The effects of race/ethnicity and income on early childhood asthma prevalence and health care use

Building resilience to extreme weather events in Phoenix: Considering contaminated sites and disadvantaged communities

The interplay of contaminated sites, climate change, and disadvantaged communities are a growing concern worldwide. Worsening extreme events may result in accidental contaminant releases from sites and waste facilities that may impact nearby communities. If such communities are already suffering from environmental, economic, health, or social burdens, they may face disproportionate impacts. Equitable resilience planning to address effects of extreme events requires information on where the impacts may be, when they may occur, and who might be impacted. Because resources are often scarce for these communities, conducting detailed modeling may be cost-prohibitive. By considering indicators for four sources of vulnerability (changing extreme heat conditions, contaminated sites, contaminant transport via wind, and population sensitivities) in one holistic framework, we provide a scientifically robust approach that can assist planners with prioritizing resources and actions. These indicators can serve as screening measures to identify communities that may be impacted most and isolate the reasons for these impacts. Through a transdisciplinary case study conducted in Maricopa County (Arizona, USA), we demonstrate how the framework and geospatial indicators can be applied to inform plans for preparedness, response, and recovery from the effects of extreme heat on contaminated sites and nearby populations. The indicators employed in this demonstration can be applied to other locations with contaminated sites to build community resilience to future climate impacts.

Parent-Centered Perspectives on a Validated Asthma Questionnaire in the Emergency Department

OBJECTIVE

Although national asthma guidelines recommend use of validated questionnaires to improve asthma care, little is known about the extent to which these questionnaires are patient-centered. This qualitative study evaluated parent perceptions of a validated asthma questionnaire.

METHODS

We administered the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) to parents of children 2 to 17 years old presenting to a large urban pediatric ED for asthma care and assessed their perceptions of the tool's utility and acceptability via a structured interview. Responses were recorded, transcribed, and analyzed using a phenomenological approach.

RESULTS

Eighty-three parents participated. Qualitative analysis revealed 2 major themes (with 5 subthemes). The first major theme (and 3 subthemes) was that the PACCI-ED facilitated communication with the health care team and caregivers: improving communication 1) with ED providers, 2) in other settings such as schools, and 3) in the primary care setting where the relationship with primary care providers was felt to be variable. The second major theme (and 2 subthemes) was that the PACCI-ED increased parents' capacity to manage their child's asthma: by helping parents understand 1) what symptoms were related to asthma and 2) how those symptoms might change over time.

CONCLUSIONS

Parents perceive that the PACCI-ED is acceptable and useful for facilitating communication in the ED and other health care settings, and for building parent capacity to track and manage their child's asthma. A validated structured asthma questionnaire in the ED may facilitate patient-centered asthma care.

How Racism "Gets Under the Skin": An Examination of the Physical- and Mental-Health Costs of Culturally Compelled Coping

Historically and contemporarily, Black Americans have been compelled to use effortful coping styles characterized by high behavioral and emotional restraint in the face of systematic racism. Lynch and colleagues have previously conceptualized a class of regulatory strategies-overcontrolled coping-characterized by emotional suppression, hypervigilance for threat, and high distress tolerance, which bear close analogy to coping styles frequently used among individuals facing chronic racial stress. However, given the inherent culture of racism in the United States, engaging in highly controlled coping strategies is often necessitated and adaptive, at least in the short term. Thus, for Black Americans this class of coping strategies is conceptualized as culturally compelled coping rather than overcontrolled coping. In the current article, I offer a critical examination of the literature and introduce a novel theoretical model-culturally compelled coping-that culturally translates selected components of Lynch's model. Cultural translation refers to considering how the meaning, function, and consequences of using overcontrolled coping strategies changes when considering how Black Americans exist and cope within a culture of systematic racism. Importantly, this model may offer broad implications for future research and treatment by contextualizing emotion regulation as a central mechanism, partially answering how racism "gets under the skin" and affects the health of Black Americans.

Can we better understand severe mental illness through the lens of Syndemics?

Current health care systems do not sufficiently address contributors, also known as modifiable behavior factors, to severe mental illnesses (SMI). Instead treatment is focused on decreasing symptom-experience rather than reducing the detrimental effect of biological predisposition and behavioral influences on illness. Health care services and patients alike call for a more comprehensive, individual approach to mental health care, especially for people with SMI. A Syndemics framework has been previously used to identify ecological and social contributors to an HIV epidemic in the 1990s, and the same framework is transferable to mental health research to identify the relationship between contributing factors and the outcomes of SMI. Using this approach, a holistic insight into mental illness experience could inform more effective health care strategies that lessen the burden of disease on people with SMI. In this review, the components of a Syndemic framework, the scientific contributions to the topic so far, and the possible future of mental health research under the implementation of a Syndemic framework approach are examined.

Association of Urinary Bisphenols Concentration with Asthma in Korean Adolescents: Data from the Third Korean National Environmental Health Survey

The effects of bisphenol A (BPA) on asthma have been reported in various in vitro, animal, and human epidemiologic studies. However, epidemiological studies on the effects of bisphenol S (BPS) and bisphenol F (BPF), which are substitutes of BPA, on asthma are lacking. The purpose of this study was to identify the association between BPA, BPS, and BPF and asthma. An asthma-related questionnaire; urinary BPA, BPS, BPF; and the possible confounders were analyzed among 922 adolescents aged 12–17 years who participated in the Korean National Environmental Health Survey 2016. In males, urinary BPA, BPS, and BPF did not show a significant relationship with the lifetime prevalence of asthma. In females, urinary BPS was higher in the asthma group (p < 0.01). High urinary BPS showed a significant relationship with a high odds ratio (OR) of lifetime asthma prevalence in the model adjusted for possible confounders (p < 0.05). High urinary BPS was particularly associated with an increase in the OR of asthma diagnosed after the age of 60 months (p < 0.01). Urinary BPS was significantly associated with asthma diagnosis, especially after the age of 60 months, among Korean adolescent females.

