERD is going to develop asthma, by any means," says William Parker, an assistant professor of surgery at Duke and a co-author of the study. "But it may mean that people with GERD may be more likely to develop asthma. If there is an upside to this, it is that developing GERD is something we can pretty much treat and control."

Parker says poor diet, a lack of exercise and obesity all contribute to the development of GERD, and that rising rates of reflux disease are part of a "perfect storm" of environmental and behavioral factors driving escalating rates of asthma, particularly in Western cultures. "People should avoid the risk factors for GERD. We strongly believe that the rise in asthma, particularly among adults in the country, is in large measure due to lifestyle choices that can be changed."

Lin and Parker agree that much more work needs to be done to fully understand the cellular and molecular mechanisms involved in the relationship between reflux disease and asthma, but both feel their study offers new directions for developing additional treatment options for both problems.

Lin says patients who already have GERD can minimize gastric reflux -- and thereby lessen their chances of developing asthma -- by following a few simple guidelines: Eat smaller meals and eat several hours before going to bed; raise the head of the bed a few inches; maintain a healthy weight; and limit fatty goods, coffee, tea, caffeine and alcohol -- they can relax the esophageal sphincter and make reflux more likely.

Funding for the study came from the Society of American Gastrointestinal Endoscopic Surgeons Research Grant and the Parks Protocol Memorial Fund.

Additional co-authors from Duke include lead author Andrew Barbas, Tacy Downing, Keki Balsara, Hung-Enn Tan, Gregory Rubinstein, Zoie Holzknecht, Bradley Collins and R. Duane Davis.

Asthma Medications: Not a Clear Advantage

The New York Times By GINA KOLATA Published: July 22, 2008

In 1992, just after she had returned from winning a gold medal in the Barcelona Olympics, the swimmer Dara Torres was running with a friend on a hot, humid day in Gainesville, Fla. She was wheezing, she said, which was nothing new. She had always had breathing problems and thought nothing of it.

But her friend, a hand surgeon, told Torres that she sounded like someone who had asthma. Torres’s father has asthma, but it had never occurred to her that she might have it, too. She did, and as soon as she started taking asthma medication, she realized how much, and how needlessly, she had been suffering.

“I was always coughing,” she said in a telephone interview last week. “And my breathing was horrible. I really had a hard time.”

Now, at 41, Torres has returned to competitive swimming and earned a place on the United States Olympic team. And she is outraged by those who say that she only recently declared she had asthma and that taking asthma drugs was the secret to her astounding success. The drugs, it is often claimed, are performance enhancers.

That is not, however, what asthma and doping experts say. Inhaled asthma drugs, according to medical consensus, allow athletes with asthma to breathe normally but do not make them better than normal. And they do nothing for athletes who do not have asthma.

Elite-level athletes with documented proof that they have asthma are allowed to take certain inhaled corticosteroids, which prevent inflammation of airways and can hold asthma symptoms at bay.

And they are allowed to take other inhaled drugs, beta-2 agonists, which relax the smooth muscle cells of airways, relieving symptoms. A few of the beta-2 agonists can increase muscle and decrease body fat if they are injected or taken orally.

But when they are inhaled, in doses used to control asthma, beta-2 agonists do not improve performance, asthma and doping experts say. And neither do corticosteroids.

“A lot of people believe they are performance enhancers,” Dr. Gary I. Wadler said about inhaled asthma drugs. But, added Wadler, who is chairman of the World Anti-Doping Agency’s prohibited list and methods subcommittee, “there is no evidence for that at all.”

Dr. Kenneth Fitch, a member of the International Olympic Committee’s medical commission, has provided some of that evidence. A professor at the School of Sport, Exercise and Health at the University of Western Australia, he conducted three double-blind studies of asthma drugs and concluded that they did not enhance performance. In the studies, neither the participants nor the researchers knew who was receiving asthma drugs or who was receiving a dummy substance.

Some, like Paula Radcliffe, who has asthma, have heard other explanations for why the drugs are banned. Radcliffe is the women’s world record holder in the marathon. The drugs, she believes, are banned for those without the condition because they can mask the presence of other performance-enhancing drugs.

“That’s what I’ve been told,” Radcliffe said in a telephone interview from her home in Britain.

But that is not true, according to Dr. Patrick Schamasch, the medical and scientific director for the I.O.C.

Wadler explained that a drug “doesn’t have to work to be on the list” of the World Anti-Doping Agency’s prohibited substances.

To be banned, a drug has to meet two of three criteria: Taking it must enhance or potentially enhance performance, place an athlete’s health at risk, or violate the spirit of sport.

In a person who does not have asthma, the drugs have no benefits, only the risk of side effects that can place an athlete’s health at risk. An athlete taking them in an attempt to gain a competitive advantage would then be violating the spirit of sport. Therefore, Wadler said, inhaled asthma drugs can be banned.

Yet there is no doubt that many elite athletes have asthma, or that asthma symptoms can be brought on by intense exercise.

That is what happened to Radcliffe. She said she learned that she had asthma at 14, when she passed out while training because she could not breathe. Running, she said, and especially running when the air is cold or polluted, brings on her symptoms. It is hard for her to train without the drugs. She said that in order to receive permission to take asthma drugs in competition, she had to stop taking drugs for 10 days before being tested for asthma.

“I struggled,” Radcliffe said. “I wheezed and my voice got creaky. And I had a dry, tickly cough that lasted for five or six hours after hard workouts.”

One indication of the prevalence of asthma among elite athletes came when researchers tested every athlete in seven sports on the 1998 United States Winter Olympic team — biathlon, cross-country skiing, figure skating, ice hockey, Nordic combined, long-track speedskating and short-track speedskating. Nearly a quarter of the athletes, including half of the cross-country skiers, had asthma. In comparison, about 5 percent of the general population has asthma.

The percentage of all United States Olympians with asthma increased from 1996, when it was 12.4 percent, until 2000, when it was 18.9 percent, according to Fitch. But in 2002, when testing became more stringent, the percentage dropped to 12.9 percent. It was 9.1 percent in 2004 and 12.1 percent in 2006, Fitch said.

Asthma is especially prevalent in swimming, distance running, cycling and skiing. That may be because those athletes are exposed to pollutants and dry air, said Dr. Thomas Casale, the chief of allergy and immunology at Creighton University in Omaha. Those who are prone to asthma, he said, can have airways that are especially sensitive to irritants.

For swimmers, the irritants may be tricholoramines used to disinfect the water, said Kenneth Rundell, the director of the Human Performance Laboratory at Marywood University in Scranton, Pa. Ice skaters may be affected by pollutants released by ice-cleaning machines, which are often powered by natural gas or propane, he said. Skiers breathe Teflon when they go in and out of the wax room.

As for distance runners and cyclists, Rundell said, they can be affected by air pollution, especially fine and ultrafine particles, and by the drying effect of breathing rapidly for long periods of time.

Pollen can make symptoms even worse for those who are allergic to it, which includes the majority of athletes with asthma, as it turns out.

None of this bodes well for the Beijing Olympics, asthma researchers say. The Chinese government has said it will reduce the air pollution, but it also warned that the Olympics will be held during pollen season.

One approach the United States has taken has been to fly its athletes to Beijing to have them tested for asthma while they exercise there.

“Our concern is that many who are asymptomatic in a place like Colorado Springs run into problems in Beijing,” said Randall Wilber, a sports physiologist at the United States Olympic Training Center in Colorado Springs. Although he said he could not reveal how many athletes were now documented asthmatics, “that certainly is being considered by many athletes as a strategy.”

Asthma mortality among Swedish children and young adults, a 10-year study

Respir Med. 2008 Jul 15. Bergström SE, Boman G, Eriksson L, Formgren H, Foucard T, Hörte LG, Janson C, Spetz-Nyström U, Hedlin G. Karolinska University Hospital, Pediatrics, Stockholm, Sweden.

BACKGROUND: Previous reports indicate that morbidity and mortality from asthma have increased during the past decades. Here, the mortality rate associated with asthma and possible risk factors in children and young adults in Sweden during the period 1994-2003 were evaluated.

METHODS: The medical profession was asked to report suspected cases of death from asthma in individuals 1-34 years of age. All death certificates containing relevant ICD codes were reviewed. Medical records and autopsy reports were assessed and telephone interviews with next-of-kin performed.

RESULTS: During the 10-year period 37 deaths due to asthma were identified. The median age at the time of death was 27 years and 6 of the deceased were younger than 15. The overall incidence of death from asthma decreased from 1.54 deaths per million in 1994 to 0.53 per million in 2003. Common risk factors were under-treatment (23/37), poor adherence to prescribed treatment (17/37) and adverse psychosocial situation (19/37). An alarming finding was that 11 of the 37 deaths were probably caused by food allergy and for 8 subjects death was associated with exposure to pet dander. The death certificates were found to contain inaccuracies with 30% of those for whom asthma was reported as the underlying cause having died from other causes.

CONCLUSION: Asthma mortality in children and young adults in Sweden decreased between 1994 and 2003. Food allergy and inadequate treatment were the major risk factors for such a death. Recognition and special care of patients with asthma who have shown signs of non-compliance, denial or severe food allergy must be encouraged.

Severe exacerbations in children with mild asthma: characterizing a pediatric phenotype

J Asthma. 2008 Aug;45(6):513-7 Carroll CL, Schramm CM, Zucker AR. Department of Pediatrics, Division of Pediatric CriticalCare, Connecticut Children's Medical Center, Hartford, Connecticut 06106, USA.

BACKGROUND: NHLBI guidelines classify asthma in children as intermittent, mild persistent, moderate persistent, and severe persistent asthma based on baseline symptoms and pulmonary function. However, this may not capture the spectrum of asthma in children, since even mild baseline disease can have significant effects on quality of life. Our objective was to describe a population of children with mild asthma admitted to the ICU with severe exacerbations.

METHODS: We examined data from all children with asthma who were admitted to the ICU with an acute exacerbation between April 1997, and December 2006. Children were defined as having mild asthma if their disease was classified as intermittent or mild persistent according to NHLBI criteria.

RESULTS: Of the 298 children admitted to the ICU with asthma, 164 (55%) were classified as having mild baseline asthma. Compared with children with more severe baseline asthma, mild asthmatic children were younger and less likely to have been previously admitted to the hospital for asthma. Other demographics, including admission severity of illness, gender, and prevalence of overweight, were similar in the two groups. There were no differences between the groups in ICU length of stay, hospital length of stay or types of therapies received. Thirteen children with mild asthma were intubated, although less frequently than those with more severe disease.

CONCLUSIONS: Children with mild asthma have severe exacerbations. This suggests that chronic asthma severity does not necessarily predict asthma phenotypes during acute exacerbations.

Disease variability in asthma: how do the patients respond?--and why?

J Asthma. 2008 Aug;45(6):507-11 Ulrik CS, Søes-Petersen U, Backer V, Lange P, Harving H, Plaschke P. Department of Heart and Lung Diseases, Hvidovre Hospital, Copenhagen.

BACKGROUND AND AIM: Asthma is a variable disease, and therapy should be tailored accordingly. The aim of this study was to explore patterns of self-management in response to disease variability in adult asthmatics.

METHODS: Adult asthmatics (n = 509), recruited through a web-based panel, answered a questionnaire concerning asthma knowledge, compliance, and treatment, including specified treatment options, through the Internet.

RESULTS: Two-thirds of the patients on inhaled corticosteroids (ICS) stepped-up and down their daily dose without prior contact to their doctor, and more than 50% took less ICS than prescribed during periods with fewer symptoms. In case of deterioration, 57% of the patients would only increase their reliever medication, whereas 23% would also increase their controller medication, although 59% were instructed by their doctor to do so. The self-perceived severity of asthma (graded as mild, moderate or severe) was not associated with the patients' response pattern. The preferred treatment strategy, differing primarily with regard to dosing and timing of controller medication, was associated with feeling safe about self-adjustment of controller medication (p < 0.001), but not with self-reported knowledge of asthma (p > 0.5).

CONCLUSION: In case of deterioration, the majority of adult asthmatics only increase their reliever medication, although instructed by their doctors also to increase their controller medication. Furthermore, the patients' preferred strategy for management of disease variability seems not to be driven by their knowledge of the disease.

Mental, emotional, and social problems among school children with asthma.

J Asthma. 2008 Aug;45(6):489-93 Collins JE, Gill TK, Chittleborough CR, Martin AJ, Taylor AW, Winefield H. Department of Health, Population Research and Outcome Studies Unit, South Australia.

OBJECTIVES: To use representative population chronic disease and risk factor data to investigate the relationship between asthma and social factors in school-age children.

METHODS: Representative cross-sectional data for children 5 to 15 years of age were collected from 2002 to June 2007 (n = 4,611) in the South Australian Monitoring and Surveillance System (SAMSS) using Computer-Assisted Telephone Interviews (CATI). Univariate and multivariate analyses were conducted to investigate the variables that were associated with asthma among children.

RESULTS: The overall prevalence of self-reported asthma among children 5 to 15 years of age was 18.6% (95% CI = 17.5-19.8). Children with asthma were more likely to have been treated for a mental health problem, have been unhappy at school, have been absent from school in the last month, have fair or poor overall health and well-being, have ongoing pain or chronic illness, and less likely to have a group of friends to play with. Asthma was also more prevalent among males and less likely to occur in children from households where the gross annual income was greater than $AU80,000.

CONCLUSIONS: Children with asthma were more likely to be treated for a mental health problem and demonstrate more negative social outcomes as well as poorer overall health and well-being. Asthma management plans need to be sensitive to these psychosocial factors for adequate care of these vulnerable young patients.

Wheezing Rhinovirus Illnesses in Early Life Predict Asthma Development in High Risk Children.

Am J Respir Crit Care Med. 2008 Jun 19 Jackson DJ, Gangnon RE, Evans MD, Roberg KA, Anderson EL, Pappas TE, Printz MC, Lee WM, Shult PA, Reisdorf E, Carlson-Dakes KT, Salazar LP, Dasilva DF, Tisler CJ, Gern JE, Lemanske Jr RF. Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA; Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA.

RATIONALE: Virus-induced wheezing episodes in infancy often precede the development of asthma. Whether infections with specific viral pathogens confer differential future asthma risk is incompletely understood.

OBJECTIVES: To define the relationship between specific viral illnesses and early childhood asthma development.

METHODS: 259 children were followed prospectively from birth to six years of age. The etiology and timing of specific viral wheezing respiratory illnesses during early childhood were assessed using nasal lavage, culture and multiplex RT-PCR. The relationships of these virus-specific wheezing illnesses and other risk factors to the development of asthma were analyzed.

MEASUREMENTS AND MAIN RESULTS: Viral etiologies were identified in 90% of wheezing illnesses. From birth to age three years, wheezing with RSV (OR=2.6), rhinovirus (RV) (OR=9.8), or both RV and RSV (OR=10) was associated with increased asthma risk at age six years. In year one, both RV wheezing (OR = 2.8) and aeroallergen sensitization (OR = 3.6) independently increased asthma risk at age six years. By age three years, wheezing with RV (OR = 25.6) was more strongly associated with asthma at age six years than aeroallergen sensitization (OR = 3.4). Nearly 90% (26 of 30) of children who wheezed with RV in year three had asthma at six years of age.

CONCLUSIONS: Among outpatient viral wheezing illnesses in infancy and early childhood, those caused by RV infections are the most significant predictors of the subsequent development of asthma at age six years in a high-risk birth cohort.

The relation between paracetamol use and asthma: a GA2LEN European case-control study.

Eur Respir J. 2008 Jun 25. Shaheen S et al. London UK.

Studies from the UK and the USA suggest that frequent use of paracetamol (acetaminophen) may increase the risk of asthma, but data across Europe are lacking.As part of a multi-centre case-control study organised by the GA(2)LEN network we have examined whether frequent paracetamol use is associated with adult asthma across Europe. The network compared 521 cases with a diagnosis of asthma and reporting asthma symptoms in the last 12 months with 507 controls with no diagnosis of asthma and no asthmatic symptoms in the last 12 months across 12 European centres. All cases and controls were selected from the same population defined by age (20-45 years) and place of residence.In a random effects meta-analysis, after controlling for confounders, the adjusted odds ratio for asthma associated with weekly use of paracetamol, compared with less frequent use, was 2.87 (95% CI: 1.49 to 5.37), P=0.002. There was no evidence for heterogeneity across centres. No association was seen between use of other analgesics and asthma

These data add to the increasing and consistent epidemiological evidence implicating frequent paracetamol use in asthma in diverse populations.

Binge drinking, poor mental health, and adherence to treatment among California adults with asthma.

J Asthma. 2008 Jun;45(5):369-76. Haskard KB, Banta JE, Williams SL, Haviland MG, DiMatteo MR, Przekop P, Werner LS, Anderson DL. Texas State University, San Marcos, Texas, USA.

Binge drinking and poor mental health may affect adherence to treatment for individuals with asthma. The purposes were to (a) examine the relationship of self-reported binge drinking and mental health to adherence to daily asthma control medications and (b) identify other demographic and health-related factors associated with asthma control medication adherence.

Secondary analyses of 2003 adult California Health Interview Survey data were undertaken, and these analyses identified 3.2 million California adults who had been told by a physician they had asthma. Of these, approximately 1.7 million were symptomatic. Binge drinking significantly predicted medication nonadherence among California adults with symptomatic asthma (OR = .63, 95% CI = .45-.89), whereas poor mental health did not. Other predictors of nonadherence (odds ratios < 1, p < .05) included being overweight, younger age, having some college education, being a current smoker, and having no usual source of medical care. Predictors of adherence (odds ratios > 1, p < .05) were older age, more frequent asthma symptoms, more ER visits, more missed work days, being African American, and being a non-citizen.

Intervention efforts could be directed toward improving medication adherence among adult asthma patients who engage in risky health behaviors such as binge drinking. Also at risk for medication nonadherence and therefore good targets for asthma control medication management interventions are adults who are overweight, younger (18-44 age range), have some college education, and no usual source of medical care.