Examining Risk Factors of Health-Related Quality of Life Impairments Among Adolescents with Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a chronic, costly, and burdensome disease that is typically diagnosed during adolescence. Despite the use of effective treatments, rates of relapse and intestinal inflammation remain high and put patients at risk for long term physical and psychosocial health complications. Given the costs associated with IBD, it is critical to examine potential risk factors of poor health-related quality of life (HRQoL) among patients for the enhancement and further development of interventions. As such, the aim of the current study was to examine how sociodemographic and disease characteristics, psychosocial problems, and adherence behaviors impact HRQoL among a sample of youth with IBD. 107 adolescents with IBD and their caregiver completed self- and parent-report measures as part of a psychosocial screening service. Medical records were reviewed to obtain information regarding diagnosis, insurance, medication use, illness severity, and disease activity. Results revealed lower HRQoL scores among adolescents with more psychosocial problems (Est. = -3.08; p < .001), greater disease severity (Est. = -.40; p = .001), and those who identified as Black (Est. = -.38; p < .05). Greater disease severity (Est. = .13 p = .004), use of nonpublic insurance (Est. = .32 p = .004), and fewer psychosocial problems (Est. = -.13 p = .04) were associated with greater adherence behaviors. These findings suggest that implementing individually tailored, evidence-based psychological interventions focused on coping with psychosocial problems and symptoms may be important in enhancing adherence behaviors and HRQoL among adolescents with IBD.

The Contribution of Neighborhood Tree and Greenspace to Asthma Emergency Room Visits: An Application of Advanced Spatial Data in Los Angeles County

This paper aims to investigate the role of neighborhood tree and greenspace on asthma morbidity, especially asthma emergency room visits. We employed advanced spatial data which allow for precisely capturing both the quantity and the features of tree and greenspace within a neighborhood environment. The results from the spatial regression models in Los Angeles County revealed that the features of trees and greenspace, such as the configuration of the tree canopy, the level of tree clustering, and private neighborhood greenspaces contribute to decreasing asthma morbidity, in addition to the quantity of tree and greenspace acreages. Notably, however, large scale greenspace, such as golf courses, school playgrounds, and parks fails to reduce the number of asthma emergency room visits at the statistically significant level. These findings imply that the creation of dense or clustered tree patches and small-scale neighborhood greenspaces might play a substantial role in mitigating air quality and consequently reducing asthma emergency room visits.

The natural environment, plant diversity, and adult asthma: A retrospective observational study using the CDC's 500 Cities Project Data

A wealth of evidence links microbial exposure to better human immune function. However, few studies have examined whether exposure to plant diversity is protective of immune diseases, despite the fact that plant leaves support ~10²⁶ bacterial cells. Using the Centers for Disease Control and Prevention's 500 cities project data, we found that a 1-SD increase in exposure to taxonomic plant diversity is associated with a 5.3 (95% CI: 4.2-6.4; p < 0.001) percentage-point decline in Census-tract level adult-asthma rate. In contrast, A 1-SD increase in overall greenness exposure (measured using the normalized difference vegetation index) was associated with a 3.8 (95% CI: 2.9-4.8; p < 0.001) percentage-point increase in adult-asthma rate. Interactions between air pollution and both overall greenness and plant diversity were positive, suggesting that air pollution may potentiate the allergic effects of plant pollen. Results show that the relationship between the natural environment and asthma may be more complex than previously thought, and the combination of air pollution and plant pollen may be a particular risk factor for asthma in adults.

Predictors of Hospital Reuse Among Publicly Insured Children Hospitalized for Status Asthmaticus

BACKGROUND

Asthma is a common cause of pediatric hospitalization. Nonadherence to asthma medications is associated with worse outcomes; however, there is a paucity of data regarding posthospitalization prescription filling and hospital reuse. Our objective was to identify patients at risk for hospital reuse after being hospitalized for asthma.

METHODS

This is a retrospective study of patients with asthma who were discharged from a children's hospital in which we use Medicaid claims data to evaluate prescription fills within 30 days and 12 months. Chart reviews were used for demographics, chronic asthma severity, admission severity, and hospital reuse. t and χ² tests were performed for continuous and categorical variables. A generalized linear mixed model was fitted to predict the odds of hospital reuse, which was defined as requiring an emergency department visit or rehospitalization. Survival analysis using log-rank testing was used for modeling the time to hospital reuse.

RESULTS

Fifty-four percent of patients discharged with asthma had hospital reuse within 1 year of discharge. There was no association between hospital reuse and prescription filling for systemic steroids (odds ratio [OR] 1.30; confidence interval [CI]: 0.85-2.00; P = .21) or controller medications (OR 1.5; CI: 0.92-2.52; P = .10). There was a higher number of controller and systemic steroid prescription fills over 12 months for patients with hospital reuse. The factors associated with greater odds of hospital reuse were severity of chronic asthma diagnosis (P = .03) as well as African American race (OR 1.92; CI: 1.17-3.13; P = .01).

CONCLUSIONS

For Medicaid-insured patients discharged with asthma, worse chronic asthma severity and African American race were associated with greater odds of hospital reuse. Decreased prescription filling was not associated with greater odds of hospital reuse.

Comparisons between 2015 US asthma prevalence and two measures of asthma burden by racial/ethnic group

Objective: Asthma affects approximately 20,383,000 Americans and costs the US $56 billion dollars annually. Asthma burden is not uniform across different racial/ethnic groups. Although annual asthma prevalences by racial/ethnic group are provided by the CDC, these numbers do not account for the influence of other sociodemographic and clinical factors. In this study, we evaluated several measures of asthma burden that controlled for sociodemographic and clinical factors and compared them to 2015 CDC asthma prevalences by racial/ethnic group. Methods: We obtained unadjusted asthma predictions directly from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) survey. To estimate average adjusted predictions (AAP) and adjusted predictions at the means (APM) for asthma, we controlled for sociodemographic and clinical factors through logistic models and subsequently calculated marginal probabilities for these results. Results: We found substantial differences at the national and state level between unadjusted prevalences and AAPs and APMs for asthma by race/ethnicity group. In addition, states that had the highest and lowest unadjusted prevalences differed from states that had the highest and lowest AAPs and APMs. For unadjusted prevalences, AAPs, and APMs, we found that states that had the highest prevalences or probabilities of asthma for Whites tended to have the widest disparities between the estimates for Whites and those of other races. Conclusions: The study's results highlight the need to account for sociodemographic and clinical factors when addressing asthma burden by racial/ethnic group across the US.

The combined effect of ambient ozone exposure and toxic air releases on hospitalization for asthma among children in Harris County, Texas

This study represents an analysis of the effect of exposure to ambient ozone and toxic air releases on hospitalization for asthma among children in Harris County, Texas. Our study identified temporal and spatial variations in asthma hospitalization across the study region and explored the combined effect of exposure to ambient ozone and air toxics on asthma hospitalization. Asthma hospitalization hot spots and clusters were mostly not located on zip codes with reported high quantities of total air releases of chemical pollutants. There was no significant interaction between ambient ozone exposure and toxic air releases relative to asthma hospitalization. The major predictor of asthma hospitalization was season, with hospitalization rate per 10,000 people for asthma being highest in winter period when ozone levels are usually lowest.

What Ancestry Can Tell Us About the Genetic Origins of Inter-Ethnic Differences in Asthma Expression

Differences in asthma prevalence have been described across different populations, suggesting that genetic ancestry can play an important role in this disease. In fact, several studies have demonstrated an association between African ancestry with increased asthma susceptibility and severity, higher immunoglobulin E levels, and lower lung function. In contrast, Native American ancestry has been shown to have a protective role for this disease. Genome-wide association studies have allowed the identification of population-specific genetic variants with varying allele frequency among populations. Additionally, the correlation of genetic ancestry at the chromosomal level with asthma and related traits by means of admixture mapping has revealed regions of the genome where ancestry is correlated with the disease. In this review, we discuss the evidence supporting the association of genetic ancestry with asthma susceptibility and asthma-related traits, and highlight the regions of the genome harboring ancestry-specific genetic risk factors.

Parents' childhood socioeconomic circumstances are associated with their children's asthma outcomes

BACKGROUND

Previous literature documents associations between low socioeconomic status (SES) and poor health outcomes, including asthma. However, this literature has largely focused on the effects of current family circumstances.

OBJECTIVE

We sought to test an intergenerational hypothesis, that the childhood SES that parents experience will be associated with asthma outcomes in their children, independent of effects of current family SES. Second, we aimed to test whether this association is in part due to difficulties in current parent-child relationships.

METHODS

This was an observational study, whereby 150 parents were interviewed about their childhood SES and their children (physician-diagnosed asthma, ages 9-17 years) were interviewed about current family stress. Asthma control was assessed by parent report and child report (primary outcome), and blood was collected from children to measure cytokine production relevant to asthma (secondary outcomes).

RESULTS

To the degree that parents had lower childhood SES, their offspring showed worse asthma outcomes across multiple indicators. This included lower asthma control scores (parent and child report, Ps < .05), and greater stimulated production of T_H2 and T_H1 cytokines by PBMCs (Ps < .05). These associations were independent of current family SES. Mediation analyses were consistent with a scenario wherein parents with low childhood SES had current family relationships that were more stressful, and these difficulties, in turn, related to worse asthma control and greater cytokine production in children.

CONCLUSIONS

These results suggest the potential "long reach" of low SES across generations, and the importance of expanding theories of how the social environment can affect childhood asthma to include characteristics of earlier generations.

Competitive Swimming and Racial Disparities in Drowning

This paper provides compelling evidence of an inverse relationship between competitive swimming rates and drowning rates using Centers for Disease Control and Prevention (CDC) data on fatal drowning rates and membership rates from USA Swimming, the governing organization of competitive swimming in the United States. Tobit and Poisson regression models are estimated using panel data by state from 1999-2007 separately for males, females, African Americans and whites. The strong inverse relationship between competitive swimming rates and unintentional deaths through fatal drowning is most pronounced among African Americans males.

Asthma prescribing, ethnicity and risk of hospital admission: an analysis of 35,864 linked primary and secondary care records in East London

Inappropriate prescribing in primary care was implicated in nearly half of asthma deaths reviewed in the UK’s recent National Review of Asthma Deaths. Using anonymised EMIS-Web data for 139 ethnically diverse general practices (total population 942,511) extracted from the North and East London Commissioning Support Unit, which holds hospital Secondary Uses Services (SUS)–linked data, we examined the prevalence of over-prescribing of short-acting β₂-agonist inhalers (SABA), under-prescribing of inhaled corticosteroid (ICS) inhalers and solo prescribing of long-acting β₂-agonists (LABA) to assess the risk of hospitalisation for people with asthma for 1 year ending August 2015. In a total asthma population of 35,864, multivariate analyses in adults showed that the risk of admission increased with greater prescription of SABA inhalers above a baseline of 1–3 (4–12 SABA: odds ratio (OR) 1.71; 95% confidence interval (CI) 1.20–2.46, ⩾13 SABA: OR 3.22; 95% CI 2.04–5.07) with increasing British Thoracic Society step (Step 3: OR 2.90; 95% CI 1.79–4.69, Step 4/5: OR 9.42; 95% CI 5.27–16.84), and among Black (OR 2.30; 95% CI 1.64–3.23) and south Asian adult populations (OR 1.83; 95% CI 1.36–2.47). Results in children were similar, but risk of hospitalisation was not related to ethnic group. There is a progressive risk of hospital admission associated with the prescription of more than three SABA inhalers a year. Adults (but not children) from Black and South Asian groups are at an increased risk of admission. Further work is needed to target care for these at-risk groups.

Health Service Utilization and Poor Health Reporting in Asthma Patients

The management and treatment of adult asthma has been associated with utilization of health services.

OBJECTIVES

First, to investigate the likelihood of health service utilization, including primary care, emergency department, and hospital stays, among persons diagnosed with an asthma condition relative to those that do not have an asthma condition. Second, to examine the likelihood of poor physical health among asthma respondents relative to those that do not have an asthma condition. Third, to demonstrate that these relationships vary with frequency of utilization. Fourth, to discuss the magnitude of differences in frequent utilization between asthma and non-asthma respondents.

DATA SOURCE

Data is derived from a random, stratified sampling of Hampton Roads adults, 18 years and older (n = 1678).

STUDY DESIGN

Study participants are interviewed to identify asthma diagnosis, access to primary care, frequency of emergency department utilization, hospital admissions, and days of poor physical health. Odds-ratios establish relationships with the covariates on the outcome variable.