Persistent impact of cigarette smoking on asthma

J Asthma. 2008 Aug;45(6):495-9. Niedoszytko M, Gruchała-Niedoszytko M, Chełminska M, Sieminska A, Jassem E. Department of Allergology, Medical University of Gdansk, Gdansk, Poland.

OBJECTIVE: In the present study we assessed the impact of former cigarette smoking on asthma control and treatment effectiveness.

METHODS: A total of 104 patients with uncontrolled asthma were included in the study. The group of former smokers consisted of 33 subjects, whereas the never smokers group consisted of 71 subjects of similar age and gender. Spirometry, classification of asthma severity, and control were assessed according to Global Initiative for Asthma (GINA) guidelines. Quality of life was measured with the use of the Saint George Hospital Respiratory Questionnaire (SGHRQ).

RESULTS: Asthma was more severe in the group of former smokers both before and after treatment; p < 0.001. Severe asthma (OR 7.8 CI 2.8-21.9) and cigarette smoking (OR 3.5 CI 1.3-9.2) were associated with difficulties in asthma control achievement. Total quality of life significantly improved in the group of non-smokers; p = 0.02, whereas in former smokers this effect was not significant; p > 0.05.

CONCLUSION: Cigarette smoking has a persistent, dose-dependent, negative impact on the response to treatment in patients with uncontrolled asthma even after smoking cessation. Smoking cessation should remain the ultimate goal in treatment of asthmatic patients. More efforts should be undertaken to decrease smoking initiation, especially in teenagers

Airway inflammation in exercise-induced bronchospasm occurring in athletes without asthma.

J Asthma. 2008 Jun;45(5):363-7. Parsons JP, Baran CP, Phillips G, Jarjoura D, Kaeding C, Bringardner B, Wadley G, Marsh CB, Mastronarde JG. The Ohio State University Medical Center, Columbus, Ohio, USA.

Exercise-induced bronchospasm (EIB) occurs in athletes with and without asthma. Studies have suggested an inflammatory basis for EIB in asthmatics; however whether inflammation plays a similar role in EIB in athletes without asthma remains unclear. Our objective was to determine whether there is evidence of an inflammatory basis for exercise-induced bronchospasm occurring in non-asthmatic athletes.

Ninety-six athletes without asthma from varsity college teams underwent eucapnic voluntary hyperventilation testing. Sputum was induced from subjects with hypertonic saline inhalation post-eucapnic voluntary hyperventilation testing and was analyzed with enzyme-linked immunosorbent assays for IL-5, IL-8, IL-13, cysteinyl-leukotrienes, prostaglandin E2, histamine, leukotriene B4, and thromboxane B2. In addition, inflammatory (neutrophils, lymphocytes, eosinophils, and macrophages) and epithelial cell counts in sputum were recorded.

Multivariate regression modeling showed a significant correlation between concentrations of select inflammatory mediators after eucapnic voluntary hyperventilation testing and severity of EIB. Means of the log-transformed concentrations of inflammatory mediators in EIB-positive athletes were significantly higher post-eucapnic voluntary hyperventilation than in EIB-negative athletes. Similar findings were not demonstrated with inflammatory cells. Concentrations of inflammatory mediators are higher in EIB-positive athletes than in EIB-negative athletes without asthma after eucapnic voluntary hyperventilation testing.

The severity of EIB in our cohort also is significantly correlated with increased concentrations of select inflammatory mediators suggesting a potential inflammatory basis for EIB in athletes without asthma.

Limitations of questioning asthma to assess asthma control in general practice.

Respir Med. 2008 Jun 21 Hagmolen Of Ten Have W, van den Berg NJ, van der Palen J, van Aalderen WM, Bindels PJ. Medical Spectrum Twente, Department of Pulmonology, Haaksbergerstraat 55, 7513 ER Enschede, The Netherlands.

BACKGROUND: The monitoring of children with asthma in primary care is based on the occurrence and frequency of asthma symptoms. We questioned whether the current approach is adequate to identify all children in whom a sufficient level of asthma control is not achieved. AIM: The aim of this study is to illustrate that in some children asthma was incorrectly considered controlled, because the children failed to report current symptoms of asthma.

PATIENTS AND METHODS: One hundred and nineteen children were identified with recent wheezing plus moderate or severe airway hyperresponsiveness. We analyzed whether these children reported current symptoms of asthma (as normally questioned during a routine visit).

RESULTS: In 20 children (18%) current asthma symptoms were absent despite moderately or severe airway hyperresponsiveness and wheezing in the last year. In addition, the usage of controller medication was very poor.

CONCLUSION: We conclude that the general practitioner has insufficient tools to adequately assess asthma control in all children. The assessment of airway hyperresponsiveness as an additional guide to manage asthma in children in general practice is recommended. In this way, better asthma control can be achieved.

Effects of Intensive Glucose Lowering in Type 2 Diabetes

N Engl J Med 358(24):2545-2559, The Action to Control Cardiovascular Risk in Diabetes Study Group

Background: Epidemiologic studies have shown a relationship between glycated hemoglobin levels and cardiovascular events in patients with type 2 diabetes. We investigated whether intensive therapy to target normal glycated hemoglobin levels would reduce cardiovascular events in patients with type 2 diabetes who had either established cardiovascular disease or additional cardiovascular risk factors.

Methods: In this randomized study, 10,251 patients (mean age, 62.2 years) with a median glycated hemoglobin level of 8.1% were assigned to receive intensive therapy (targeting a glycated hemoglobin level below 6.0%) or standard therapy (targeting a level from 7.0 to 7.9%). Of these patients, 38% were women, and 35% had had a previous cardiovascular event. The primary outcome was a composite of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes. The finding of higher mortality in the intensive-therapy group led to a discontinuation of intensive therapy after a mean of 3.5 years of follow-up.

Results: At 1 year, stable median glycated hemoglobin levels of 6.4% and 7.5% were achieved in the intensive-therapy group and the standard-therapy group, respectively. During follow-up, the primary outcome occurred in 352 patients in the intensive-therapy group, as compared with 371 in the standard-therapy group (hazard ratio, 0.90; 95% confidence interval [CI], 0.78 to 1.04; P=0.16). At the same time, 257 patients in the intensive-therapy group died, as compared with 203 patients in the standard-therapy group (hazard ratio, 1.22; 95% CI, 1.01 to 1.46; P=0.04). Hypoglycemia requiring assistance and weight gain of more than 10 kg were more frequent in the intensive-therapy group (P<0.001).

Conclusions: As compared with standard therapy, the use of intensive therapy to target normal glycated hemoglobin levels for 3.5 years increased mortality and did not significantly reduce major cardiovascular events. These findings identify a previously unrecognized harm of intensive glucose lowering in high-risk patients with type 2 diabetes.

Non-atopic Children with Multi-trigger Wheezing have Airway Pathology Comparable to Atopic Asthma.

Am J Respir Crit Care Med. 2008 May 29. Turato G, Barbato A, Baraldo S, Zanin ME, Bazzan E, Lokar-Oliani K, Calabrese F, Panizzolo C, Snijders D, Maestrelli P, Zuin R, Fabbri LM, Saetta M. Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy.

RATIONALE: Epidemiological studies have shown that in atopic children wheezing is more likely to persist into adulthood, eventually becoming asthma, while it appears to resolve by adolescence in non-atopic children.

OBJECTIVES: To investigate whether among children with multi-trigger wheeze responsive to bronchodilators the airway pathology would be different in non-atopic wheezers, who are often considered non-asthmatic, compared to atopic wheezers, who are more frequently diagnosed as having asthma.

METHODS: Bronchial biopsies were obtained from 55 children undergoing bronchoscopy for appropriate clinical indications: 18 non-atopic children with multi-trigger wheeze (median age, range: 5, 2-10 yrs), 20 atopic children with multi-trigger wheeze (5, 2-15 yrs) and 17 control children with no atopy or wheeze (4, 2-14 yrs). By histochemistry and immunohistochemistry, we quantified epithelial loss, basement membrane thickness, angiogenesis, inflammatory cells, IL-4(+) and IL-5(+) cells in subepithelium.

MEASUREMENTS AND MAIN RESULTS: Unexpectedly, all pathological features examined were similar in atopic and non-atopic wheezing children. Compared to controls, both non-atopic and atopic wheezing children had increased epithelial loss (p=0.03; p=0.002), thickened basement membrane (both p<0.0001), increased number of vessels (p=0.003; p=0.03) and of eosinophils (p<0.0001; p=0.002). Moreover, they had increased cytokine expression, which was highly significant for IL-4 (p=0.002; p=0.0001) and marginal for IL-5 (p=0.02; p=0.08).

CONCLUSIONS: This study shows that the airway pathology typical of asthma is present in non-atopic wheezing children just as in atopic wheezing children. These results suggest that when multi-trigger wheezing responsive to bronchodilators is present, it is associated with pathological features of asthma even in non-atopic children.

Workplace specific challenges as a contribution to the diagnosis of occupational asthma

Eur Respir J. 2008 May 28. Rioux JP, Malo JL, L'archevêque J, Rabhi K, Labrecque M. Hôpital du Sacré-Cur de Montréal.

The diagnosis of occupational asthma (OA) can be made by exposing workers to the relevant agent either in a hospital laboratory through specific inhalation challenges (SIC) or at the workplace. As suggested by several authors, workers with negative laboratory SIC can be monitored at the workplace under supervision.

Aim: Assess the frequency of and identify factors associated with a positive workplace reaction in workers with negative SIC in the laboratory.

We examined the results of workplace challenges in 99 workers who underwent negative SIC between 1994 and 2004. A positive reaction either in the SIC or in the workplace was a sustained fall in FEV1 of 20% or more.

Twenty-two workers (22.2%) showed positive responses at the workplace. These subjects more often had increased baseline methacholine responsiveness (90.5% vs 67.6%, p=0.05). They also underwent more days of SIC testing (4.9 vs 3.3 days, p=0.004) and were exposed more often to two or more agents (56% vs 28.4%, p=0.002) and for a longer period (363.3 min vs 220.4 min, p=0.002) in the laboratory.

This study illustrates the usefulness of workplace monitoring of airway function in the investigation of OA and identifies factors that are more often associated with a positive reaction.

Outdoor Swimming Pools and the Risks of Asthma and Allergies during Adolescence

Eur Respir J. 2008 May 28. Bernard A, Nickmilder M, Voisin C. Catholic University of Louvain, Belgium.

Exposure to indoor chlorinated swimming pools can be detrimental to the airways of swimmers and increase asthma risks but it is unknown whether these effects concern outdoor pools.

We studied 847 secondary school adolescents who had attended at a variable rate residential or non-residential outdoor chlorinated pools. Main outcomes were ever asthma (physician-diagnosed at any time), current asthma (ever asthma under medication and/or with exercise-induced bronchoconstriction), elevated exhaled nitric oxide and aeroallergens-specific IgE in serum.

The prevalences of ever and current asthma increased with the lifetime number of hours spent in outdoor pools by up to four and eight times, respectively, among adolescents with the highest attendance (>500 hours) and a low exposure to indoor pools (<250 hours) (all P for trend <0.001). Odds for asthma were significantly increased among adolescents with total serum IgE above 25 kIU.l(-1), on average by one to two units for each 100 hours-increase in pool attendance. Use of residential outdoor pools was also associated with higher risks of elevated exhaled nitric oxide and sensitization to cat or house-dust mite allergens.

Outdoor chlorinated pools attendance is associated with higher risks of asthma, airways inflammation and some respiratory allergies.

Association between early life history of respiratory disease and morbidity and mortality in adulthood.

Thorax. 2008 May;63(5):423-9 Galobardes B, McCarron P, Jeffreys M, Davey Smith G. Department of Social Medicine, University of Bristol, Whiteladies Road, Canynge Hall, Bristol BS8 2PR, UK.

BACKGROUND: Early life exposure to respiratory diseases is associated with lung impairment in adulthood. The objective of this study was to investigate morbidity, and respiratory and other cause specific mortality, among people who reported a medical history of bronchitis, pneumonia and asthma early in life.

METHODS: We studied an historical cohort of male students who attended Glasgow University between 1948 and 1968 and for whom long term follow-up and cause specific mortality were available (9544 students, 1553 deaths). A medical history of respiratory diseases, including bronchitis, pneumonia and asthma, along with other disease risk factors and socioeconomic conditions, were collected during university health examinations. A subsample responded to a postal follow-up in adulthood (n = 4044), which included respiratory and other chronic disease questions.

RESULTS: A medical history of a respiratory disease (bronchitis, pneumonia and asthma) in early life was associated with a 57% greater risk of overall respiratory disease mortality in adulthood and a more than twofold increase in chronic obstructive pulmonary disease mortality (fully adjusted hazard ratio (HR) 2.37; 95% CI 1.16, 4.83). In addition, students reporting a history of bronchitis had a 38% higher risk of cardiovascular disease mortality (95% CI 1.06, 1.80). Respiratory disease in early life was also associated with a higher risk in adulthood of chronic phlegm, dyspnoea and doctor's diagnosis of asthma, bronchitis and emphysema (adjusted odds ratios ranging from 1.40 to 6.95 for these outcomes).

CONCLUSION: An early life history of respiratory diseases is associated with higher mortality and morbidity risk in adulthood in men, the associations being seen particularly for respiratory related and cardiovascular deaths among those with a history of bronchitis. All early life respiratory diseases appeared to be negatively associated with later adult respiratory health.

The asthma emergency department visit: treating a crisis in the midst of uncontrolled disease

Ann Allergy Asthma Immunol. 2008 Mar;100(3):237-43. Lenhardt RO, Catrambone CD, Walter J, McDermott MF, Weiss KB. Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois 60612, USA.

BACKGROUND: Patients with asthma who require emergency department (ED) care are burdened with asthma symptoms, are at risk for hospitalization, and use expensive resources.

OBJECTIVE: To examine whether an ED-based surveillance system that characterized asthma symptoms and care before, during, and after an ED visit enhances our understanding of the natural history of asthma exacerbations.

METHODS: This cross-sectional follow-up enrolled 225 adult patients who presented to 1 of 6 Illinois EDs for asthma care. Clinical characteristics before ED presentation, care provided in the EDs, and 1-month follow-up status were assessed by self-administered questionnaire, medical record review, and telephone interview, respectively.

RESULTS: Persistent asthma symptoms were reported by 85.8% and 84.9% (P = .37) of patients before their ED visit and follow-up call, respectively. For patients with persistent symptoms before the ED visit and follow-up call, 54.4% and 73.8% (P = .02) reported using an inhaled corticosteroid, respectively. Inhaled corticosteroids were recommended for 49.4% of discharged patients with persistent symptoms. Relapse rates for return ED visits and return hospitalizations were 26.4% and 9.6%, respectively. Patients had low asthma-specific and general quality-of-life scores at follow-up.

CONCLUSIONS: Patients with asthma exacerbations most often had uncontrolled asthma before the ED visit that subsequently deteriorated, temporarily improved with ED treatment, and continued as uncontrolled asthma after the ED visit. Although improvements in care were reported 1 month after the ED visit, opportunities for additional improvement were observed

Prevalence of Masked Hypertension in Subjects Treated with Antihypertensive Drugs as Assessed by Morning versus Evening Home Blood Pressure Measurements: the J-HOME study.

Clin Exp Hypertens. 2008 Apr;30(3):277-87. Obara T, Ohkubo T, Asayama K, Kikuya M, Metoki H, Inoue R, Komai R, Murai K, Hashimoto J, Totsune K, Imai Y; J-Home Study Group. Department of Clinical Pharmacology, Tohoku University Graduate School of Pharmaceutical Sciences and Medicine, Sendai, Japan.

To investigate the relationship between morning and evening home blood pressure (BP) measurements to make a diagnosis of masked hypertension, we collected information on the characteristics of 3,303 essential hypertensive outpatients receiving antihypertensive medication in Japan using a physician, self-administered questionnaire. All patients were asked to measure their home BP once every morning and once every evening for two weeks. Morning and evening home BP values of each patient were defined as the average of all morning and all evening home BP values, respectively. The mean BP values of all study subjects were 142.8/80.6 mmHg for office BP, 139.8/81.8 mmHg for morning home BP, 133.7/76.9 mmHg for evening home BP, and 136.8/79.3 mmHg for the average of the morning and evening home BPs. Masked hypertension was defined as an office BP < 140/90 mmHg and a home BP > or = 135/85 mmHg. The prevalence of masked hypertension diagnosed using morning home BP (23.1%) was higher than that diagnosed by evening home BP (14.7%); the prevalence was 19.0% when diagnosed using the average of the morning and evening home BPs. Among the 1,386 patients with a normal office BP, the diagnosis of masked hypertension based on morning and evening home BP values differed in 28.8% of patients for systolic BP and 20.9% for diastolic BP (kappa coefficient = 0.43).

The present study showed that the prevalence of masked hypertension was underestimated when the diagnosis of masked hypertension was made on the basis of evening home BP.

Training Improves Physical Fitness and Decreases CRP Also in Asthmatic Conscripts.

J Asthma. 2008 Apr;45(3):237-42 Juvonen R, Bloigu A, Peitso A, Silvennoinen-Kassinen S, Saikku P, Leinonen M, Hassi J, Harju T. Department of Otorhinolaryngology, Kainuu Central Hospital, Kajaani, Finland.

To study the respiratory and physical health of young men, 224 asthmatic and 668 non-asthmatic military conscripts were recruited from the intake groups of July 2004 and January 2005 in Kajaani, Finland. Factors affecting respiratory health were elicited by a questionnaire at the beginning of the service, and results of high sensitive C-reactive protein (hsCRP) determination, peak expiratory flow (PEF), and 12-minute running test were collected at the beginning and the end of the service. Respiratory infections were diagnosed by a study physician.