FINDINGS

Those with asthma are found more likely (OR 1.50, 95% CI 1.05-2.15) to report poor physical health relative to non-asthma study participants. Further, asthma respondents are found more likely (OR 4.23, 95% CI 1.56-11.69) to frequently utilize primary care that may be associated with the management of the condition and are also more likely to utilize treatment services, such as the emergency department (OR 1.87, 95% CI 1.32-2.65) and hospitalization (OR 2.21, 95% CI 1.39-3.50), associated with acute and episodic care. Further, it is a novel finding that these likelihoods increase with frequency of utilization for emergency department visits and hospital stays.

CONCLUSION

Continuity in care and better management of the diseases may result in less demand for emergency department services and hospitalization. Health care systems need to recognize that asthma patients are increasingly more likely to be characterized as frequent utilizers of both primary and emergency department care as the threshold for what constitutes frequent utilization increases. Investments in prevention and better management of the chronic condition may result in less demand for acute care services, especially among high frequency utilizers.

The intersection between asthma and acute chest syndrome in children with sickle-cell anaemia

Acute chest syndrome is a frequent cause of acute lung disease in children with sickle-cell disease. Asthma is common in children with sickle-cell disease and is associated with increased incidence of vaso-occlusive pain events, acute chest syndrome episodes, and earlier death. Risk factors for asthma exacerbation and an acute chest syndrome episode are similar, and both can present with shortness of breath, chest pain, cough, and wheezing. Despite overlapping risk factors and symptoms, an acute exacerbation of asthma or an episode of acute chest syndrome are two distinct entities that need disease-specific management strategies. Although understanding has increased about asthma as a comorbidity in sickle-cell disease and its effects on morbidity, substantial gaps remain in knowledge about best management.

The Impact of Evolutionary Driving Forces on Human Complex Diseases: A Population Genetics Approach

Investigating the molecular evolution of human genome has paved the way to understand genetic adaptation of humans to the environmental changes and corresponding complex diseases. In this review, we discussed the historical origin of genetic diversity among human populations, the evolutionary driving forces that can affect genetic diversity among populations, and the effects of human movement into new environments and gene flow on population genetic diversity. Furthermore, we presented the role of natural selection on genetic diversity and complex diseases. Then we reviewed the disadvantageous consequences of historical selection events in modern time and their relation to the development of complex diseases. In addition, we discussed the effect of consanguinity on the incidence of complex diseases in human populations. Finally, we presented the latest information about the role of ancient genes acquired from interbreeding with ancient hominids in the development of complex diseases.

Sensitization to mouse and cockroach allergens and asthma morbidity in urban minority youth: Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II)

BACKGROUND

Pest allergen sensitization is associated with asthma morbidity in urban youth but minimally explored in Latino populations. Specifically, the effect of mouse sensitization on the risk of asthma exacerbation has been unexplored in Latino subgroups.

OBJECTIVE

To evaluate whether pest allergen sensitization is a predictor of asthma exacerbations and poor asthma control in urban minority children with asthma.

METHODS

Latino and African American children (8-21 years old) with asthma were recruited from 4 sites across the United States. Logistic regression models evaluated the association of mouse or cockroach sensitization with asthma-related acute care visits or hospitalizations.

RESULTS

A total of 1,992 children with asthma in the Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II) cohorts were studied. Asthmatic children from New York had the highest rate of pest allergen sensitization (42% mouse, 56% cockroach), with the lowest rate in San Francisco (4% mouse, 8% cockroach). Mouse sensitization, more than cockroach, was associated with increased odds of acute care visits (adjusted odds ratio [aOR], 1.47; 95% CI, 1.07-2.03) or hospitalizations (aOR, 3.07; 95% CI, 1.81-5.18), even after controlling for self-reported race and site of recruitment. In stratified analyses, Mexican youth sensitized to mouse allergen did not have higher odds of asthma exacerbation. Other Latino and Puerto Rican youth sensitized to mouse had higher odds of hospitalization for asthma (aORs, 4.57 [95% CI, 1.86-11.22] and 10.01 [95% CI, 1.77-56.6], respectively) but not emergency department visits.

CONCLUSION

Pest allergen sensitization is associated with a higher odds of asthma exacerbations in urban minority youth. Puerto Rican and Other Latino youth sensitized to mouse were more likely to have asthma-related hospitalizations than Mexican youth.

Routinely sleeping away from home and the association with child asthma readmission

The increased prevalence of transitions between households may have implications for child asthma morbidity. We, therefore, sought to enumerate the prevalence of regularly spending nights sleeping away from home among children admitted to the hospital for asthma and to examine the relationship of nights away to asthma-related readmission. This was a population-based, prospective cohort of 774 children, aged 1-16 years, who were admitted with asthma or bronchodilator-responsive wheezing and enrolled in the Greater Cincinnati Asthma Risks Study. The study took place at Cincinnati Children's Hospital Medical Center, an urban, academic children's hospital in the Midwest. The primary exposure was regularly spending nights away from home. Selected covariates included caregiver marital status, shift work, child's race, income, psychological distress, and running out of/not having medications on hand. The primary outcome was asthma-related readmission within 12 months. A total of 19 % were readmitted within 12 months. The 33 % of children that spent ≥1 night away from home per week were significantly more likely to be readmitted than those who spent no nights away (25 % vs. 16 %, p = 0.002). Spending nights away from home [adjusted relative risk (aRR) 1.5, 95 % confidence interval (CI) 1.2-2.0] and lower income (aRR 2.6, 95 % CI 1.1-6.4) were the strongest independent predictors of readmission after adjusting for child age, gender, and race, and caregiver marital status, shift work, risk of psychological distress, and running out of meds. Increased awareness of the multiple settings in which children with asthma live may help shape more comprehensive approaches to asthma care.

Divorce and Childhood Chronic Illness: A Grounded Theory of Trust, Gender, and Third-Party Care Providers

Divorced parents face distinct challenges in providing care for chronically ill children. Children's residence in two households necessitates the development of family-specific strategies to ensure coparents' supervision of regimen adherence and the management of children's health care. Utilizing a risk and resilience perspective, a grounded theory study was conducted with 14 divorced parents of children with chronic illnesses. The importance of trust, gender, and relationships with third-party care providers emerged as key themes related to the development of effective coparenting relationships for maintaining children's health. Divorced parents were best able to support the management of their children's chronic conditions when care providers operated as neutral third parties and intermediaries. Collaborative family care may require health care practitioners to avoid being drawn into contentious inter-parental conflicts.