Upon entering military service, asthmatics had frequent exercise- and cold-related asthma symptoms (69.6% and 76.3%), and 48% of them had no medication for asthma. At the beginning, 25.8% of asthmatics and 19.1% of non-asthmatics had a poor result of less than 2,200 m (p = 0.05) in the 12-minute running test, and after 180 to 362 days of service, the corresponding percentages were 11.7% and 9.7% (p = 0.434). The levels of hsCRP, a marker of low-grade systemic inflammation, decreased significantly among both asthmatics, 1.5 (p = 0.001), and non-asthmatics, 1.6 mg/L (p < 0.001). Asthmatic men had 0.2 and non-asthmatics 0.1 respiratory infections per month (p < 0.001).

In summary, asthmatic conscripts can enhance their physical fitness by training similarly to non-asthmatic ones. Their levels of hsCRP also decrease.

Happy air(r): a school-based educational program to maximize detection of asthma in children

J Asthma. 2008 Apr;45(3):197-200. Chini L, Borruto M, Chianca M, Corrente S, Graziani S, Iannini R, La Rocca M, Angelini F, Roscioni S, Visconti G, Moschese V. Policlinico Tor Vergata, Centro Interdisciplinare di Pediatria Specialistica-Allergologia e Immunologia, University of Rome Tor Vergata, Rome, Italy.

Objective. To investigate whether an active partnership among school, parents, and pediatricians allows early identification and treatment of asthmatic children.

Methods: An asthma educational program (Happy Air(R)), based on a strong family-physician-school interrelationship, was performed in six primary schools (2,765 children) before administering a screening questionnaire to the parents.

Results. A high response rate (96%) demonstrated 2,649 responders available for the asthma screening: 135 children (5%) received a diagnosis of asthma, of which 37 (27%) were recognized de novo.

Conclusion. The active participation of school and parents is the determining factor for the success of an asthma screening program.

Sleep quality in asthma: results of a large prospective clinical trial.

J Asthma. 2008 Apr;45(3):183-9 Mastronarde JG, Wise RA, Shade DM, Olopade CO, Scharf SM, Centers FT. The Ohio State University, Columbus, Ohio, USA.

Rationale. Previous studies have suggested that asthmatics have an increased incidence of sleep disturbances. However, these studies have been limited by reliance on population surveys or small numbers of participants.

Objectives. We sought to measure sleep quality and daytime sleepiness in a cohort of symptomatic asthmatics and to measure the effects of improved asthma control on sleep quality.

Methods. Data were collected in sub-study of a large multi-center randomized double-masked controlled trial of mild-moderate asthmatics evaluating the effect of low-dose theophylline on asthma control in comparison to montelukast and placebo. Each participant was administered sleep symptom questionnaires at randomization and at the final visit (6 months after randomization). These included the Pittsburgh Sleep Quality Questionnaire (PSQI) and the Epworth Sleepiness Scale (ESS).

Measurements and main results. Data were available for 487 participants. Baseline mean values were: age 40 +/- 15 years, 74% female, forced expiratory volume in 1 second (FEV(1)) 79 +16 percent predicted, Juniper Asthma Control Questionnaire (ACQ) score 2.35 +/- 0.63, PSQI 7.8 +/-4, and ESS 8.5 +/-4.9. There were no significant differences in the PSQI or ESS between the three treatment groups. Significant correlations were found at baseline between the global PSQI score and ACQ and quality of life and marginally with lung function. Significant correlation existed between improvements in PSQI and ESS with improved asthma control and quality of life.

Conclusions. Sleep disturbances are common in asthmatics and are associated with asthma control and quality of life. Clinicians caring for asthmatics may need to complete a more detailed sleep history in patients with poorly controlled asthma. In addition, low-dose theophylline does not seem to impair sleep quality in asthmatics

Hypertension and CKD: Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES), 1999-2004.

Am J Kidney Dis. 2008 Apr;51(4 Suppl 2):S30-7 Rao MV, Qiu Y, Wang C, Bakris G. Department of Medicine, Section of Nephrology, University of Chicago, Pritzker School of Medicine, Chicago, IL 60637, USA.

BACKGROUND: The prevalence and incidence of hypertension are increasing, and they correlate with the chronic kidney disease rate in the United States. Early identification and achievement of blood pressure goals may improve chronic kidney disease outcomes.

METHODS: In this cross-sectional study, subjects were participants in the Kidney Early Evaluation Program (KEEP), a voluntary community-based health-screening program enrolling individuals 18 years and older with diabetes, hypertension, or family history of kidney disease, diabetes, or hypertension, administered by the National Kidney Foundation; and the National Health and Nutrition Examination Survey (NHANES), administered by the National Center for Health Statistics. All studied individuals in both databases were US residents aged 18 years or older. We evaluated multiple variables for participants in KEEP 2000-2006 and participants in NHANES 1999-2004 in this logistic analysis.

RESULTS: Although distributions of hypertension were similar between databases, KEEP participants with cardiovascular risk factors, especially current smoking, have a greater prevalence of hypertension than similar NHANES participants. Of hypertensive participants, 35.8% were African American in KEEP data, and 13.2% in NHANES data. Associations with increased prevalence of hypertension were decreasing estimated glomerular filtration rate by increments of 10 mL/min/1.73 m(2), increasing age, obesity, African American race, and microalbuminuria. In both KEEP and NHANES data, study group participants younger than 46 years were more likely to have achieved goal blood pressure.

CONCLUSION: Several elements were identified by both registries as risk factors for linearly associated worsening of hypertension. In addition to the traditional risk factors of age, race, and geographic residence, such novel markers as microalbuminuria may also increase the risk.

Achievement of guideline-defined treatment goals in primary care: the German Coronary Risk Management (CoRiMa) study.

Eur Heart J. 2007 Dec;28(24):3051-8 Geller JC, Cassens S, Brosz M, Keil U, Bernarding J, Kropf S, Bierwirth RA, Lippmann-Grob B, Schultheiss HP, Schlüter K, Pels K. Division of Cardiology, Zentralklinik Bad Berka, Robert Koch Allee 9, Bad Berka, Germany.

AIMS: The success in achieving treatment goals for cardiovascular risk factors in primary care is largely unknown. Therefore, the goals of this study were (i) to assess whether routinely collected practice data can be used to evaluate treatment in primary care, (ii) to compare current treatment with goals of published guidelines, and (iii) to calculate future risk for cardiovascular events using these real-life data.

METHODS AND RESULTS: In 110 physician offices in Germany, data from the patient management systems of all patients seen between January 1998 and June 2005 were extracted and analysed (715 644) with current guidelines used for reference. Of those patents, 284 096 (40% of all patients analysed) had one of the following diseases: 157 101 (55% of 284 096) had hypertension, 83 005 (29%) diabetes, 64 205 (23%) coronary artery disease (CAD), 174 787 (62%) hyperlipidaemia, and 136 360 (48%) had more than one of the listed diagnoses. During the last visit, treatment goals were achieved for total and LDL cholesterol in 9 and 29%, respectively, for blood pressure in 28%, and for HbA1c in 36%. Low achievement of treatment goals was also seen in patients with CAD or diabetes. Using the Framingham risk model and the SCORE Deutschland risk charts, 20 and 22% of patients had a high 10-year risk for a primary cardiovascular event and a fatal cardiovascular event, respectively. Achieving treatment goals for all risk factors would significantly reduce the number of high-risk patients.

CONCLUSION:

1)Routinely collected practice data can be used to evaluate quality of care;
2)40% of patients in primary care have cardiovascular disease or diabetes;
3)even in high-risk patients, the majority does not achieve treatment goals; and
4)achieving the treatment goals would reduce the proportion of high-risk patients from 20 to <5%.

Nebulisers or spacers for the administration of bronchodilators to those with asthma attending emergency departments?

Respir Med. 2008 Apr 4 Mason N, Roberts N, Yard N, Partridge MR. NHLI Division, Faculty of Medicine, Imperial College London, Charing Cross Campus, London W6 8RP, UK.

BACKGROUND: Systematic reviews and national guidelines conclude that the nebulised route of administration of bronchodilators has no advantage over the use of a spacer in moderately severe exacerbations of asthma. Whether this recommendation is implemented and whether it might affect use of staff time is unknown.

OBJECTIVES: To determine the current method of administration of bronchodilators to those with non-life-threatening asthma attending emergency departments (ED) in London, UK and to monitor the implementation of a new policy to administer bronchodilators by spacers in one ED with a special reference to the time taken by nurses to administer the therapy by two different routes.

METHODS: Thirty-five EDs in Greater London were surveyed regarding their current practice. A time and motion study was then undertaken in one department observing nurses administering bronchodilators in the 3 weeks before and 3 weeks after a departmental policy change to favour the use of spacer devices rather than nebulisers.

RESULTS: The majority of EDs (94.3%) in Greater London were using the nebulised route of administering bronchodilators to the majority of their adult patients. Spacers were more commonly used for the treatment of children (60.3% of departments using spacers and nebulisers or spacers alone). Over half of the hospitals surveyed (51.4%) were unaware that the British Guidelines on Asthma Management suggested that outcomes were the same and that there were potential advantages in the use of a spacer for both adults and children. Time and motion studies showed that the use of a spacer took no more nursing time than administration of the bronchodilator via a nebuliser; in fact treatment and set-up time were considerably lower for spacers.

CONCLUSION: Spacer administration of bronchodilators to those with asthma attending EDs utilises less treatment time than use of a nebuliser. A survey of EDs in Greater London has shown that despite guideline conclusions there appears to be little evidence of reduction in use of nebulisers; a fear that use of alternatives might take nurses longer is not supported by this study.

Are asymptomatic airway hyperresponsiveness and allergy risk factors for asthma? A longitudinal study.

Eur Respir J. 2008 Apr 2 van den Nieuwenhof L, Schermer T, Heijdra Y, Bottema B, Akkermans R, Folgering H, van Weel C. Radboud University Nijmegen Medical Centre, the Netherlands.

Airway hyperresponsiveness(AHR) is a characteristic feature of asthma, but it is yet unclear whether asymptomatic AHR is associated with a higher risk of asthma. The present study assessed whether there is an association between asymptomatic AHR in adolescence and asthma in adulthood. We also looked at the association between allergy and development of asthma.14 years follow-up of a general population cohort of adolescents.

Respiratory status was assessed at baseline in 1989 and at follow-up in 2004 by respiratory symptoms questionnaire, spirometry, and histamine challenge. Allergy status was also assessed.The respiratory status of 199 subjects was assessed twice. Ninety-one subjects (46%) had the same AHR status in combination with respiratory symptoms at follow-up as at baseline. Adjusted for age, gender, allergy, family history of asthma and smoking history, having asymptomatic AHR was not statistically significant related with asthma 14 years later (OddsRatio 2.15, p=0.20, 95%CI: 0.67-6.83). For subjects with allergy at baseline, the OR for developing asthma was 4.45 (p=0.009, 95%CI 1.46-13.54).

Screening for asymptomatic AHR in adolescence does not identify subjects at risk for developing asthma. On the other hand, the presence of allergy in adolescence does seem to be a risk factor for asthma development.

Frequency and impact of allergic rhinitis in asthma patients in everyday general medical practice: a French observational cross-sectional study.

Allergy. 2008 Mar;63(3):292-8. Magnan A, Meunier JP, Saugnac C, Gasteau J, Neukirch F. INSERM, Nantes; Université de Nantes, Faculté de Médecine, Nantes and CHU Nantes, l'Institut du Thorax, Service de Pneumologie, Nantes, France.

BACKGROUND: Allergic rhinitis (AR) and asthma are inflammatory conditions of the airways that often occur concomitantly. This observational, cross-sectional, national study was undertaken to describe the frequency and severity of AR in asthmatic patients. The impact of AR on the quality of life and the therapeutic management of patients in everyday general medical practice were also assessed.

METHODS: From April to October 2005, 1906 French general practitioners (GP) participated in the study. Each physician had to fill out a questionnaire (including the Juniper Asthma Control Questionnaire and a Rhinitis Questionnaire) for up to 10 consecutive adult asthmatic patients. The first three patients with a confirmed diagnosis of AR (Allergic Rhinitis and its Impact on Asthma classification) were asked to complete the Juniper Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ).

RESULTS: A total of 14,703 patient questionnaires and 4335 auto-questionnaires were analysed. Patients presented with intermittent (45%), mild (25%), moderate (25%) and severe (4%) persistent asthma. The frequency of AR in asthmatic patients was 55.2% (CI: 95%, 54.4-56.0%). Allergic rhinitis was mild for 54% and moderate/severe for 46% of patients. The frequency and severity of AR increased with the severity of asthma (P < 0.001). Moreover, AR was associated with worse asthma control whatever be the severity of asthma (P < 0.001). The global RQLQ scores of AR patients worsened with the severity of asthma (P < 0.001). Prescription of anti-asthma treatments significantly increased with the severity of AR. The majority of AR patients (81%) were treated for rhinitis.

CONCLUSIONS: This survey suggested that AR was associated with more severe asthma, more difficulty to control asthma and substantial impairment of quality of life. The high frequency of AR in asthma patients requires that these conditions should be recognized and managed by GP.

The effects of second-hand and direct exposure to tobacco smoke on asthma and lung function in adolescence.

Paediatr Respir Rev. 2008 Mar;9(1):29-38. Tager IB. School of Public Health, University of California, Berkeley, CA, USA.

Cigarette smoking still is quite common in many parts of the world. In parallel, exposure to second-hand smoke continues to be common despite declines in smoking in developed countries and despite evidence of serious health effects in infants and children. This paper focuses on the effects of second-hand and direct exposure (personal smoking) on the respiratory health of adolescents, in particular effects on the occurrence of asthma and on lung function.

Published data indicate that, in addition to whatever effects direct and postnatal second-hand tobacco smoke exposure have on the occurrence of asthma and impaired levels and growth of lung function in adolescents, there is an underlying alteration in the prenatal and early postnatal development of the structural and mechanical characteristics of the lung that contribute substantially to these deficits.

These developmental effects may be important contributors to the future risks for impaired pulmonary function.

Effects of early cigarette smoke exposure on early immune development and respiratory disease.

Paediatr Respir Rev. 2008 Mar;9(1):3-10. Prescott SL. School of Paediatrics and Child Health, University of Western Australia, Princess Margaret Hospital for Children, GPO Box D184, Perth, Western Australia 6840, Australia.

Exposure to tobacco constituents during early development remains a common but avoidable toxic exposure, which has been clearly linked with decreased lung growth and subsequent wheezing illness. There is also now emerging evidence that tobacco smoke can influence early immune function. This includes alterations in cytokine production by the fetoplacental unit, as detected ex vivo in cord blood, as well as in patterns of fetal mononuclear cell responses in vitro.

Recent studies also suggest that the newborns of smoking mothers have altered signalling through Toll-like receptors (TLRs) that are essential for innate microbial responses. This may be implicated in the increased predisposition to infection in exposed infants. TLR-mediated innate response pathways are also believed to be important in promoting regulatory pathways that inhibit allergic immune responses. However, although a number of studies have documented associations between early cigarette smoke exposure and subsequent allergic disease, this remains controversial.

This review explores the consequences of smoking on these important aspects of early development, including potential mechanisms, interactions with predisposing asthma genes and a potential role in epigenetic regulation.

Although parental smoking may not be the primary factor in the changing prevalence of asthma and respiratory disease, we propose that it is an important contributor, with significant potential to interact with other genetic factors and environmental risk factors to influence disease propensity.

Astma vaak over het hoofd gezien bij schoolkinderen

Zorgkrant.nl

De meerderheid van de schoolkinderen met astma wordt niet gediagnosticeerd. Dat concludeert René van Gent in zijn proefschrift. Hij onderzocht 1758 kinderen in de regio Veldhoven. De kinderen ondergingen allemaal een longfunctieonderzoek en de ouders moesten een vragenlijst invullen. Kinderen waarvan vermoed werd dat ze astma hadden, werden naar de huisarts gestuurd.

De invloed van niet-gediagnosticeerd astma op het dagelijks leven is groot: kinderen hebben een lagere longfunctie, lagere scores voor kwaliteit van leven en een hoger schoolverzuim dan hun gezonde klasgenoten. Het komt vaker voor bij schoolkinderen met meer dan normaal schoolverzuim, luchtwegklachten of minder specifieke problemen (vermoeidheid of slaapproblemen).

Herkenning, diagnose en behandeling kan leiden tot een belangrijke verbetering van het functioneren van kinderen en vermindering van de invloed van astma op schoolkinderen. Astma is de meest voorkomende chronische ziekte op de kinderleeftijd. Kinderen met astma of astmaklachten worden benauwd, ademen 'piepend' of moeten hoesten.

Increased Airway Smooth Muscle Mass in Children with Asthma, Cystic Fibrosis and Bronchiectasis

Am J Respir Crit Care Med. 2008 Jan 24 Regamey N, Ochs M, Hilliard TN, Muhlfeld C, Cornish N, Fleming L, Saglani S, Alton EW, Bush A, Jeffery PK, Davies JC. Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom; Department of Gene Therapy, National Heart and Lung Institute, Imperial College London, London, United Kingdom.

RATIONALE: Structural alterations to airway smooth muscle (ASM) are a feature of asthma and cystic fibrosis (CF) in adults.

OBJECTIVE: We investigated whether increase in ASM mass is already present in children with chronic inflammatory lung disease.

METHODS: Fibreoptic bronchoscopy was performed in 78 children (median age (IQR): 11.3 years (8.5-13.8)): 24 with asthma, 27 with CF, 16 with non-CF bronchiectasis (BX), and 11 control children without lower respiratory tract disease. Endobronchial biopsy ASM content, and myocyte number and size were quantified using stereology.