Predicting future emergency department visits and hospitalizations for asthma using the Pediatric Asthma Control and Communication Instrument - Emergency Department version (PACCI-ED)

OBJECTIVE

Emergency departments (EDs) are potential settings for interventions to improve asthma outcomes. Screening tools can identify children at risk of future morbidity. Our objective was to determine the predictive validity of the Pediatric Asthma Control and Communication Instrument - Emergency Department version (PACCI-ED) for future asthma-related ED visits and hospitalizations.

METHODS

This was a retrospective cohort study of 108 children 1-17 years old who visited an ED for asthma and completed the PACCI-ED. The PACCI-ED queries parents about prior 12-month ED visits, hospitalizations, steroid use, perceived asthma morbidity and burden, and asthma control (over prior 1-2 weeks). The primary outcome was subsequent ED visits and hospitalizations within 1 year of enrollment. Poisson regression was used to model PACCI-ED questions for future ED visits controlling for age and socioeconomic status.

RESULTS

Reported ED visits predicted future ED visits (adjusted incidence rate ratio (aIRR) 3.1, 95% confidence interval (CI): 1.3-7.2) but not future hospitalizations. Reported hospitalizations predicted future ED visits (aIRR 3.3; 95% CI 1.7-6.3) and hospitalizations (aIRR 6.4; 95% CI 2.3-17.6). The remaining PACCI-ED questions did not predict future ED visits or hospitalizations.

CONCLUSIONS

The PACCI-ED risk domain was the only domain that predicted future asthma ED visits and hospitalizations. Questions about previous ED visits and hospitalizations are the most effective questions when screening children with asthma in EDs for the risk of future health-care use.

Emergency Department Frequent Utilization for Non-Emergent Presentments: Results from a Regional Urban Trauma Center Study

OBJECTIVES

First, to test a model of the drivers of frequent emergency department utilization conceptualized as falling within predisposing, enabling, and need dimensions. Second, to extend the model to include social networks and service quality as predictors of frequent utilization. Third, to illustrate the variation in thresholds that define frequent utilization in terms of the number of emergency department encounters by the predictors within the model.

DATA SOURCE

Primary data collection over an eight week period within a level-1 trauma urban hospital's emergency department.

STUDY DESIGN

Representative randomized sample of 1,443 adult patients triaged ESI levels 4-5. Physicians and research staff interviewed patients as they received services. Relationships with the outcome variable, utilization, were tested using logistic regression to establish odds-ratios.

PRINCIPAL FINDINGS

70.6 percent of patients have two or more, 48.3 percent have three or more, 25.3 percent have four or more, and 14.9 percent have five or more emergency department visits within 12 months. Factors associated with frequent utilization include gender, race, poor mental health, mental health drugs, prescription drug abuse, social networks, employment, perceptions of service quality, seriousness of condition, persistence of condition, and previous hospital admittance.

CONCLUSIONS

Interventions targeting associated factors will change global emergency department encounters, although the mutability varies. Policy interventions to address predisposing factors such as substance abuse or access to mental health treatment as well as interventions that speak to enabling factors such as promoting the resiliency of social networks may result in decreased frequency of emergency department utilization.

How do people respond to health news? The role of personality traits

When a patient receives a health diagnosis, their response (e.g. changes in behaviour, seeking support) can have significant consequences for long-term health and well-being. Characteristics of health news are known to influence these responses, but personality traits have been omitted from this line of research. The current study examines the role of personality traits in predicting response to health news. Participants (N = 298) read scenarios in which they received health news that was manipulated to vary in severity, controllability and likelihood of outcomes. Participants then rated how likely they were to engage in a number of response behaviours. We examined the main effects and interaction of situational manipulations and personality traits on ratings of these behaviours. Both situations and personality traits influenced behavioural responses to health events. In particular, conscientiousness predicted taking action and seeking social support. Neuroticism predicted both maladaptive and adaptive behavioural responses, providing support for the 'healthy neurotic' hypothesis. Moreover, personality traits predicted best in weak (unlikely, controllable) situations. Both personality traits and situational characteristics contribute to behavioural responses to health news.

Mapping asthma-associated variants in admixed populations

Admixed populations arise when two or more previously isolated populations interbreed. Mapping asthma susceptibility loci in an admixed population using admixture mapping (AM) involves screening the genome of individuals of mixed ancestry for chromosomal regions that have a higher frequency of alleles from a parental population with higher asthma risk as compared with parental population with lower asthma risk. AM takes advantage of the admixture created in populations of mixed ancestry to identify genomic regions where an association exists between genetic ancestry and asthma (in contrast to between the genotype of the marker and asthma). The theory behind AM is that chromosomal segments of affected individuals contain a significantly higher-than-average proportion of alleles from the high-risk parental population and thus are more likely to harbor disease-associated loci. Criteria to evaluate the applicability of AM as a gene mapping approach include: (1) the prevalence of the disease differences in ancestral populations from which the admixed population was formed; (2) a measurable difference in disease-causing alleles between the parental populations; (3) reduced linkage disequilibrium (LD) between unlinked loci across chromosomes and strong LD between neighboring loci; (4) a set of markers with noticeable allele-frequency differences between parental populations that contributes to the admixed population (single nucleotide polymorphisms (SNPs) are the markers of choice because they are abundant, stable, relatively cheap to genotype, and informative with regard to the LD structure of chromosomal segments); and (5) there is an understanding of the extent of segmental chromosomal admixtures and their interactions with environmental factors. Although genome-wide association studies have contributed greatly to our understanding of the genetic components of asthma, the large and increasing degree of admixture in populations across the world create many challenges for further efforts to map disease-causing genes. This review, summarizes the historical context of admixed populations and AM, and considers current opportunities to use AM to map asthma genes. In addition, we provide an overview of the potential limitations and future directions of AM in biomedical research, including joint admixture and association mapping for asthma and asthma-related disorders.

Asthma in a university campus: a survey of students and staff of Obafemi Awolowo University, Ile-Ife, Nigeria

BACKGROUND

Asthma continues to be an important cause of morbidity and mortality in developing countries. But, its burden among adult populations in university campuses is not well described.

METHOD

Through a multistage cluster sampling of students and staff of the Obafemi Awolowo University, Ile-Ife, Nigeria, we obtained a representative sample, each for students and staff. We administered the European Community Respiratory Health Survey (ECRHS) screening questionnaire to all the respondents. A subgroup did a spirometry test and completed a detailed questionnaire. Asthma was considered "possible", if a respondent provided affirmative response to symptoms of "wheezing or whistling", "attack of shortness of breath", "diagnosed attack of asthma" in the last 12 months or "currently taking medicines for asthma".

RESULTS

From population of 13,750 students and 1428 staff of the university, we systematically sampled 2750 (20%) students and all the staff. Amongst these, 2372 students and 455 staff completed the screening questionnaire. The mean age (SD) of the responders was 21.9 (3.2) and 46.1 (8.9) for students and staff and most of them were men; 58.6% and 65.9%, respectively. While an estimated 2.6% (95% CI: 1.7-3.5) of students had an asthma attack in the preceding 12 months, 14.5% (95% CI: 12.5-16.5) and 25.2% (95% CI: 22.8-27.7) reported shortness of breath and nocturnal cough, respectively. The staff population reported fewer symptoms. The proportion with "possible asthma" was 18.2% (95% CI: 16.0-20.4) for students and 8.0% (95% CI: 5.4-10.7) for staff.

CONCLUSION

The prevalence of asthma is high among students and staff of Obafemi Awolowo University, Nigeria.

The Impact of Parent's Health Literacy on Pediatric Asthma Outcomes

Background: Health literacy has been associated with health disparities in many disease outcomes, including children's asthma. Parents are responsible for most of children's healthcare. Therefore, parents' health literacy may impact children's health outcomes, including asthma control. This study sought to determine the association between parent health literacy and children's asthma control among a cohort of predominately minority urban children aged between 6 and 12 years. Methods: This cross-sectional study assessed children with asthma and their parents at a single outpatient visit. English-speaking parents and their children, aged between 6 and 12 years with physician-diagnosed asthma, were eligible for this study. Healthcare providers assessed asthma control and severity, and parents completed demographic, health literacy, asthma control, and asthma knowledge measures. Children completed a pulmonary function test as part of the Asthma Control Questionnaire (ACQ) scoring. Results: A total of 281 parent-child dyads provided data, with the majority of parents being mothers and African American, with a high school level education or less. Lower parent health literacy was associated with worse asthma control as rated both by the provider (p=0.007) and the ACQ (p=0.013), despite only moderate concordance between ratings (ρ=0.408, p<0.0001). Lower parent health literacy also was associated with less asthma knowledge, which was associated with worse asthma control. Conclusions: Higher parent health literacy was associated with more parent asthma knowledge and better child asthma control. Pediatric providers should consider tailoring education or treatment plans or utilizing universal precautions for low health literacy.

Systematic assessment of the correlations of household income with infectious, biochemical, physiological, and environmental factors in the United States, 1999-2006

A fuller understanding of the social epidemiology of disease requires an extended description of the relationships between social factors and health indicators in a systematic manner. In the present study, we investigated the correlations between income and 330 indicators of physiological, biochemical, and environmental health in participants in the US National Health and Nutrition Examination Survey (NHANES) (1999-2006). We combined data from 3 survey waves (n = 249-23,649 for various indicators) to search for linear and nonlinear (quadratic) correlates of income, and we validated significant (P < 0.00015) correlations in an independent testing data set (n = 255-7,855). We validated 66 out of 330 factors, including infectious (e.g., hepatitis A), biochemical (e.g., carotenoids, high-density lipoprotein cholesterol), physiological (e.g., upper leg length), and environmental (e.g., lead, cotinine) measures. We found only a modest amount of association modification by age, race/ethnicity, and gender, and there was no association modification for blacks. The present study is descriptive, not causal. We have shown in our systematic investigation the crucial place income has in relation to health risk factors. Future research can use these correlations to better inform theory and studies of pathways to disease, as well as utilize these findings to understand when confounding by income is most likely to introduce bias.

Polycyclic aromatic hydrocarbons and childhood asthma

Asthma is the most common chronic illness in children living in developed countries and the leading cause of childhood hospitalization and school absenteeism. Prevalence rates of asthma are increasing and show disparities across gender, geographic regions, and ethnic/racial groups. Common risk factors for developing childhood asthma include exposure to tobacco smoke, previous allergic reactions, a family history of asthma, allergic rhinitis or eczema, living in an urban environment, obesity and lack of physical exercise, severe lower respiratory tract infections, and male gender. Asthma exacerbation in children can be triggered by a variety of factors, including allergens (e.g., pollen, dust mites, and animal dander), viral and bacterial infections, exercise, and exposure to airway irritants. Recent studies have shown that exposure to polycyclic aromatic hydrocarbons (PAHs), a major component of fine particulate matter from combustion sources, is also associated with onset of asthma, and increasing asthmatic symptoms. In this paper, we review sources of childhood PAH exposure and the association between airborne PAH exposure and childhood asthma prevalence and exacerbation.

Nocturnal asthma and the importance of race/ethnicity and genetic ancestry

RATIONALE

Nocturnal asthma is a common presentation and is associated with a more severe form of the disease. However, there are few epidemiologic studies of nocturnal asthma, particularly in minority populations.

OBJECTIVES

To identify factors associated with nocturnal asthma, including the contribution of self-identified race/ethnicity and genetic ancestry.

METHODS

The analysis included individuals from the Study for Asthma Phenotypes and Pharmacogenomic Interactions by Race-ethnicity (SAPPHIRE) cohort. Nocturnal asthma symptoms were assessed by questionnaire. Genome-wide genotype data were used to estimate genetic ancestry in a subset of African American participants. Logistic regression was used evaluate the association of various factors with nocturnal asthma, such as self-identified race/ethnicity and genetic ancestry.