MEASUREMENTS AND MAIN RESULTS: The median (IQR) volume fraction of subepithelial tissue occupied by ASM was increased in the children with asthma (0.27, 0.12-0.49; p<0.0001), CF (0.12, 0.06-0.21; p<0.01) and BX (0.16, 0.04-0.21; p<0.01) compared to controls (0.04, 0.02-0.05). ASM content was related to bronchodilator responsiveness in the asthmatic group (r=0.66, p<0.01). Median (IQR) myocyte number (cells per mm(2) of reticular basement membrane) was 8204 (5270-11749; p<0.05) in asthma, 4504 (2838-8962; n.s.) in CF, 4971 (3476-10057; n.s.) in BX, and 1944 (1596-6318) in controls. Mean (SD) myocyte size (microm(3)) was 3344 (801; p<0.01) in asthma, 3264 (809; p<0.01) in CF, 3177 (873; p<0.05) in BX and 1927 (386) in controls. In all disease groups, the volume fraction of ASM in subepithelial tissue was related to myocyte number (asthma: r=0.84, p<0.001; CF: r=0.81, p<0.01; BX: r=0.95, p<0.001), but not to myocyte size.

CONCLUSIONS: Increases in ASM (both number and size) occur in children with chronic inflammatory lung diseases that include CF, asthma and non-CF bronchiectasis.

438,000 deaths – the number of American deaths-per-year caused by smoking

American Lung Association

$13 billion – the amount Big Tobacco spends on promotions and advertising.

If these numbers don't add up, pretend you're a Big Tobacco executive: more than 400,000 Americans are dying from smoking every year – that's a lot of customers to replace. That's why, despite promises to stop, Big Tobacco continues to court new teen smokers to become its "replacement generation."

We need your help to push back against Big Tobacco's youth marketing onslaught. A $50 dollar, tax-deductible donation will help us protect teens from Big Tobacco – and provide them with a future without cigarettes:

Just look at the marketing for Camel's new No. 9 cigarette – pink packaging, advertising in magazines popular with girls, and promotional giveaways including berry lip balm and cell phone jewelry. It's the latest in Big Tobacco's teen girl recruitment drive.

And when teens just give smoking a try, they're getting addicted quicker and finding it harder to stop. Big Tobacco has increased the amount of nicotine in cigarettes – it is their way to hook those they lure in.

But your American Lung Association is fighting back hard in trying to protect our children. In addition to our very active teen education and cessation programs, we're pushing Congress to give the U.S. Food and Drug Administration authority over tobacco products. This would restrict Big Tobacco's efforts to target children, including the Camel No. 9 "light and luscious" marketing you see here.

And one of the best ways to prevent children and teens from smoking is to increase the tax on cigarettes. We are working hard to convince Congress to pass a bill that would do exactly that (and would also provide health care to children). We've already helped pass a number of state-level cigarette tax increases – eight in 2007.

We don't have a $13 billion budget, but we do have something much more important: dedicated supporters like you. Please donate $50 dollars, and help us protect our children from Big Tobacco.

Traffic-related exposures, airway function, inflammation, and respiratory symptoms in children.

Am J Respir Crit Care Med. 2007 Dec 15;176(12):1236-42 Holguin F, Flores S, Ross Z, Cortez M, Molina M, Molina L, Rincon C, Jerrett M, Berhane K, Granados A, Romieu I. Emory University, Atlanta, Georgia, USA.

RATIONALE: Traffic-related emissions have been associated with respiratory symptoms in some studies. However, there is limited information on how traffic-related emissions relate to lung function and airway inflammation.

OBJECTIVES: To determine the differential association of traffic-related exposures with exhaled nitric oxide (NO) and lung volumes and symptoms in children with and without asthma.

METHODS: We performed a longitudinal study of 200 children from ages 6 to 12 years of whom half had physician-diagnosed asthma. Two-week NO(2) and 48-hour average levels of elemental carbon and particulate matter of less than 2.5 microm (PM(2.5)) were measured at participating schools. Road and traffic densities were determined at schools and at each participant's house.

MEASUREMENTS AND MAIN RESULTS: In children with asthma, an interquartile increase in road density within the 50-, 100-, and 200-m home buffer areas was associated with increased exhaled NO (50 m: 28%; P = 0.03; 95% confidence interval [CI], 3-60; 100 m: 27%; P = 0.005; 95% CI, 8-49; 200 m: 17%, P = 0.09, 95% CI, -2 to 40), and reduced FEV(1) (50 m: -0.091 L; P = 0.038; 95% CI, -0.174 to -0.007; 100 m: -0.072 L, P = -0.028, 95% CI, -0.134 to -0.009; 200 m: -0.106 L, P = 0.002, 95% CI, -0.171 to -0.041]). Exposure to NO(2) at schools was marginally associated with reduced FEV(1) (-0.020; P = 0.060; 95% CI, -0.042 to 0.001). We did not observe significant associations with PM(2.5) or elemental carbon on exhaled NO. We did not observe significant reductions in lung volumes or changes in exhaled NO among healthy children.

CONCLUSIONS: Vehicular traffic exposures are associated with increased levels of exhaled NO and reduced lung volumes in children with asthma.

Global strategy for asthma management and prevention: GINA executive summary.

Eur Respir J. 2008 Jan;31(1):143-78. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, Fitzgerald M, Gibson P, Ohta K, O'Byrne P, Pedersen SE, Pizzichini E, Sullivan SD, Wenzel SE, Zar HJ. University of Cape Town Lung Institute, PO Box 34560, Groote School, 7700 Mowbray, Cape Town, South Africa.

Asthma is a serious health problem throughout the world. During the past two decades, many scientific advances have improved our understanding of asthma and ability to manage and control it effectively. However, recommendations for asthma care need to be adapted to local conditions, resources and services.

Since it was formed in 1993, the Global Initiative for Asthma, a network of individuals, organisations and public health officials, has played a leading role in disseminating information about the care of patients with asthma based on a process of continuous review of published scientific investigations. A comprehensive workshop report entitled "A Global Strategy for Asthma Management and Prevention", first published in 1995, has been widely adopted, translated and reproduced, and forms the basis for many national guidelines.

The 2006 report contains important new themes. First, it asserts that "it is reasonable to expect that in most patients with asthma, control of the disease can and should be achieved and maintained," and recommends a change in approach to asthma management, with asthma control, rather than asthma severity, being the focus of treatment decisions. The importance of the patient-care giver partnership and guided self-management, along with setting goals for treatment, are also emphasised.

The relationship of physical activity and percentage of body fat to the risk of asthma in 8- to 10-year-old children

J Asthma. 2007 Dec;44(10):885-9. Ownby DR, Peterson EL, Nelson D, Joseph CC, Williams LK, Johnson CC. Department of Pediatrics, Medical College of Georgia, Augusta, Georgia 30912-3790, USA.

To evaluate physical activity, obesity and asthma, we analyzed information from children attending a racially diverse middle-class suburban school district. Physical activity in metabolic equivalents (METS) and percent body fat were related to diagnosed asthma.

On average the, 636 children were 8.9 years of age, 64.0% black, and 11.8% with reported asthma. Children with asthma were more active: 6,438 versus 5,432 METs/year, p = 0.03. Logistic regression considering METs, percent fat, gender and race showed METs were a significant risk factor for asthma, odds ratio (OR) = 1.24 (95% CI 1.01-1.52, p = 0.045).

Higher levels of physical activity were related to more diagnosed asthma.

An association between asthma and BMI in adolescents: results from the California Healthy Kids Survey.

J Asthma. 2007 Dec;44(10):873-9. Davis A, Lipsett M, Milet M, Etherton M, Kreutzer R. American Lung Association of California, Emeryville, CA 94608, USA.

We examined the relationship between asthma prevalence and BMI in a cross-sectional survey of 471,969 adolescents. The size of the survey allowed us to investigate this relationship with much greater resolution than previously possible.

Both lifetime and current asthma prevalence increased monotonically with increasing BMI, starting with individuals as low as the 45th to 55th percentiles of BMI. The pattern was similar between males and females and among six racial/ethnic groups.

The results suggest that weight reduction even among persons not classified as overweight or obese may be an important component of asthma management.

The relationship between age of asthma onset and cardiovascular disease in Canadians.

J Asthma. 2007 Dec;44(10):849-54. Dogra S, Ardern CI, Baker J. Lifespan Health and Performance Laboratory.

PURPOSE: To quantify the association between cardiovascular disease (CVD) and asthma in Canadian adults and to determine whether age of asthma onset is a moderator of this association.

METHODS: We used a sample of 74 342 participants with a mean age of 56.4 +/- 12.5 from cycle 1.1 of the Canadian Community Health Survey. Asthma age of onset was categorized into early-onset (0-20 years) and adult-onset (21-54 years). Three major outcomes were used to estimate the relationship between asthma and CVD, namely: high blood pressure, heart disease, and stroke.

RESULTS: Multiple logistic regression models revealed that asthmatics were 43% (OR = 1.43, CI = 1.19-1.72) more likely to have heart disease, and 36% (OR = 1.36, CI = 1.21-1.53) more likely to have high blood pressure than non-asthmatics. There were no consistent results for age of onset with high blood pressure, heart disease, or stroke.

CONCLUSION: Using a population-based dataset we confirmed that asthmatics are at increased odds of cardiovascular disease compared to non-asthmatics; furthermore, age of asthma onset did not appear to moderate this relationship. Future research should focus on determining whether asthma severity or allergic/non-allergic phenotypes have a differential effect on the asthma-CVD relationship.

Asthma and atypical bacterial infection.

Chest. 2007 Dec;132(6):1962-6. Sutherland ER, Martin RJ. National Jewish Medical and Research Center, Department of Medicine, 1400 Jackson St, J220, Denver, CO 80206.

A growing body of basic and clinical science implicates the atypical bacterial pathogens Mycoplasma pneumoniae and Chlamydophila (formerly Chlamydia) pneumoniae as potentially important factors in asthma, although their exact contribution to asthma development and/or persistence remains to be determined. Evidence from human studies links both M pneumoniae and C pneumoniae to new-onset wheezing, exacerbations of prevalent asthma, and long-term decrements in lung function, suggesting that these organisms can play an important role in the natural history of asthma. Furthermore, animal models of acute and chronic infection with these organisms indicate that they have the ability to modulate allergic sensitization and pulmonary physiologic and immune response to allergen challenge.
These findings raise the possibility that, in at least some individuals with asthma, antibiotic therapy might have a role in long-term treatment. While antibiotics do not currently have a defined role in the treatment of stable patients with chronic asthma, there is emerging evidence that asthma symptoms and biomarkers of airway inflammation can improve when patients who have atypical bacterial infection as a cofactor in their asthma are treated with macrolide antibiotics.
Ongoing research into the importance of atypical pathogens in asthma will further elucidate whether these infections are important in disease development or whether their prevalence is increased in asthmatic subjects due to chronic airway inflammation or other, yet unidentified, predisposing factors.
Current studies will further define the role of macrolide antibiotics in the treatment of stable patients with asthma, ultimately determining whether these therapeutic agents have a place in asthma management.

Risk Factors Associated With Persistent Airflow Limitation in Severe or Difficult-to-Treat Asthma: Insights From the TENOR Study.

Chest. 2007 Dec;132(6):1882-9. Lee JH, Haselkorn T, Borish L, Rasouliyan L, Chipps BE, Wenzel SE. Genentech, Inc., 1 DNA Way, MS 453B, South San Francisco, CA 94080.

BACKGROUND: The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study is among the largest to assess persistent airflow limitation and the first to evaluate a wide range of potential risk factors in high-risk patients with severe or difficult-to-treat asthma. A better understanding is needed regarding factors associated with persistent airway obstruction; this study was performed to determine demographic and clinical characteristics associated with persistent airflow limitation.

METHODS: Data from adult patients (>/= 18 years old) with severe or difficult-to-treat asthma were evaluated. Patients with COPD, obesity with a restrictive respiratory pattern, or a >/= 30 pack-year history of smoking were excluded. Patients with persistent airflow limitation (postbronchodilator FEV(1)/FVC ratio
RESULTS: Of 1,017 patients, 612 patients (60%) showed evidence of persistent airflow limitation. Risk factors were as follows: older age (odds ratio [OR] per 10 years, 1.4; 95% confidence interval [CI], 1.3 to 1.6); male gender (OR, 4.5; 95% CI, 2.3 to 8.5); black ethnicity (OR, 2.2; 95% CI, 1.3 to 3.8); current or past smoking (OR, 3.9; 95% CI, 1.8 to 8.6; and OR, 1.6; 95% CI, 1.2 to 2.3, respectively); aspirin sensitivity (OR, 1.5; 95% CI, 1.0 to 2.4); and longer asthma duration (OR per 10 years, 1.6; 95% CI, 1.4 to 1.8). Protective factors were Hispanic ethnicity, higher education, family history of atopic dermatitis, pet(s) in the home, and dust sensitivity.

CONCLUSIONS: Persistent airflow limitation is prevalent in patients with severe or difficult-to-treat asthma and is associated with identifiable clinical and demographic characteristics.

Advancing a multilevel framework for epidemiologic research on asthma disparities.

Chest. 2007 Nov;132(5 Suppl):757S-69S. Wright RJ, Subramanian SV. Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Our understanding of asthma epidemiology is growing increasingly complex. Asthma outcomes are clearly socially patterned, with asthma ranking as a leading cause of health disparities among minority and low socioeconomic groups. Yet, the increasing prevalence and marked disparities in asthma remain largely unexplained by known risk factors. In the United States, asthma disproportionately affects nonwhite children living in urban areas and children living in poverty. Low socioeconomic status (SES), ethnic minority group status, and residence in an inner-city environment are closely intertwined in the United States, making it a challenge to fully disentangle the independent effects of each of these characteristics on asthma morbidity. In addition, studies show geographic variation in asthma outcomes across large cities and neighborhoods within cities that cannot be explained by economic factors alone. Although more limited data are available, studies in rural areas also suggest the stratification of risk based on SES and the proportion of minorities. Among low-SES areas, those with predominantly minority, segregated populations seem especially burdened. Marginalized populations of lower socioeconomic position are disproportionately exposed to irritants (eg, tobacco smoke), pollutants (eg, diesel-related particles), and indoor allergens (eg, cockroach and mouse allergen). Moreover, these marginalized individuals may also live in communities that are increasingly socially toxic, which, in turn, may be related to the increased experience of psychosocial stress that may influence asthma morbidity. Epidemiologic trends suggest that asthma may provide an excellent paradigm for understanding the role of community-level contextual factors in disease. Specifically, a multilevel approach that includes an ecological perspective may help to explain heterogeneities in asthma expression across socioeconomic and geographic boundaries that, to date, remain largely unexplained. Traditionally, asthma epidemiology has focused on individual-level risk factors and family factors. Far less attention has been given to the broader social context in which individuals live. A multilevel approach that explicitly recognizes the embedding of asthma within its biological, psycho-socioeconomic, environmental, and community contexts, is likely to provide a better understanding of asthma disparities at different stages in the life course. Is it simply asthma disparities or is it social disparities in asthma?

First months of employment and new onset of rhinitis in adolescents.

Eur Respir J. 2007 Sep;30(3):549-55. Riu E, Dressel H, Windstetter D, Weinmayr G, Weiland S, Vogelberg C, Leupold W, von Mutius E, Nowak D, Radon K. Unit for Occupational and Environmental Epidemiology and Net Teaching, Institute for Occupational and Environmental Medicine, Ludwig-Maximilians-University Munich, Ziemssenstrasse 1, D-80336 Munich, Germany.

The aim of the present study was to investigate the incidence of rhinitis in adolescents, taking into account the duration and type of employment in holiday and vocational jobs, and to study latency until development of symptoms.

Participants of the International Study of Asthma and Allergies in Childhood (ISAAC)-II study in Munich and Dresden (Germany), who were enrolled in 1995, were re-contacted by a postal questionnaire in 2002 (aged 16-18 yrs). The questionnaire focused on allergic rhinitis, type and duration of all jobs, and potential confounders.

All jobs held for >/=8 h.week(-1) and >/=1 month were coded and occupational exposure was assigned by a job-exposure matrix. Out of the 3,785 participants, 964 reported an employment history. The median (25th-75th percentile) duration of employment was 10 (1-16) months. After adjusting for potential confounders, those working in high-risk occupations (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.0-2.1) had an increased risk for new onset of rhinitis, especially those exposed to low molecular weight agents (OR 1.8, 95% CI 1.1-2.8). The incidence of rhinitis was highest among those currently employed in a high-risk job for <10 months.

Teenagers who start working in high-risk occupations have a higher incidence of rhinitis compared with those not working. This increased risk might occur early on during employment.

Respiratory effects of exposure to diesel traffic in persons with asthma

N Engl J Med. 2007 Dec 6;357(23):2348-58.
McCreanor J, Cullinan P, Nieuwenhuijsen MJ, Stewart-Evans J, Malliarou E, Jarup L, Harrington R, Svartengren M, Han IK, Ohman-Strickland P, Chung KF, Zhang J.
National Heart and Lung Institute, Imperial College, and Royal Brompton Hospital, London, United Kingdom.

BACKGROUND: Air pollution from road traffic is a serious health hazard, and people with preexisting respiratory disease may be at increased risk. We investigated the effects of short-term exposure to diesel traffic in people with asthma in an urban, roadside environment.

METHODS: We recruited 60 adults with either mild or moderate asthma to participate in a randomized, crossover study. Each participant walked for 2 hours along a London street (Oxford Street) and, on a separate occasion, through a nearby park (Hyde Park). We performed detailed real-time exposure, physiological, and immunologic measurements.

RESULTS: Participants had significantly higher exposures to fine particles (<2.5 microm in aerodynamic diameter), ultrafine particles, elemental carbon, and nitrogen dioxide on Oxford Street than in Hyde Park. Walking for 2 hours on Oxford Street induced asymptomatic but consistent reductions in the forced expiratory volume in 1 second (FEV1) (up to 6.1%) and forced vital capacity (FVC) (up to 5.4%) that were significantly larger than the reductions in FEV1 and FVC after exposure in Hyde Park (P=0.04 and P=0.01, respectively, for the overall effect of exposure, and P<0.005 at some time points). The effects were greater in subjects with moderate asthma than in those with mild asthma. These changes were accompanied by increases in biomarkers of neutrophilic inflammation (sputum myeloperoxidase, 4.24 ng per milliliter after exposure in Hyde Park vs. 24.5 ng per milliliter after exposure on Oxford Street; P=0.05) and airway acidification (maximum decrease in pH, 0.04% after exposure in Hyde Park and 1.9% after exposure on Oxford Street; P=0.003). The changes were associated most consistently with exposures to ultrafine particles and elemental carbon.

CONCLUSIONS: Our observations serve as a demonstration and explanation of the epidemiologic evidence that associates the degree of traffic exposure with lung function in asthma

Daytime and Nighttime Blood Pressure as Predictors of Death and Cause-Specific Cardiovascular Events in Hypertension

Hypertension. 2007 Nov 26
Fagard RH, Celis H, Thijs L, Staessen JA, Clement DL, De Buyzere ML, De Bacquer DA.
Hypertension and Cardiovascular Rehabilitation Unit, Faculty of Medicine, University of Leuven; the Department of Cardiovascular Diseases, Ghent University; and the Department of Public Health, Ghent University, Belgium.

Our aim was to assess the prognostic significance of nighttime and daytime ambulatory blood pressure and their ratio for mortality and cause-specific cardiovascular events in hypertensive patients without major cardiovascular disease at baseline.

We performed a meta-analysis on individual data of 3468 patients from 4 prospective studies performed in Europe. Age of the subjects averaged 61+/-13 years, 45% were men, 13.7% smoked, 8.4% had diabetes, and 61% were under antihypertensive treatment at the time of ambulatory blood pressure monitoring. Office, daytime, and nighttime blood pressure averaged 159+/-20/91+/-12, 143+/-17/87+/-12, and 130+/-18/75+/-12 mm Hg. Total follow-up amounted to 23 164 patient-years. We used multivariable Cox regression analysis to assess the hazard ratios associated with 1 standard deviation higher blood pressure. Daytime and nighttime systolic blood pressure predicted all-cause and cardiovascular mortality, coronary heart disease, and stroke, independently from office blood pressure and confounding variables. When these blood pressures were entered simultaneously into the models, nighttime blood pressure predicted all outcomes, whereas daytime blood pressure did not add prognostic precision to nighttime pressure. Appropriate interaction terms indicated that the results were similar in men and women, in younger and older patients, and in treated and untreated patients The systolic night-day blood pressure ratio predicted all outcomes, which only persisted for all-cause mortality after adjustment for 24-hour blood pressure.

In conclusion, nighttime blood pressure is in general a better predictor of outcome than daytime pressure in hypertensive patients, and the night-day blood pressure ratio predicts mortality, even after adjustment for 24-hour blood pressure.

Hospital admission rates among men and women with symptoms of chronic bronchitis and airflow limitation corresponding to the GOLD stages of chronic obstructive pulmonary disease-A population-based stu

Respir Med. 2008 Jan;102(1):109-20.
Ekberg-Aronsson M, Löfdahl K, Nilsson JA, Löfdahl CG, Nilsson PM.
Department of Respiratory Medicine and Allergology, University of Lund, S-221 85 Lund, Sweden.

Chronic obstructive pulmonary disease is a major cause of increased morbidity and mortality. The aim of this study was to investigate hospital admission rates among individuals with symptoms of chronic bronchitis and among those with airflow limitation corresponding to GOLD stages 1-4.

METHOD: Between 1974 and 1992, 22044 middle-aged individuals participated in a health screening, which included spirometry (without broncho-dilation), as well as recording of respiratory symptoms and smoking habits. Information on hospital admissions until 31 December 2002 was obtained from local and national registers. The hospital admission rates due to all causes, obstructive lung disease and cardiovascular disease were analysed among individuals with symptoms of chronic bronchitis and among those with airflow limitation corresponding to GOLD stages 1-4 using ordinal regression with adjustment for age and with individuals with normal lung function and without symptoms of chronic bronchitis as reference group.

RESULTS: Symptoms of chronic bronchitis and GOLD stages 1-4 showed increased hospital admission rates (hospital admission rates due to obstructive lung disease excluded) among smokers of both genders. Furthermore, symptoms of chronic bronchitis showed increased hospital admission rates due to obstructive lung disease among smoking women. There were also increased hospital admission rates due to obstructive lung disease among smokers of GOLD stages 1-4 and increased hospital admission rates due to cardiovascular disease among female smokers of GOLD stage 2.

CONCLUSION: Among smokers, symptoms of chronic bronchitis as well airflow limitation corresponding to GOLD stages 1-4 conveyed a substantial morbidity with increased hospital admission rates due to all causes. The burden of disease is most likely underestimated among individuals with symptoms of chronic bronchitis and chronic obstructive pulmonary disease.

Mobile phone-based remote patient monitoring system for management of hypertension in diabetic patients

Am J Hypertens. 2007 Sep;20(9):942-8.
Logan AG, McIsaac WJ, Tisler A, Irvine MJ, Saunders A, Dunai A, Rizo CA, Feig DS, Hamill M, Trudel M, Cafazzo JA.
Prosserman Centre for Health Research, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Canada.

BACKGROUND: Rising concern over the poor level of blood-pressure (BP) control among hypertensive patients has prompted searches for novel ways of managing hypertension. The objectives of this study were to develop and pilot-test a home BP tele-management system that actively engages patients in the process of care.

METHODS: Phase 1 involved a series of focus-group meetings with patients and primary care providers to guide the system's development. In Phase 2, 33 diabetic patients with uncontrolled ambulatory hypertension were enrolled in a 4-month pilot study, using a before-and-after design to assess its effectiveness in lowering BP, its acceptability to users, and the reliability of home BP measurements.

RESULTS: The system, developed using commodity hardware, comprised a Bluetooth-enabled home BP monitor, a mobile phone to receive and transmit data, a central server for data processing, a fax-back system to send physicians' reports, and a BP alerting system. In the pilot study, 24-h ambulatory BP fell by 11/5 (+/-13/7 SD) mm Hg (both P < .001), and BP control improved significantly. Substantially more home readings were received by the server than expected, based on the preset monitoring schedule. Of 42 BP alerts sent to patients, almost half (n = 20) were due to low BP. Physicians received no critical BP alerts. Patients perceived the system as acceptable and effective.

CONCLUSIONS: The encouraging results of this study provide a strong rationale for a long-term, randomized, clinical trial to determine whether this home BP tele-management system improves BP control in the community among patients with uncontrolled hypertension.

Declines in hospital admissions for acute myocardial infarction in new york state after implementation of a comprehensive smoking ban.

Am J Public Health. 2007 Nov;97(11):2035-9.
Juster HR, Loomis BR, Hinman TM, Farrelly MC, Hyland A, Bauer UE, Birkhead GS.
New York State Department of Health, Bureau of Chronic Disease Epidemiology and Surveillance, Albany, NY 12237-0679, USA.

OBJECTIVES: Reductions in exposure to environmental tobacco smoke have been shown to attenuate the risk of cardiovascular disease. We examined whether the 2003 implementation of a comprehensive smoking ban in New York State was associated with reduced hospital admissions for acute myocardial infarction and stroke, beyond the effect of moderate, local and statewide smoking restrictions, and independent of secular trends.

METHODS: We analyzed trends in county-level, age-adjusted, monthly hospital admission rates for acute myocardial infarction and stroke from 1995 to 2004 to identify any association between admission rates and implementation of the smoking ban. We used regression models to adjust for the effects of pre-existing smoking restrictions, seasonal trends in admissions, differences across counties, and secular trends.

RESULTS: In 2004, there were 3813 fewer hospital admissions for acute myocardial infarction than would have been expected in the absence of the comprehensive smoking ban. Direct health care cost savings of $56 million were realized in 2004. There was no reduction in the number of admissions for stroke.

CONCLUSIONS: Hospital admission rates for acute myocardial infarction were reduced by 8% as a result of a comprehensive smoking ban in New York State after we controlled for other relevant factors. Comprehensive smoking bans constitute a simple, effective intervention to substantially improve the public's health.

The validity of diagnostic support of an asthma/COPD service in primary care.

Br J Gen Pract. 2007 Nov;57(544):892-896.
Lucas A, Smeenk F, Smeele I, Brouwer T, van Schayck O.
Primary Care Heath Care Centre 'Orion', Eindhoven, The Netherlands; Department of General Practice (HAG), Maastricht University, Maastricht, The Netherlands.

BACKGROUND: To support GPs in diagnosing and monitoring their patients with asthma/chronic obstructive pulmonary disease (COPD), 'asthma/COPD services' have been developed. Within these services, pulmonologists perform structured diagnostic and therapeutic assessments based on the combination of written history data and spirometry.

AIM: This study determines the validity of the diagnosis and advice when assessed using only written information.

DESIGN OF STUDY: The results of the diagnostic procedures of an asthma/COPD service were compared with the results of regular office consultations by pulmonologists.

SETTING: From January until August 2004, two pulmonologists examined 80 randomly selected patients referred to an asthma/COPD service in Eindhoven, the Netherlands.

METHOD: Concordance was analysed between diagnosis and advice based on written spirometry and history data, with assessments based on live consultations with the same patients by pulmonologists.

RESULTS: The validity of the assessed diagnosis was high (Cohen's kappa = 0.82). When the diagnosis was uncertain, the advice for medical treatment scored low in validity (Cohen's kappa = 0.39). The advice for additional diagnostic examinations had a high internal validity: in half of the patients, uncertainty in diagnosis turned into a definite diagnosis of asthma/COPD, or another cause for the complaints of the patient was revealed; in the other half, the diagnosis of asthma/COPD could be rejected.

CONCLUSIONS: A structured asthma/COPD service offering diagnosis and diagnostic advice assessed from written spirometry and history data is a new and valid facility that can support the GP who faces the complicated diagnostic procedures in a progressive number of patients with asthma/COPD.

Sub-optimal asthma control: prevalence, detection and consequences in primary practice.

Eur Respir J. 2007 Oct 24;
Chapman KR, Boulet LP, Rea RM, Franssen E.
Toronto, Ontario, Canada.

Telephone surveys describing sub-optimal asthma control may be biased by low response rates. To obtain an unbiased assessment of asthma control and assess its impact in primary care Primary practitioners used a one page control questionnaire in 50 consecutive asthma patients.

Of 10,428 patients assessed by 354 physicians, 59% were uncontrolled, 19% well-controlled and 23% totally controlled. Physicians overestimated control, regarding only 42% of patients as uncontrolled. Physicians were more likely to report plans to alter the regimens of uncontrolled patients than controlled patients (1.29 versus 0.20 medication changes per patient, p<0.01) doing so in a fashion consistent with guideline recommendations. Of uncontrolled patients, 59% required one or more urgent care or specialist visits versus 26% of well-controlled and 15% of totally controlled patients. Patients were more likely to report short term symptom control when they had not required urgent or specialist care (OR 5.68; 95% CI 4.91-6.58).

The majority of asthma patients treated in primary practice are uncontrolled. Lack of control can be recognized by physicians who are likely to consider appropriate changes to therapy. A lack of short term symptom control of asthma is associated with excess health care utilization.

Parent-reported symptoms may not be adequate to define asthma control in children.

Pediatr Pulmonol. 2007 Oct 25;
Dell SD, Foty R, Becker A, Franssen E, Chapman KR.
Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.

INTRODUCTION: Asthma guidelines have suggested that treatment decisions should be guided by indices of asthma control and not only by disease severity. In adults, symptom-based asthma control parameters have been shown to predict exacerbations and health care services use (HSU). We hypothesize that defining asthma control using parent-reported symptoms alone is not adequate in children.

MATERIALS AND METHODS: Cross-sectional data from the population-based asthma in Canada study were reanalyzed. Random-digit dialing was used to produce the final sample, consisting of 1,001 asthmatics: 801 adults (aged 16+) and 200 children (aged 4-15) participating by parental proxy. Weighted frequencies of Canadian guideline defined asthma control parameters, perceived asthma control, HSU and medication use were calculated separately for adults and children. Stratified analyses compared HSU in controlled versus uncontrolled asthmatics.

RESULTS: Over 90% of parents of asthmatic children believed their child's asthma to be controlled. Only 45% were actually controlled as defined by guideline parameters. Among controlled asthmatics, children reported higher HSU (32% reported 2+ health care encounters versus 17% of adults, P < 0.001). Irrespective of control and despite similar use of controller therapy, children reported a higher number of health care encounters than adults (any emergency department visits 37% vs. 24%, P = 0.00003; unscheduled doctor visits 59% vs. 36%, P < 0.00001). While reporting higher HSU, asthmatic children had less frequent episodes of excessive daytime symptoms than adults (29% vs. 49%, respectively, P < 0.0001).

DISCUSSION: Current symptom-based asthma control parameters reported by parental proxy are likely poor predictors of asthma HSU and may not provide adequate asthma control estimates in children.

Continued Exposure to Maternal Distress in Early Life Increases the Risk of Childhood Asthma.

Am J Respir Crit Care Med. 2007 Oct 11;
Kozyrskyj AL, Mai XM, McGrath P, Hayglass KT, Becker AB, Macneil B.
Faculty of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada; Department Community Health Sciences, University of Manitoba, Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada; Department of Pediatrics and Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.

RATIONALE AND OBJECTIVES: Evidence is emerging that exposure to maternal distress in early life plays a causal role in the development of childhood asthma. As much of the data is from high-risk cohorts, we undertook a birth cohort study in a complete population of children to test this association.

METHODS AND MEASUREMENTS: Using Manitoba, Canada's health care and prescription databases, this longitudinal study assessed the association between maternal distress during the first year of life and onwards, and asthma at age 7 in a 1995 birth cohort of 13,907 children. Maternal distress was defined on the basis of health care or prescription medication use for depression or anxiety. Asthma status was derived from health care and prescription records for asthma, using a definition validated by comparison to pediatric allergist diagnosis. Multiple logistic regression was employed to determine the likelihood of asthma (OR, 95% CI).

MAIN RESULTS: Independent of well-known asthma risk factors, our population-based study of a non high-risk cohort demonstrated an increased risk of childhood asthma (OR=1.25, 95% CI: 1.01-1.55) among children exposed to continued maternal distress from birth until age 7. Exposure to maternal depression and anxiety limited to the first year of life did not have a demonstrable association with subsequent asthma. Of interest, we observed that the risk of asthma associated with continued maternal distress was increased in children living in high versus low income households (OR=1.44, 95% CI: 1.12-1.85).

CONCLUSIONS: Maternal distress in early life plays a role in the development of childhood asthma, especially if it continues beyond the postpartum period.

The Use of Household Cleaning Sprays and Adult Asthma: An International Longitudinal Study.

Am J Respir Crit Care Med. 2007 Jun 21
Zock JP, Plana E, Jarvis D, Anto JM, Kromhout H, Kennedy SM, Kunzli N, Villani S, Olivieri M, Toren K, Radon K, Sunyer J, Dahlman-Hoglund A, Norback D, Kogevinas M.
Centre for Research in Environmental Epidemiology (CREAL), Municipal Institute of Medical Research (IMIM), Barcelona, Spain.

RATIONALE: Cleaning work and professional use of certain cleaning products have been associated with asthma, but respiratory effects of non-professional home cleaning have rarely been studied.

OBJECTIVES: To investigate the risk of new-onset asthma in relation to the use of common household cleaners.

METHODS: Within the follow-up of the European Community Respiratory Health Survey in 10 countries, we identified 3,503 persons doing the cleaning in their homes and free of asthma at baseline. Frequency of use of 15 types of cleaning products was obtained in a face-to-face interview at follow-up. We studied the incidence of asthma defined as physician diagnosis and as symptoms or medication usage at follow-up. Associations between asthma and the use of cleaning products were evaluated usingmultivariable Cox' proportional hazards or logbinomial regression analysis.

MAIN RESULTS: The use of cleaning sprays at least weekly (42% of participants) was associated with the incidence of asthma symptoms or medication (Relative Risk (RR) 1.49; 95% confidence interval 1.12-1.99) and wheeze (RR 1.39; 1.06-1.80). The incidence of physician-diagnosed asthma was higher among those using sprays at least four days per week (RR 2.11; 1.15-3.89). These associations were consistent for subgroups and not modified by atopy. Dose-response relationships (p<0.05) were apparent for the frequency of use and the number of different sprays. Risks were predominantly found for the commonly used glass cleaning, furniture and air refreshing sprays. Cleaning products not applied in spray-form were not associated with asthma.

CONCLUSIONS: Frequent use of common household cleaning sprays may be an important risk factor for adult asthma.

Body mass index and response to emergency department treatment among adults with severe asthma exacerbations: a prospective cohort study.

Chest. 2007 Sep 21
Rodrigo GJ, Plaza V.
Departamento de Emergencia, Hospital Central de las FF.AA. Av. 8 de Octubre 3020, Montevideo 11600, Uruguay. Phone: (5982) 487-0165, Fax (5982) 487-2506.

Background
In acute asthma (AA), overweight/obesity (BMI >/= 25 kg/m(2)) have been related to poorer outcomes and higher risk of complications.

Methods
We designed a prospective cohort study to determine if overweight/obese adults with severe episodes of AA require longer duration of ED treatment and have higher hospitalization rates compared with underweight/normal asthmatics (BMI<25 kg/m(2)). All patients received inhaled albuterol (maximum 6 h). Patients were discharged or admitted according to standard accepted criteria. The weight and height of each patient were measured during the ED stay.