MEASUREMENT AND MAIN RESULTS

The study comprised 3,380 African American and 1,818 European Americans individuals with asthma. After adjusting for other potential explanatory variables, including controller medication use, African Americans were more than twice as likely (odds ratio, 2.56; 95% confidence interval, 2.24-2.93) to report nocturnal asthma when compared with European American individuals. Among the subset of African American participants with genome-wide genotype data (n = 1,040), estimated proportion of African ancestry was also associated with an increased risk of nocturnal asthma (P = 0.007). Differences in lung function explained a small, but statistically significant (P = 0.02), proportion of the relationship between genetic ancestry and nocturnal asthma symptoms.

CONCLUSIONS

Both self-identified race/ethnicity and African ancestry appear to be independent predictors of nocturnal asthma. The mechanism by which genetic ancestry contributes to population-level differences in nocturnal asthma appears to be largely independent of lung function.

Operational definitions of asthma in recent epidemiological studies are inconsistent

OBJECTIVE

The best combination of questions to define asthma in epidemiological asthma studies is not known. We summarized the operational definitions of asthma used in prevalence studies and empirically assess how asthma prevalence estimates vary depending on the definition used.

METHODS

We searched the Thomson Reuters ISI Web of knowledge and included (1) cross-sectional studies (2) on asthma prevalence (3) conducted in the general population and (4) containing an explicit definition of asthma. The search was limited to the 100 most-cited papers or published since January 2010. For each paper, we recorded the asthma definition used and other variables. Then we applied the definitions to the data of the Portuguese National Asthma survey (INAsma) and of the 2005-2006 National Health and Nutrition Examination Survey (NHANES) computing asthma prevalence estimates for the different definitions.

RESULTS

Of 1738 papers retrieved, 117 were included for analysis. Lifetime asthma, diagnosed asthma and current asthma were defined in 8, 12 and 29 different ways, respectively. By applying definitions of current asthma on INAsma and NHANES data, the prevalence ranged between 5.3%-24.4% and 1.1%-17.2%, respectively.

CONCLUSIONS

There is considerable heterogeneity in the definitions of asthma used in epidemiological studies leading to highly variable estimates of asthma prevalence. Studies to inform a standardized operational definition are needed. Meanwhile, we propose a set of questions to be reported when defining asthma in epidemiological studies.

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children

OBJECTIVES

To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children.

METHODS

We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP.

RESULTS

One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06).

CONCLUSIONS

Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.

Association of short-term increases in ambient air pollution and timing of initial asthma diagnosis among Medicaid-enrolled children in a metropolitan area

OBJECTIVE

We investigated associations of short-term changes in ambient ozone (O3), fine particulate matter (PM2.5) and nitrogen dioxide (NO2) concentrations and the timing of new-onset asthma, using a large, high-risk population in an area with historically high ozone levels.

METHODS

The study population included 18,289 incident asthma cases identified among Medicaid-enrolled children in Harris County Texas between 2005-2007, using Medicaid Analytic Extract enrollment and claims files. We used a time-stratified case-crossover design and conditional logistic regression to assess the effect of increased short-term pollutant concentrations on the timing of asthma onset.

RESULTS

Each 10 ppb increase in ozone was significantly associated with new-onset asthma during the warm season (May-October), with the strongest association seen when a 6-day cumulative average period was used as the exposure metric (odds ratio [OR]=1.05, 95% confidence interval [CI], 1.02-1.08). Similar results were seen for NO2 and PM2.5 (OR=1.07, 95% CI, 1.03-1.11 and OR=1.12, 95% CI, 1.03-1.22, respectively), and PM2.5 also had significant effects in the cold season (November-April), 5-day cumulative lag (OR=1.11. 95% CI, 1.00-1.22). Significantly increased ORs for O3 and NO2 during the warm season persisted in co-pollutant models including PM2.5. Race and age at diagnosis modified associations between ozone and onset of asthma.

CONCLUSION

Our results indicate that among children in this low-income urban population who developed asthma, their initial date of diagnosis was more likely to occur following periods of higher short-term ambient pollutant levels.

Longitudinal validation of a tool for asthma self-monitoring

OBJECTIVES

To establish longitudinal validation of a new tool, the Asthma Symptom Tracker (AST). AST combines weekly use of the Asthma Control Test with a color-coded graph for visual trending.

METHODS

Prospective cohort study of children age 2 to 18 years admitted for asthma. Parents or children (n = 210) completed baseline AST assessments during hospitalization, then over 6 months after discharge. Concurrent with the first 5 AST assessments, the Asthma Control Questionnaire (ACQ) was administered for comparison.

RESULTS

Test-retest reliability (intraclass correlation) was moderate, with a small longitudinal variation of AST measurements within subjects during follow-ups. Internal consistency was strong at baseline (Cronbach's α 0.70) and during follow-ups (Cronbach's α 0.82-0.90). Criterion validity demonstrated a significant correlation between AST and ACQ scores at baseline (r = -0.80, P < .01) and during follow-ups (r = -0.64, -0.72, -0.63, and -0.69). The AST was responsive to change over time; an increased ACQ score by 1 point was associated with a decreased AST score by 2.65 points (P < .01) at baseline and 3.11 points (P < .01) during follow-ups. Discriminant validity demonstrated a strong association between decreased AST scores and increased oral corticosteroid use (odds ratio 1.13, 95% confidence interval, 1.10-1.16, P < .01) and increased unscheduled acute asthma visits (odds ratio 1.23, 95% confidence interval, 1.18-1.28, P < .01).

CONCLUSIONS

The AST is reliable, valid, and responsive to change over time, and can facilitate ongoing monitoring of asthma control and proactive medical decision-making in children.

The impact of natural selection on health and disease: uses of the population genetics approach in humans

Investigations of the legacy of natural selection in the human genome have proved particularly informative, pinpointing functionally important regions that have participated in our genetic adaptation to the environment. Furthermore, genetic dissection of the intensity and type of selection acting on human genes can be used to predict involvement in different forms and severities of human diseases. We review here the progress made in population genetics studies toward understanding the effects of selection, in its different forms and intensities, on human genome diversity. We discuss some outstanding, robust examples of genes and biological functions subject to strong dietary, climatic and pathogen selection pressures. We also explore the possible relationship between cancer and natural selection, a topic that has been largely neglected because cancer is generally seen as a late-onset disease. Finally, we discuss how the present-day incidence of some diseases of modern societies may represent a by-product of past adaptation to other selective forces and changes in lifestyle. This perspective thus illustrates the value of adopting a population genetics approach in delineating the biological mechanisms that have played a major evolutionary role in the way humans have genetically adapted to different environments and lifestyles over time.