Results
Four hundred twenty-six patients (33.4 +/- 11.5 y, 63% female) with severe exacerbations (FEV(1) = 28.2 +/- 11.9%) were enrolled. One hundred sixty three patients (38.3%) were classified as overweight/obese. BMI >/= 25 patients showed significant increases in the length of ED stay (2.3 h vs. 1.9 h, p = 0.01), and in the rate of hospitalization (13.7% vs. 6.8%, p = 0.02), despite adjustments for other confounding variables. They also presented a higher rate of use of inhaled steroids and theophylline within the past seven days. At the end of treatment overweight/obese patients displayed more wheezing. Multivariate analysis demonstrated that a BMI >/= 25 resulted unrelated to final change PEF from baseline. By contrast, BMI >/= 25 was related with duration of ED treatment (p = 0.002).

Conclusions
Overweight/obese patients were admitted more frequently than underweight/normal patients. This may reflect a difference in the perception of dyspnea or may reflect and underlying difference in asthma severity between the two groups.

Asthma flares harm lung function: study

Reuters Health
Last Updated: 2007-09-19 12:43:33 -0400 (Reuters Health)

Intermittent periods of worsening airway inflammation, indicated by exacerbations in asthma, lead to excess lung function decline, according to a study published this month.

Dr. T. R. Bai, of the University of British Columbia, Vancouver, Canada, and colleagues examined the long-term impact of asthma flares on annual lung function decline in 93 non-smoking asthmatic patients with moderate-to-severe asthma.

During a median of 11 years, 56 patients (60.2 percent) experienced at least one severe asthma exacerbation -- defined as being admitted to the hospital for worsening asthma or as a significant and reversible reduction in FEV1 -- a standard measure of lung function.

Decline in lung function was much more pronounced in those individuals with frequent asthma attacks relative to individuals with infrequent asthma attacks, Bai and colleagues report.

It's been proposed, they note, that worsening of airway inflammation associated with asthma exacerbations fuel potentially harmful structural changes in the airway that occur as asthma progresses.

The current results, they add, "provide additional rationale for the notion that the prevention of exacerbations should be the primary end-point in trials of asthma therapy."

Pesticide exposure tied to asthma in farmers

Last Updated: 2007-09-17 10:38:16 -0400 (Reuters Health)
By Anthony J. Brown, MD

NEW YORK (Reuters Health) - Exposure to several commonly used pesticides appears to increase the risk of asthma, US researchers report.

This finding stems from a study of nearly 20,000 farmers, which was presented Sunday at the European Respiratory Society Annual Congress in Stockholm.

Pesticide exposure is a "potential risk factor for asthma and respiratory symptoms among farmers," lead author Dr. Jane A. Hoppin, from the National Institute of Environmental Health Sciences in Research Triangle Park, North Carolina, told Reuters Health.

"Because grains and animals are more common exposures in agricultural settings, pesticides may be overlooked," Hoppin warned, adding: "Better education and training of farmers and pesticide handlers may help to reduce asthma risk."

Of the 19,704 farmers included in the study, 127 had self-reported (doctor diagnosed) allergic asthma and 314 had non-allergic asthma.

The main finding was that a history of high pesticide exposure was associated with a doubling of asthma risk, Hoppin noted. The link remained statistically significant after adjusting for a variety of potentially confounding factors including age, smoking, body weight, and state of residence.

Overall, 16 of the pesticides studied were associated with asthma: 12 with the allergic variety of asthma and 4 with the non-allergic type. Coumaphos, EPTC, lindane, parathion, heptachlor, and 2,4,5-TP were most strongly linked to allergic asthma. For non-allergic asthma, DDT, malathion, and phorate had the strongest effect.

"This is the first study with sufficient power to evaluate individual pesticides and adult asthma among individuals who routinely apply pesticides," Hoppin noted. Moreover, this is the only study to date to do this for allergic and non-allergic asthma separately, the researcher said.

Negative Trends in Lung Disease Affecting Diverse Populations

American Lung Association Examines Ongoing Disparities Driven by Socioeconomic and Genetic Factors

NEW YORK, NY – August 23, 2007— Diverse Communities throughout the United States continue to be disproportionately affected by specific lung diseases such as asthma, tuberculosis, lung cancer and chronic obstructive pulmonary disease (COPD), and/or have more risk factors such as genetic predisposition, poor living conditions, and unequal access to healthcare and medications, according to the American Lung Association State of Lung Disease in Diverse Communities 2007 report.

"One alarming trend we see reflected in our research is that diverse communities are especially vulnerable to asthma and other breathing problems linked to both indoor and outdoor air pollution because many of these diverse groups often reside in high pollution areas," said Dr. Norman Edelman, Chief Medical Officer for the American Lung Association. "It’s just one example of the magnitude of lung disease within diverse communities all across America and increasing understanding of the complex risk factors that cause or contribute to lung disease."

Over the past 20 years, the air quality levels for pollutants have improved in the United States. However, about 141 million tons of air pollution were released into the air in 2005 and approximately 122 million people in the United States lived in counties that did not meet standards set by the U.S. Environmental Protection Agency (EPA). African Americans are disproportionately exposed to hazardous air pollution. One study found that in 2002, 71 percent of African Americans lived in counties that violated federal air pollution standards, compared to 58 percent of the White population. Another reported found that in 2004 more than 19 million (50%) of Hispanics lived in areas that violated the federal air pollution standard for ozone, one of the major triggers of asthma attacks.

Asthma statistics present a striking example of disparity. While it is prevalent among all populations, Puerto Ricans living in the U.S. and inner-city African Americans have the highest prevalence of asthma. Occupational asthma is the most prevalent occupational lung disease in the U.S., and Hispanics are more likely to be employed in high-risk occupations than any other racial or ethnic group, setting the stage for those Hispanic individuals to be overexposed to respiratory hazards.

"This publication serves as a call to action to legislators and community leaders to fight for stricter air pollution standards," says Dr. Hugo Alvarez, Deputy Medical Officer and UM/QI Associate Medical Director for Access Community Health Network . "The disparities in lung health continue to drive the American Lung Association’s ongoing work to educate these communities about lung disease, invest in research and advocate for increased access to quality health care for all."

The American Lung Association State of Lung Disease in Diverse Communities 2007, which presents analyses of data from various surveys and reports across many ethnic and racial groups, illustrates African Americans’ particular vulnerability to lung cancer, COPD, sleep disorders, tuberculosis (TB) and HIV/AIDS. While the spikes in some disease rates may be linked to cigarette smoking and occupational exposures, other findings shed light on genetic and socioeconomic factors. African Americans are less likely to develop or die from COPD, yet they have more emergency room visits and similar disease severity compared to whites who have smoked cigarettes over a longer period of time and are heavier smokers.

"The American Lung Association prides itself on being the most powerful enemy of lung disease that we can be, particularly for vulnerable individuals," says Dr. Leroy Graham, Partner with the Georgia Pediatric Pulmonology Associates. "Part of that fight involves taking a hard look at who is most affected by lung diseases, and creating stronger connections with diverse populations so that our education, advocacy and research are as effective as possible."

Costs of asthma in Italy: Results of the SIRIO (Social Impact of Respiratory Integrated Outcomes) study.

Respir Med. 2007 Sep 4;
Dal Negro RW, Micheletto C, Tosatto R, Dionisi M, Turco P, Donner CF.
Divisione di Pneumologia, Ospedale Orlandi, Bussolengo (VR), Italy; CESFAR, Centro Studi Nazionale FISAR di Farmacoeconomia e Farmacoepidemiologia Respiratoria, Verona, Italy.

Bronchial asthma is a costly disease and the correlated social impact is ever increasing. The aim of the Social Impact of Respiratory Integrated Outcomes (SIRIO) study was to measure the health resources consumption and the costs generated in 1 year by asthmatic patients investigated in a real-life setting.

This bottom-up, observational, prospective, multicentric study was based on the collection of demographic, clinical, diagnostic, therapeutic and outcome data of 577 patients with bronchial asthma who reported spontaneously to the pneumology centers involved in the study. Of these, 485 patients (300 f, mean age 49.2 years+/-16.3 S.D.) were eligible for analysis. At the baseline visit, the asthma severity was as follows: 26.2% intermittent, 37.1% mild persistent, 29.5% moderate, and 6.6% severe. In the 12 months prior to enrollment, 243 patients (50.1%) had visited the general practitioner (GP); 349 (72%) consulted a National Health Service (NHS) specialist; 68 (14%) utilized Emergency Care; and 50 (10.3%) had been admitted to hospital on account of asthma, with a total of 2059 work days lost. At the end of the 1-year survey, asthma severity changed as follows: 32.8% intermittent, 38.1% mild persistent, 23.7% moderate, and 4.3% severe, with a substantial drop in corresponding outcomes: 39.6% visited their GP, 51.5% visited an NHS specialist, 5.2% used Emergency Care, and 4.3% were admitted to hospital. Compared to baseline, the total average cost per patient decreased globally by 17.9% (p<0.001) after the 1-year survey.

In conclusion, during the study period we observed a significant decline in health resources consumption and thus in asthma cost of illness, even though specific costs for the pharmaceutical treatment of asthma increased substantially. These results are likely due to a more strict control of patients and to their more appropriate clinical management.

Astma door zwemmen in binnenbad

Kinderen die regelmatig een duik nemen in zwemwater dat chloor bevat, lopen een verhoogd risico op het ontwikkelen van astma. Dat zeggen onderzoekers van de Katholieke Universiteit Leuven in België.

Met name binnenbaden met chloor vormen een risico. Omdat de baden teveel chloor bevatten en er onvoldoende wordt gelucht, bevat de lucht allerlei gevaarlijke bijproducten van chloor. Deze kunnen astma veroorzaken.

In totaal werden 190.000 Europese kinderen van 13 en 14 jaar oud onderzocht. Volgens de wetenschappers moeten zwembaden de concentraties chloor in het zwembad beter controleren en moeten ze hun binnenbaden beter ventileren.

Exercise Challenge Test in 3- to 6-Year-Old Asthmatic Children.

Chest. 2007 Aug;132(2):497-503
Vilozni D, Bentur L, Efrati O, Barak A, Szeinberg A, Shoseyov D, Yahav Y, Augarten A.
Pediatric Pulmonary Unit, The Edmond and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Tel HaShomer, Ramat-Gan 52621, Israel.

Rationale: The exercise challenge test (ECT) is a common tool to assess exercise-induced asthma (EIA) in school-aged children. EIA has not been explored in the early childhood setting.

OBJECTIVE: To assess the existence of EIA in children in this age group.

Measurements and main results:A 6-min, controlled, free-run test was performed in 55 children (age range, 3 to 6 years old) who were classified into the following groups: 30 children in whom asthma had been previously diagnosed (group A); and 25 children with prolonged coughing (group B). Spirometry measurements were obtained before the run, and at 1, 2, 3, 5, 10, and 20 min after the run. A positive finding of EIA was defined as a 13% decrease from baseline FEV(1) or baseline forced expiratory volume in the first 0.5 s (FEV(0.5)). The actual duration of each run was age-related (mean [+/- SD] duration, 4.8 +/- 0.8 min). The nadir in indexes occurred after a mean time of 2.98 +/- 1.31 min. A positive EIA finding determined by FEV(1) was present in 15 children, and by FEV(0.5) in 34 children. Twenty-six children were from group A, but only 8 children were from group B. Wheezing and/or prolonged expiration were associated with a positive test result in 31 of 34 children. Coughing was frequent in children with both negative and positive ECT findings.

CONCLUSION: The present study documents for the first time the presence of EIA in response to a free-run test in early childhood. Our findings suggest that a free-run test for the presence of EIA is suitable, but that the running duration is limited by age. The duration of airflow limitation after exercise is significantly earlier and shorter in young children with asthma compared with older children. FEV(0.5) is a better index than the traditional FEV(1) for describing positive ECT results in young children. The association of wheezing and/or prolonged expiration may help in defining EIA in early childhood in the absence of a spirometer.

Negative Trends in Lung Disease Affecting Diverse Populations

American Lung Association Examines Ongoing Disparities Driven by Socioeconomic and Genetic Factors

“One alarming trend we see reflected in our research is that diverse communities are especially vulnerable to asthma and other breathing problems linked to both indoor and outdoor air pollution because many of these diverse groups often reside in high pollution areas,” said Dr. Norman Edelman, Chief Medical Officer for the American Lung Association. “It’s just one example of the magnitude of lung disease within diverse communities all across America and increasing understanding of the complex risk factors that cause or contribute to lung disease.”

“This publication serves as a call to action to legislators and community leaders to fight for stricter air pollution standards,” says Dr. Hugo Alvarez, Deputy Medical Officer and UM/QI Associate Medical Director for Access Community Health Network . “The disparities in lung health continue to drive the American Lung Association’s ongoing work to educate these communities about lung disease, invest in research and advocate for increased access to quality health care for all.”

The American Lung Association State of Lung Disease in Diverse Communities 2007, which presents analyses of data from various surveys and reports across many ethnic and racial groups, illustrates African Americans’ particular vulnerability to lung cancer, COPD, sleep disorders, tuberculosis (TB) and HIV/AIDS. While the spikes in some disease rates may be linked to cigarette smoking and occupational exposures, other findings shed light on genetic and socioeconomic factors. African Americans are less likely to develop or die from COPD, yet they have more emergency room visits and similar disease severity compared to whites who have smoked cigarettes over a longer period of time and are heavier smokers.

“The American Lung Association prides itself on being the most powerful enemy of lung disease that we can be, particularly for vulnerable individuals,” says Dr. Leroy Graham, Partner with the Georgia Pediatric Pulmonology Associates. “Part of that fight involves taking a hard look at who is most affected by lung diseases, and creating stronger connections with diverse populations so that our education, advocacy and research are as effective as possible.”

SOURCE: American Lung Association

Red Flag Raised for Millions of Kids with Asthma

American Lung Association Survey Finds Dangerous Misinformation & Miscommunication about State Laws, Kids’ Medications, and Asthma Action Plans

NEW YORK (August 20, 2007)—Students with asthma soon returning to classrooms across the U.S. may face dangerous situations when needing access to lifesaving inhalers, according to an American Lung Association survey released today.

The online survey of parents of children with asthma examined students’ access to “quick relief” medications, the use of Asthma Action Plans, and parents’ awareness of state laws allowing students to carry and use inhalers.

Results revealed that 58.7 percent of respondents were unsure if their state has a law allowing students to carry and self-administer fast-acting “quick relief” inhalers. In fact, 46 states and the District of Columbia require that the self-administration of asthma medication be allowed in public and private schools. An overwhelming 74.4 percent of parents whose children do have inhalers at school responded that their child’s school does not allow students to keep rescue inhalers with them (in their desks, pockets, etc.). Forty percent have never heard of an Asthma Action Plan, the recommended asthma management and communication tool for parents, physicians and schools.

“The American Lung Association’s survey results send a dramatic red flag to parents of students with asthma and to school officials,” said Bernadette A. Toomey, American Lung Association President & Chief Executive Officer. “The breakdown in critical communication links among parents, schools, and teachers means that some children are facing situations at school that can lead to medical emergencies. They must have immediate access to lifesaving medications.”

Access to “quick-relief” or “rescue” medications is critical for people with asthma, as these medications immediately open the airways during an asthma attack. The longer it takes to administer quick-relief medications, the more severe the asthma attack may become. More than 6.5 million American children under age 18 have asthma.

Nearly 22% of respondents indicated that their children may not have immediate access to their lifesaving inhalers during an attack. Those respondents indicated that if their children have trouble with asthma symptoms during the school day, the school calls a parent or caregiver who brings quick-relief medicine to the child; the child does not get his/her rescue medicine until they get home from school; or the school calls an ambulance.

Every state except Connecticut, Louisiana, South Dakota, and Vermont has a statewide law or regulation in place that requires schools to allow students to carry and use asthma inhalers.

“If a state law does exist, that doesn’t mean that all children with asthma should be carrying and giving themselves medication, but the American Lung Association wants as many students as possible to carry their rescue medications,” explained Norman H. Edelman, M.D., American Lung Association Chief Medical Officer. “For each child and each situation, the school, parents, and healthcare provider together must evaluate many factors. They need to consider the student’s maturity level, understanding of their symptoms and when they need medication, and their willingness to follow the school’s policies about carrying your own medication. That relationship among the family, school officials and the child’s health care provider, who must be directing and communicating a specific asthma management plan, is critical.”

As part of its asthma and school health programs, the American Lung Association (ALA) has partnered with the American Association of School Administrators (AASA) to build capacity of local community coalitions and education agencies to address the impact of asthma. Both agencies focus efforts on strengthening communication between schools and parents.

“We applaud the American Lung Association for working to raise awareness about back-to-school asthma,” said AASA Executive Director Paul Houston. “AASA is committed to ensuring that district-level decision-makers play an active role in asthma management, and we are committed to increasing the capacity of these leaders to work with parents to provide the safest learning environment for their children.”

The National Heart, Lung & Blood Institute’s National Asthma Education and Prevention Program recommends that written action plans be created as part of an overall effort to educate patients in self-management. Schools play pivotal roles in students’ asthma management by providing an asthma-friendly school environment, communicating with parents about students’ specific health experiences while at school, and facilitating referrals to healthcare providers and other community resources when necessary.

“The survey results help the American Lung Association and our school, medical, and community partners focus our efforts to increase parents’ and school officials’ abilities to best manage students’ asthma,” said Toomey. “It is a shared responsibility. Parents must be sure that children who have prescribed rescue inhalers have them at school. Physicians must provide written plans for schools and parents. And schools must communicate clearly with parents and follow state law and local policies to ensure that students have immediate access to lifesaving medications,” she said.

SOURCE: American Lung Association

The economic consequences of asthma among adults in Sweden.

Respir Med. 2007 Aug 3;
Jansson SA, Rönmark E, Forsberg B, Löfgren C, Lindberg A, Lundbäck B.
Karolinska Institutet, National Institute of Environmental Medicine, Stockholm, Sweden.

OBJECTIVES: Asthma is a common disease in most countries. The objective of this study was to estimate the societal costs for subjects with asthma.

METHODS: Telephone interviews regarding resource utilization were made in a representative sample of 115 randomly selected subjects with asthma derived from a large population study of obstructive airway diseases. Direct and indirect costs were measured, and the costs were also transformed with the estimated prevalence of asthma in Sweden.

RESULTS: Average annual costs were SEK 15919 (USD 1592; EUR 1768) per subject with asthma in the ages between 25 and 56 years. The direct and indirect costs were SEK 4931 (31.0%) and SEK 10988 (69.0%), respectively, and were highly dependent of age and disease severity. Assuming that the prevalence is representative for Sweden as a whole, the asthmatics would amount to 226000 in the ages between 25 and 56 years, corresponding to an overall prevalence in Sweden of 6-7%. The total costs of asthma for the society amounted thus to SEK 3.7 billion in these ages.

CONCLUSIONS: The total costs of asthma for the society could be estimated at 3.7 billion SEK in the age range of 25-56 years, and thus approximately twice as high in the whole population of Sweden. The costs were strongly dependent on disease severity and increasing age.

Relationship of body mass index with asthma indicators in head start children

Ann Allergy Asthma Immunol. 2007 Jul;99(1):22-8.
Vargas PA, Perry TT, Robles E, Jo CH, Simpson PM, Magee JM, Feild CR, Hakkak R, Carroll PA, Jones SM.
Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock 72202-3591, USA.

OBJECTIVE: To examine the relationship of body mass index (BMI) and asthma indicators on children with asthma in a Head Start (HS) program.

METHODS: In this cross-sectional study (November 18, 2000, to December 12, 2003) of children aged 3 to 5 years with asthma, we compared the BMI data of HS asthmatic patients (n = 213) with the data of peer control subjects from a sample (n = 816) of the National Health and Nutrition Examination Survey aged 3 to 5 years and with children in prekindergarten in Arkansas public schools (n = 1,024). Parental reports of asthma symptoms, health care use, medication use, school days missed, and quality of life were used as indicators of asthma morbidity. Categorical analysis and chi2 tests were performed to examine the relationship between BMI and asthma morbidity.

RESULTS: The prevalence of overweight (> or =95th percentile) was significantly higher in HS children with asthma compared with the National Health and Nutrition Examination Survey children (P < .001) and Arkansas prekindergarten children (P = .05). Compared with HS asthmatic children with a BMI less than the 85th percentile, HS asthmatic patients with a BMI of the 85th percentile or greater reported significantly more school days missed (P = .02), lifetime hospitalizations (P = .04), emergency department visits (P = .02), and activity limitations (P = .03) and fewer oral corticosteroid bursts (P = .04). There was also a trend for more daytime symptoms (P = .05) and lower quality of life (P = .06). No differences were observed in rescue (P = .28) or controller (P = .47) medications, environmental tobacco smoke exposure (P = .47), positive allergy test results (P = .85), and nighttime symptoms (P > .99).

CONCLUSIONS: Having an increased BMI was associated with more asthma morbidity in this group of HS asthmatic patients. Despite the lack of a clear explanation for the link between asthma and BMI, our data suggest that an increased BMI significantly affects the well-being of young asthmatic patients and should be further addressed.

Use of inhaled corticosteroids and healthcare costs in mild persistent asthma

J Asthma. 2007 Jul;44(6):479-83.
Colice G, Wu EQ, Birnbaum H, Daher M, Maryna BM.
Washington Hospital Center, Washington, DC.

Healthcare costs were determined for mild persistent asthma patients (n = 796) who used inhaled corticosteroids infrequently (0 to 2 claims) or consistently (3 or more claims).

Study patients, selected from a privately insured claims database (1999-2003), had at least one asthma diagnosis, no diagnosis of chronic obstructive pulmonary disease (COPD), and mild persistent asthma as defined by the 2005 Health Plan Employer Data and Information Set (HEDIS), Leidy's reliever and oral steroid methods, and the 2004 Global Initiative for Asthma (GINA) guidelines.

Healthcare and asthma-specific costs were significantly higher for the infrequent inhaled corticosteroid users than the consistent users. The infrequent inhaled corticosteroid users had significantly more hospitalizations and emergency department visits compared with consistent users.

Asthma and insulin resistance in morbidly obese children and adolescents.

J Asthma. 2007 Jul;44(6):469-73
Al-Shawwa BA, Al-Huniti NH, Demattia L, Gershan W.
Medical College of Wisconsin, Milwaukee, Wisconsin.

Background.
Obesity is well recognized as a state of increased insulin resistance and has been implicated as a significant risk factor for both asthma prevalence and asthma severity in children and adolescents. However, little is known about the specific factors that relate asthma and obesity. Recently, the pro-inflammatory state in obesity and its association with insulin resistance have been recognized. We hypothesize that the effect of morbid obesity on asthma is related to insulin resistance.

Methods.
The patient cohort in the obesity management program at the Children's Hospital of Wisconsin was retrospectively reviewed. Variables were collected from the program data base and chart review was done for missing variables. Patients were considered to have asthma if the evaluating physician confirmed the diagnosis through history and/or the patient had been on inhaled corticosteroids. Insulin resistance (IR) was calculated using a homeostasis model assessment (HOMA). Multivariate logistic regression was performed to identify variables that were significantly related to the odds of having asthma.

Results.
Of the 415 patients included in the study, 146 (35%) were asthmatic and 269 (65%) were non-asthmatic. The asthma (AG) and non-asthma (NAG) groups were similar with respect to mean age (11.3 vs. 11.5 years), gender (45% vs. 43% males), mean body mass index (BMI) (36.4 vs. 34.9), and exposure to smoking (43% vs. 42%). Fhx of asthma was significantly higher in AG (71%) compared to NAG (40%). IR level +/- SD was 8.5 +/- 9.7 in AG compared to 5.3 +/- 6.7 in NAG (p < 0.0001). Multivariate regression analysis found the following variables to be associated with having asthma: younger age (p < 0.05), smoking exposure (p < 0.05), positive Fhx of asthma (p < 0.0001, odds ratio of 3.1), and IR (p < 0.0001, odds ratio of 4.1).

Conclusion.
Morbidly obese asthma patients have a higher degree of insulin resistance compared to morbidly obese non-asthma patients. We speculate that the pro-inflammatory state of insulin resistance may contribute to the pathogenesis of asthma in obese patients. Future prospective studies should address insulin resistance as a possible risk factor for asthma in obese children and adolescents.

Asthma control: do patients' and physicians' opinions fit in with patients' asthma control status?

J Asthma. 2007 Jul;44(6):461-7.
Prieto L, Badiola C, Villa JR, Plaza V, Molina J, Cimas E.
Allergology, Hospital Dr. Peset, Valencia.

The aim of this study was to determine the level of asthma control and the concordance between physicians' and patients' opinions and the real patients' situation.

A total of 777 subjects (55% female) with asthma were recruited. The study comprised a 4-week follow-up period, during which subjects completed a diary recording peak expiratory flow (PEF), symptoms, and use of rescue medication. At the end, both physicians and patients rated asthma control status. The level of control was evaluated using a composite measure. Agreement among subjective assessments of asthma control by patients and physicians and objective evaluation with the composite measure was assessed through kappa scores.

A total of 518 (67%) patients had "not well-controlled asthma," being the remaining "totally controlled" (8%) or "well-controlled" (25%). "Not well-controlled asthma" was more frequent in smokers (82%) than in ex-smokers (70%) or in non-smokers (62%; p = 0.0002). Kappa scores between patients' and physicians' opinions and the real patients' status were 0.02 (95% CI, 0.01-0.05) and 0.07 (95% CI, 0.03-0.09), respectively.

In conclusion, current level of asthma control is suboptimal for a majority (67%) of patients in Spain. Besides, asthma control is worse in smokers. Neither patients' nor physicians' opinions agree with patients' real situation. Both patients and physicians accept as normal a suboptimal status of their disease.

Exposure to substances in the workplace and new-onset asthma: an international prospective population-based study (ECRHS-II)

The Lancet 2007; 370:336-341
DOI:10.1016/S0140-6736(07)61164-7
Prof Manolis Kogevinas MD et al.

Background

The role of exposure to substances in the workplace in new-onset asthma is not well characterised in population-based studies. We therefore aimed to estimate the relative and attributable risks of new-onset asthma in relation to occupations, work-related exposures, and inhalation accidents.

Methods

We studied prospectively 6837 participants from 13 countries who previously took part in the European Community Respiratory Health Survey (1990–95) and did not report respiratory symptoms or a history of asthma at the time of the first study. Asthma was assessed by methacholine challenge test and by questionnaire data on asthma symptoms. Exposures were defined by high-risk occupations, an asthma-specific job exposure matrix with additional expert judgment, and through self-report of acute inhalation events. Relative risks for new onset asthma were calculated with log-binomial models adjusted for age, sex, smoking, and study centre.

Findings

A significant excess asthma risk was seen after exposure to substances known to cause occupational asthma (Relative risk=1·6, 95% CI 1·1–2·3, p=0·017). Risks were highest for asthma defined by bronchial hyper-reactivity in addition to symptoms (2·4, 1·3–4·6, p=0·008). Of common occupations, a significant excess risk of asthma was seen for nursing (2·2, 1·3–4·0, p=0·007). Asthma risk was also increased in participants who reported an acute symptomatic inhalation event such as fire, mixing cleaning products, or chemical spills (RR=3·3, 95% CI 1·0–11·1, p=0·051). The population-attributable risk for adult asthma due to occupational exposures ranged from 10% to 25%, equivalent to an incidence of new-onset occupational asthma of 250–300 cases per million people per year.

Interpretation

Occupational exposures account for a substantial proportion of adult asthma incidence. The increased risk of asthma after inhalation accidents suggests that workers who have such accidents should be monitored closely.

Food allergy as a risk factor for asthma morbidity in adults.

J Asthma. 2007 Jun;44(5):377-81.
Berns SH, Halm EA, Sampson HA, Sicherer SH, Busse PJ, Wisnivesky JP. Division of General Internal Medicine, Mount Sinai School of Medicine. New York, NY.

Background.
The objective of this study was to evaluate the relationship between food allergy and asthma morbidity in adults.

Methods.
We interviewed a cohort of persistent asthmatics from an inner-city clinic. Allergies to food were assessed by patient report of convincing symptoms of acute allergic reactions. Outcome variables included health resource utilization and medication use.

Results.
The prevalence of allergy to fish, peanut, tree-nut, shellfish, and seed allergies were 3%, 3%, 3%, 13%, and 1%. Patients with allergies to > 1 food had increased asthma hospitalizations, ED visits, and use of oral steroids (p < 0.05 for all comparisons). Specifically, allergy to fish was associated with a greater risk of health resource utilization and increased frequency of oral steroid use (p

Conclusions.
Self-reported allergy to foods was associated with worse outcomes, suggesting that food allergy may be a risk factor for increased asthma morbidity in adults.

Rhinitis and asthma symptoms in non-domestic cleaners from the Sao Paulo metropolitan area, Brazil.

Occup Environ Med. 2007 Jul;64(7):446-53
de Fátima Maçãira E, Algranti E, Medina Coeli Mendonça E, Antônio Bussacos M.
Division of Medicine--FUNDACENTRO, São Paulo-SP, Brazil.

BACKGROUND: Exposure to cleaning products has frequently been reported as a symptom trigger by workers with work-related asthma diagnosed in workers' health clinics in the city of São Paulo, Brazil.

OBJECTIVES: To estimate rhinitis and asthma symptoms prevalence and to analyse associated risk factors.

METHOD: A respiratory symptoms questionnaire (Medical Research Council 1976) and the International Study of Asthma and Allergies in Childhood questionnaire were applied to 341 cleaners working in the city of São Paulo, along with obtaining full occupational histories, skin prick tests and spirometry. Timing their symptoms onset in relation to occupational history allowed estimation of work-related asthma and/or rhinitis. Risk factors related to selected outcomes were analysed by logistic regression.

RESULTS: 11% and 35% of the cleaners had asthma and rhinitis, respectively. The risk of work-related asthma/rhinitis increased with years of employment in non-domestic cleaning (OR 1.09, 95% CI 1.00 to 1.18, >0.92-3 years; OR 1.28, 95% CI 1.01 to 1.63, >3-6.5 years; OR 1.71, 95% CI 1.02 to 2.89, >6.5 years). Atopy was associated with asthma and rhinitis (OR 2.91, 95% CI 1.36 to 6.71; OR 2.06, 95% CI 1.28 to 3.35, respectively). There was a higher risk of rhinitis in women (OR 2.07, 95% CI 1.20 to 3.70).

CONCLUSIONS: Cleaning workers are at risk of contracting work-related asthma and/or rhinitis, and the risk increases with years of employment in non-domestic cleaning. Women present higher risk of rhinitis than men.

Allergy and risk of childhood leukaemia: Results from the UKCCS

Int J Cancer. 2007 Aug 15;121(4):819-24.
Hughes AM, Lightfoot T, Simpson J, Ansell P, McKinney PA, Kinsey SE, Mitchell CD, Eden TO, Greaves M, Roman E; on behalf of the United Kingdom Childhood Cancer Study Investigators.
Epidemiology and Genetics Unit, Department of Health Sciences, University of York, York, United Kingdom.

We investigated the relationship between childhood leukaemia and preceding history of allergy. A nationwide case-control study of childhood cancers was conducted in the United Kingdom with population-based sampling of cases (n = 839) and controls (n = 1,337), matched on age, sex and region of residence. Information about clinically diagnosed allergies was obtained from primary care records.

More than a third of subjects had at least one allergy diagnosed prior to leukaemia diagnosis (cases) or pseudo-diagnosis (controls). For both total acute lymphoblastic leukaemia (ALL) and common-ALL/precursor B-cell ALL (c-ALL), a history of eczema was associated with a 30% significant reduction in risk: the odds ratios (OR) and 95% confidence intervals (CI) were 0.70 (0.51-0.97) and 0.68 (0.48-0.98), respectively. Similar associations were observed for hayfever (OR = 0.47; 95% CI: 0.26-0.85 and OR = 0.62; 95% CI: 0.33-1.16 for ALL and c-ALL, respectively). No such patterns were seen either for asthma and ALL, or for any allergy and acute myeloid leukaemia. A comparative analysis of primary care records with parents recall of allergy revealed only moderate agreement with contemporaneous clinical diagnoses for both cases and controls-confirming the unreliability of parental report at interview.

Our finding of a reciprocal relationship between allergy and ALL in children is compatible with the hypothesis that a dysregulated immune response is a critical determinant of childhood ALL.

Comparative overview of indoor air quality in Antwerp, Belgium.

Environ Int. 2007 Aug;33(6):789-97
Stranger M, Potgieter-Vermaak SS, Van Grieken R.
Department of Chemistry, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium; Higher Institute for Product Development, Design Sciences, University College of Antwerp, Ambtmanstraat 1, B-2000 Antwerpen, Belgium.

This comprehensive study, a first in Belgium, aimed at characterizing the residential and school indoor air quality of subgroups that took part in the European Community Respiratory Health Survey and the International Study of Asthma and Allergy in Childhood [Masoli M, Fabian D, Holt S, Beasley R. Global Burden of Asthma, Medical Research Institute of New Zealand, University of Southampton; 2004.] questionnaire-based asthma and related illnesses studies.

The principal aim was to perform a base-line study to assess the indoor air quality in Antwerp in terms of various gaseous and particulate pollutants. Secondly, it aimed to establish correlations between these pollutants investigated, the pollutant levels in the indoor and outdoor micro-environments, findings of the previous questionnaire-based studies and an epidemiological study which ran in conjunction with this study. Lastly, these results were compared and evaluated with current indoor and ambient guidelines in various countries.

This paper presents selected results on PM1, PM2.5 and PM10 mass concentrations and elemental C estimates as black smoke, as well as gaseous NO(2), SO(2), O(3) and BTEX concentrations of 18 residences and 27 schools. These are related to current guidelines of Flanders, Germany, Norway, China and Canada and evaluated with reference to selected similar studies. It was found that indoor sources such as tobacco smoking and carpets, the latter causing re-suspension of dust, are responsible for elevated indoor respirable particulate matter and place school children and residents at risk.

Both PM2.5 and PM10 equalled or exceeded the current guidelines adopted by Flanders, noting that 12-h and 24-h PM2.5 were compared with an annual limit value. Indoor and ambient NO(2) concentrations in the school campaign were higher than the annual EU ambient norm. The other studied pollutant levels were below the current guidelines.

Prevalence of asthma-like symptoms in young children.

Pediatr Pulmonol. 2007 Aug;42(8):723-8.
Bisgaard H, Szefler S.
Danish Pediatric Asthma Center, Copenhagen University Hospital, Gentofte, Copenhagen, Denmark.

OBJECTIVE: To determine the prevalence, impact, and treatment of asthma-like symptoms in preschool children in USA and Europe.

STUDY DESIGN: 7251 households in USA and Europe with at least one child aged 1-5 years were interviewed by telephone for recurrent days troubled by cough, wheeze or breathlessness during the recent 6 winter months.

RESULTS: 9490 young children were identified, 32% of whom were reported to suffer from recurrent days with troublesome cough, wheeze or breathlessness. Detailed interview with the 2700 mothers of the symptomatic children showed that 24% of this interview population suffered weekly symptoms despite current treatment with considerable impact on lifestyle and healthcare resource use. Antibiotics, cough- and herbal-medications were the most commonly used treatments. Anti-asthmatic and anti-allergy agents were prescribed in the order: inhaled beta(2)-agonists > inhaled corticosteroid > oral anti-histamines > oral corticosteroids. The reported symptom burden was higher in Southern Europe and there were pronounced regional differences in treatment and diagnostic terms.

CONCLUSIONS: Recurrent days with cough, wheeze or breathlessness in preschool children represents a major cause of morbidity in preschool children despite current treatment. There is a striking lack of international consensus on diagnosis and treatment. This uncontrolled morbidity highlights a significant unmet clinical need in preschool children.

Atopic Sensitisation and the International Variation of Asthma Symptom Prevalence in Children.

Am J Respir Crit Care Med. 2007 Jun 15;
Weinmayr G, Weiland SK, Bjorksten B, Brunekreef B, Buchele G, Cookson WO, Garcia-Marcos L, Gotua M, Gratziou C, van Hage M, von Mutius E, Riikjarv MA, Rzehak P, Stein RT, Strachan DP, Tsanakas J, Wickens K, Wong GW.
Institute of Epidemiology, Ulm University, Ulm, Germany.

BACKGROUND: Atopic sensitisation has long been known to be related to asthma in children. We investigated its role in the large international variation in the prevalence of childhood asthma.

METHODS: Cross-sectional studies of random samples of 8-12-year-old children (n=1000 per centre) were carried out according to the standardised methodology of Phase Two of the International Study of Asthma and Allergy in Childhood (ISAAC). Thirty study centres in 22 countries worldwide participated and reflect a wide range of living conditions from rural Africa to urban Europe. Data were collected by parental questionnaires (n=54,439), skin prick tests (n=31,759) and measurements of allergen-specific IgE levels in serum (n=8,951). Economic development was assessed by gross national income per capita (GNI).

RESULTS: The prevalence of current wheeze (i.e. during the past year) ranged from 0.8% in Pichincha (Ecuador) to 25.6% in Uruguaiana (Brazil). The fraction of current wheeze attributable to atopic sensitisation ranged from 0% in Ankara (Turkey) to 93.8% in Guangzhou (China). There were no correlations between prevalence rates of current wheeze and atopic sensitisation, and only weak correlations of both with GNI. However, the fractions and prevalence rates of wheeze attributable to skin test reactivity correlated strongly with GNI (Spearman rank-order coefficient rho=0.50; p=0.006 and rho=0.74; p<0.0001, respectively). In addition, the strength of the association between current wheeze and skin test reactivity, assessed by odds ratios, increased with GNI (rho=0.47; p=0.01).

CONCLUSION: The link between atopic sensitisation and asthma symptoms in children differs strongly between populations and increases with economic development.

Female gender is associated with higher incidence and more stable respiratory symptoms during adolescence.

Respir Med. 2007 May;101(5):896-902
Tollefsen E, Langhammer A, Romundstad P, Bjermer L, Johnsen R, Holmen TL.
Department of Respiratory Medicine, Trondheim University Hospital, Trondheim, Norway.

Childhood asthma and wheeze is more common among boys than girls, while the opposite is found in adults. The main objective was to study the incidence and the course of wheeze and asthma during adolescence with focus on gender differences. In addition, we explored associations between lifestyle factors at baseline and wheeze at follow-up.

A total of 2399 adolescents answered validated questionnaires on respiratory symptoms and lifestyle in 1995-1997 (13-15 years) and at follow-up in 2000-2001 (17-19 years). The risk of reporting wheeze and asthma at follow-up was greater in girls compared to boys among subjects reporting no respiratory symptoms at baseline; Relative risk: 1.4 and 2.4, respectively. More girls than boys reported current wheeze at follow-up, both among those with current wheeze (girls 60%, boys 48%) and previous wheeze (girls 33%, boys 28%) at baseline. In girls, development of current wheeze was significantly associated with current smoking (OR=2.8) and stable current wheeze was significantly associated with overweight (OR=2.4). Similar associations were not significant in boys.

More girls than boys developed wheeze, had stable wheeze or had relapse of previous symptoms during the four year follow-up. The impact of smoking and overweight may put girls at a higher risk of respiratory symptoms than boys. Awareness of the gender difference in respiratory symptoms is important for diagnosis and preventive strategies during adolescence.

Severe exacerbations predict excess lung function decline in asthma.

Eur Respir J. 2007 May 30;
Bai TR, Vonk JM, Postma DS, Boezen HM.
St Paul's Hospital, University of British Columbia, Vancouver BC, Canada.

Severe asthma exacerbations are periods of intense airway inflammation that have been hypothesized to contribute to structural changes in the airways. If so, accelerated lung function decline over time should be more prevalent in adult patients with asthma who have frequent exacerbations than those without, but this has not been demonstrated so far.

We performed a cohort study investigating the effect of severe exacerbations on the progression of airway obstruction in 93 non-smoking asthmatics with moderate to severe disease prior to starting inhaled corticosteroids. Subjects were followed for at least 5 years (median follow-up was 11 yrs).
Fifty-six subjects (60.2%) experienced at least one severe exacerbation (median rate 0.10.yr(-1)). Oral corticosteroid use and more severe airway obstruction at baseline were associated with a higher exacerbation rate. Independent of these variables, asthma patients with frequent exacerbations had a significantly larger annual decline in FEV1 (median difference=16.9 mls.yr(-1) (95% CI: 1.5-32.2). Exacerbation rate significantly predicted an excess decline in FEV1, so that one severe exacerbation per year was associated with a 30.2 ml greater annual decline in FEV1.

These data support the hypothesis that exacerbations, indicating intermittent periods of worsening airway inflammation, are associated with excess lung function decline in asthma.

Identifying asthma exacerbations in a pediatric emergency department: A feasibility study.

Int J Med Inform. 2007 Jul;76(7):557-64.
Sanders DL, Gregg W, Aronsky D.
Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.

BACKGROUND: Asthma is a common pediatric chronic disease and is estimated to account for more than 2 million emergency department visits per year. Asthma guidelines have demonstrated improved outcomes, but remain underutilized due to several barriers. Computerized methods to automatically identify asthma exacerbations may be beneficial to initiate guideline recommended treatment, but have not been described. The goal of the study was to examine the accuracy of an algorithm to identify asthma patients at triage in real-time using only electronically available data.

METHODS: During a 9-month period, the five most frequent presenting chief complaints for Emergency Department asthma patients aged 2-18 years were identified and accounted for >95% of asthma visits: wheezing, shortness of breath, fever, cough, and dyspnea. During a following 1-month period (November 2004), medical records of all patients with one of the five chief complaints were reviewed to establish a reference standard diagnosis. An asthma identification algorithm was developed that considered only data available in electronic format at the time of triage and included the presenting chief complaint, information from the computerized problem list (past medical history; current medications, such as beta-agonists, steroids, and other asthma medications), and ICD-9 billing codes from previous encounters.

RESULTS: From 1835 Emergency Department visits, 368 visits (154 with asthma) had one of the five chief complaints and were included. A problem list was available in 203 (55.2%) and an ICD-9 code in 68 (18.5%) patients. Wheezing accounted for 56.5% of asthma visits, while fever was the most frequent chief complaint among all patients (43.8%). The asthma identification algorithm had a sensitivity of 44.8% (95% CI: 36.8-53.0%), a specificity of 91.6% (CI: 87.0-94.9%), a positive predictive value of 79.3% (CI: 69.3-87.3%) and a negative predictive value of 69.8% (CI: 64.0-75.1%). The positive and negative likelihood ratios were 5.3 (CI: 3.3-8.6) and 0.6 (CI: 0.5-0.7), respectively.

CONCLUSION: The simple identification algorithm demonstrated good accuracy for identifying asthma episodes. The algorithm may represent a promising and feasible approach to create computerized reminders or automatic triggers that can facilitate the initiation of guideline-based asthma treatment in the Emergency Department.

Tobacco as an allergen in bronchial disease.

Ann Allergy Asthma Immunol. 2007 Apr;98(4):329-36. Armentia A, Bartolome B, Puyo M, Paredes C, Calderon S, Asensio T, del Villar V. Seccion de Alergia del Hospital Universitario Rio Hortega, Valladolid, Spain.

BACKGROUND: Skin testing and sera measurements have verified the existence of tobacco specific IgE. However, the few published studies on this matter report conflicting results concerning their clinical significance.

OBJECTIVE: To verify if a specific clinical allergenic response against tobacco might be possible in allergenic and nonallergenic bronchial diseases.

METHODS: We performed a cross-sectional observational case-control analysis on 180 patients with asthma, chronic obstructive pulmonary disease (COPD), and bronchial carcinoma and controls who were randomly chosen. Skin prick tests and serum specific IgE to tobacco and related allergens, bronchial challenge with cigarettes and tobacco extract, patch tests with tobacco and nicotine, sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblotting, and Enzyme AllergoSorbent Test (EAST) inhibition were performed.

RESULTS: Twenty-eight patients had positive tobacco skin prick test results. The association among positive skin prick test results, IgE, and bronchial challenge was strong (P < .001). Tobacco sensitivity was higher in patients with pollen asthma than in patients with COPD and carcinoma and negative in patients with intrinsic asthma and controls. A positive bronchial challenge result was related to the length of habit (P < .001) and the tobacco index in patients who had stopped smoking (P < .001). Delayed bronchial and patch response was more common in patients with COPD (P < .001). Tobacco IgE response (EAST) was related to sensitivity to Lolium perenne (rye grass) pollen (P < .001) but not to other vegetables that belong to the Solanaceae family. EAST inhibition showed cross-reactivity between tobacco and Lolium pollen.

CONCLUSIONS: Tobacco may be responsible for a specific IgE response. Patients with pollen asthma were those with more positive responses to tobacco due to cross-reactivity between Lolium and tobacco allergens.

Environmental tobacco smoke and the epidemic of asthma in children: the role of cigarette use.

Ann Allergy Asthma Immunol. 2007 May;98(5):447-54.
Goodwin RD.
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York 10032, USA.

BACKGROUND: Asthma is the most common chronic disease affecting youth worldwide. The prevalence of asthma has increased at least 3-fold during the past several decades. The reason for this increase remains unknown. Objective: To examine one possible factor that may be affecting the increase in prevalence of asthma among youth.

METHODS: Data on the incidence of asthma among youth were aggregated using the National Health Interview Survey (sample of 4,500 children) and were compared on an ecologic level with data on cigarette consumption in the United States from 1900 to 2003 from the American Lung Association.

RESULTS: Our results suggest a parallel increase in the rates of cigarette use among adults and asthma in children. These findings show an increase in cigarette use during the past 4 birth cohorts, with subsequent leveling off at a population level with a progressively more prominent increase in cigarette use among women in the United States.

CONCLUSION: We present one possible factor that may be contributing to the epidemic of childhood asthma. We hypothesize that (1) there has been a marked increase in smoking during the past century, (2) this increase in smoking has resulted in a substantial increase in exposure to environmental tobacco smoke among children, and (3) increased exposure to environmental tobacco smoke has contributed to the increase in childhood asthma. Data on trends in cigarette use among adults and asthma prevalence among children during the past century are presented as ecological evidence in support of this hypothesis. Future studies will be needed to confirm these findings with community-level analyses in a variety of geographic regions.

Occupational asthma and work-exacerbated asthma: factors associated with time to diagnostic steps.

Chest. 2007 May 15; Santos MS, Jung H, Peyrovi J, Lou W, Liss GM, Tarlo SM. Gage Occupational and Environmental Health Unit, Canada.

Background
Little is known regarding factors associated with the times for patients' first physician visit, first physician suspicion of work-related asthma and final diagnosis, after the onset of work-related asthma symptoms. This study examined individual and work-related factors associated with longer times to these diagnostic milestones among groups with occupational asthma (OA) and work-exacerbated asthma (WEA).

Method
Suspected work-related asthma cases were identified from an occupational lung disease clinic and claimants to the Ontario Workplace Safety and Insurance Board (WSIB)[100 patients each]. Questionnaire administration and chart review were undertaken. Results 80 participants were classified as sensitizer-induced OA and 87 as WEA. For the OA group, risk factors for delay included male sex, being unmarried, low education and lack of awareness of associations of symptoms with work. Other factors included older age, being the sole income earner and lack of knowledge of the Workplace Hazardous Materials Information System (WHMIS) program. For WEA, lower household income, lower education, absence of a Health and Safety Program at work, absence of a union, lack of awareness of OA and of agents at work which could affect asthma significantly increased time to diagnostic milestones. Conclusions
Different factors affect diagnostic milestones for OA and WEA. Findings suggest a need for educational programs for workers at risk of OA and WEA and a need for further primary care physician education on work-related asthma.

Overweight, Obesity, and Incident Asthma

American Journal of Respiratory and Critical Care Medicine Vol 175. pp. 661-666, (2007)
David A. Beuther1,2 and E. Rand Sutherland1,2
1 Department of Medicine, National Jewish Medical and Research Center, Denver, Colorado; and 2 University of Colorado at Denver and Health Sciences Center, Denver, Colorado

Rationale: Although obesity has been implicated as an asthma risk factor, there is heterogeneity in the published literature regarding its role in asthma incidence, particularly in men.

Objectives: To quantify the relationship between categories of body mass index (BMI) and incident asthma in adults and to evaluate the impact of sex on this relationship.

Methods: Online bibliographic databases were searched for prospective studies evaluating BMI and incident asthma in adults. Independent observers extracted data regarding annualized asthma incidence from studies meeting predetermined criteria, within defined categories of normal weight (BMI < 25), overweight (BMI, 25–29.9), and obesity (BMI >=30). Data were analyzed by inverse-variance–weighted, random-effects meta-analysis. Stratified analysis between BMI categories and within sex was performed.

Results: Seven studies (n = 333,102 subjects) met inclusion criteria. Compared with normal weight, overweight and obesity (BMI >=25) conferred increased odds of incident asthma, with an odds ratio (OR) of 1.51 (95% confidence interval [CI], 1.27–1.80). A dose–response effect of elevated BMI on asthma incidence was observed; the OR for incident asthma for normal-weight versus overweight subjects was 1.38 (95% CI, 1.17–1.62) and was further elevated for normal weight versus obesity (OR, 1.92; 95% CI, 1.43–2.59; p < 0.0001 for the trend). A similar increase in the OR of incident asthma due to overweight and obesity was observed in men (OR, 1.46; 95% CI, 1.05–2.02) and women (OR, 1.68; 95% CI, 1.45–1.94; p = 0.232 for the comparison).

Conclusions: Overweight and obesity are associated with a dose-dependent increase in the odds of incident asthma in men and women, suggesting asthma incidence could be reduced by interventions targeting overweight and obesity.

Airway smooth muscle dynamics: a common pathway of airway obstruction in asthma.

Eur Respir J. 2007 May;29(5):834-60. An SS, Bai TR, Bates JH, Black JL, Brown RH, Brusasco V, Chitano P, Deng L, Dowell M, Eidelman DH, Fabry B, Fairbank NJ, Ford LE, Fredberg JJ, Gerthoffer WT, Gilbert SH, Gosens R, Gunst SJ, Halayko AJ, Ingram RH, Irvin CG, James AL, Janssen LJ, King GG, Knight DA, Lauzon AM, Lakser OJ, Ludwig MS, Lutchen KR, Maksym GN, Martin JG, Mauad T, McParland BE, Mijailovich SM, Mitchell HW, Mitchell RW, Mitzner W, Murphy TM, Pare PD, Pellegrino R, Sanderson MJ, Schellenberg RR, Seow CY, Silveira PS, Smith PG, Solway J, Stephens NL, Sterk PJ, Stewart AG, Tang DD, Tepper RS, Tran T, Wang L. James Hogg iCAPTURE Centre, University of British Columbia, 1081 Burrard Street, Room 166, Vancouver, BC, V6Z 1Y6, Canada.

Excessive airway obstruction is the cause of symptoms and abnormal lung function in asthma. As airway smooth muscle (ASM) is the effecter controlling airway calibre, it is suspected that dysfunction of ASM contributes to the pathophysiology of asthma. However, the precise role of ASM in the series of events leading to asthmatic symptoms is not clear. It is not certain whether, in asthma, there is a change in the intrinsic properties of ASM, a change in the structure and mechanical properties of the noncontractile components of the airway wall, or a change in the interdependence of the airway wall with the surrounding lung parenchyma. All these potential changes could result from acute or chronic airway inflammation and associated tissue repair and remodelling. Anti-inflammatory therapy, however, does not "cure" asthma, and airway hyperresponsiveness can persist in asthmatics, even in the absence of airway inflammation. This is perhaps because the therapy does not directly address a fundamental abnormality of asthma, that of exaggerated airway narrowing due to excessive shortening of ASM. In the present study, a central role for airway smooth muscle in the pathogenesis of airway hyperresponsiveness in asthma is explored.

Factors associated with mortality after an asthma admission: A national United Kingdom database analysis.

Respir Med. 2007 Apr 24;
Watson L, Turk F, James P, Holgate ST. Phimap, Adelphi Mill, Bollington, Cheshire SK10 5JB, UK.

BACKGROUND: Lack of a United Kingdom (UK) fatal asthma registry has resulted in few recent analyses regarding patient characteristics, co-morbidities, and admission type in relation to mortality post an asthma admission. This study aims to report these factors in addition to season of event for the years 2000-2005 to provide data regarding asthma burden in the in-patient hospital setting.

METHODS: Data were analysed from the CHKS database collated from UK National Health Service data providing 70% of in-patient coverage in the UK. Patients with admissions under ICD-10 codes J45 "Asthma" and J46 "acute severe asthma" were included. Codes for associated co-morbidity at time of admission were identified, as well as month of admission and death, age, gender and length of stay

RESULTS: The mortality rate over the 5-year period was 1063 patients from 250,043 asthma admissions (0.43%). Critical care mortality was far higher and an annual rate indicated that for every 100,000 admissions 2878 (95% CI 2091;3857) patients died. Respiratory infection, cardiovascular disease and diabetes were common co-morbidities for all admissions. December and January had the peak number of deaths post asthma admission which were nearly all in adults, death being rarer in children. Women and those over 45 years had the highest rate of death which may reflect asthma prevalence.

CONCLUSIONS: Co-morbid conditions experienced by older asthma patients may contribute to mortality post an asthma admiss