The challenge of asthma in minority populations

The burden and disparity of asthma in race/ethnic minorities present a significant challenge. In this review, we will evaluate data on asthma epidemiology in minorities, examine potential reasons for asthma disparities, and discuss strategies of intervention and culturally sensitive care.

Genetic ancestry and its association with asthma exacerbations among African American subjects with asthma

BACKGROUND

There are large and persisting disparities in severe asthma exacerbations by race-ethnicity, and African American subjects are among those at greatest risk. It is unclear whether this increased risk solely represents differences in environmental exposures and health care or whether there is a predisposing genetic component.

OBJECTIVE

We sought to assess the relationship between genetic ancestry and severe exacerbations among African American subjects with asthma.

METHODS

Participants were part of the Study of Asthma Phenotypes and Pharmacogenomic Interactions by Race-ethnicity (SAPPHIRE). These subjects were 12 to 56 years of age, received care from a single large health system, and had a physician's diagnosis of asthma. Genetic ancestry was estimated by using a set of validated ancestry informative markers. Severe exacerbations (ie, asthma-related emergency department visits, hospitalizations, and burst oral steroid use) were prospectively identified from health care claims.

RESULTS

We assessed genetic ancestry in 392 African American subjects with asthma. The average proportion of African ancestry was 76.1%. A significant interaction was identified between ancestry and sex on severe exacerbations, such that the risk was significantly higher with increasing African ancestry among male but not female subjects. The association among male subjects persisted after adjusting for potential confounders (relative rate, 4.30 for every 20% increase in African ancestry; P = .029).

CONCLUSIONS

African ancestry was significantly and positively associated with severe exacerbations among male African American subjects. These findings suggest that a portion of the risk of asthma exacerbations in this high-risk group is attributable to a genetic risk factor that partitions with ancestry.

Factors that mediate racial/ethnic disparities in US fetal death rates

OBJECTIVES

We sought to determine the importance of socioeconomic factors, maternal comorbid conditions, antepartum and intrapartum complications of pregnancy, and fetal factors in mediating racial disparities in fetal deaths. METHODS. We undertook a mediation analysis on a retrospective cohort study of hospital-based deliveries with a gestational age between 23 and 44 weeks in California, Missouri, and Pennsylvania from 1993 to 2005 (n = 7,104,674).

RESULTS

Among non-Hispanic Black women and Hispanic women, the fetal death rate was higher than among non-Hispanic White women (5.9 and 3.6 per 1000 deliveries, respectively, vs 2.6 per 1000 deliveries; P < .01). For Black women, fetal factors mediated the largest percentage (49.6%; 95% confidence interval [CI] = 42.7, 54.7) of the disparity in fetal deaths, whereas antepartum and intrapartum factors mediated some of the difference in fetal deaths for both Black and Asian women. Among Hispanic women, socioeconomic factors mediated 35.8% of the disparity in fetal deaths (95% CI = 25.8%, 46.2%).

CONCLUSIONS

The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities.

Racial and ethnic differences in the management of childhood asthma in the United States

OBJECTIVES

We examined racial and ethnic differences in the management of childhood asthma in the United States and the extent that care conformed to clinical best practices.

METHODS

Two years of pooled data from the National Health Interview Survey were analyzed using logistic regression. The sample included all children between ages 2 and 17 years who had asthma currently and had been diagnosed with asthma by a doctor or health professional (n = 1757; 465 African-American, 212 Mexican-American, 190 Puerto Rican and other Hispanic, 806 white, non-Hispanic, and 84 children of other and multiple races and ethnicities).

RESULTS

African-American children with asthma were significantly less likely than white, non-Hispanic children to have taken preventive asthma medication, but more likely to have had an asthma management plan. Mexican-American and Puerto Rican and other Hispanic children did not differ significantly from white, non-Hispanic children in either receiving preventive asthma medication or having an asthma management plan. Caregivers of African-American and Puerto Rican and other Hispanic children were more likely to report that they or their child had taken a course or class on how to manage their child's asthma. We did not find racial or ethnic differences in the extent children used quick-relief asthma medication or received advice about reducing asthma triggers in their home, school, or work environments.

CONCLUSIONS

This work highlights a need for more research on racial and ethnic differences in asthma management. Implications for public health responses and racial and ethnic disparities in asthma morbidity are discussed.

Factors associated with disparities in emergency department use among Latino children with asthma

BACKGROUND

Significant disparities in emergency department (ED) rates exist for Latinos; however, few studies have investigated the factors that may account for these disparities.

OBJECTIVES

To examine individual/family and health system factors among Latino and non-Latino white (NLW) children with asthma to explain disparities in ED rates.

METHODS

The study was carried out in Puerto Rico (PR) and Rhode Island (RI) with the same design: a cross-sectional, observational approach with repeated measurements of selected variables.

RESULTS

The sample was composed of 804 children ages 7 to 15 years, with 405 from PR and 399 from RI. Latino children from both sites had significantly higher rates of ED use as compared with NLWs from RI. Regression analyses showed site, asthma control, parental reported severity of asthma and public insurance to be significantly associated with ED use.

CONCLUSION

Latino ethnicity and public insurance were among the most important factors related to frequent ED use. Revisions of the policies driving public insurance to assure better access to specialists, preventive education, and evidence-based treatment are needed. The results also suggest the need for the development of interventions in the ED that are geared toward educating families on how best to use emergency services.

Associations between genetic variants in vitamin D metabolism and asthma characteristics in young African Americans: a pilot study

INTRODUCTION

Low vitamin D levels have been associated with asthma severity in children. Young, urban African Americans (AAs) have high rates of hypovitaminosis D and asthma. Our objective was to determine associations between variants in vitamin D metabolism genes and asthma characteristics in a pilot study of young urban AAs.

MATERIALS AND METHODS

Two urban AA cohorts of subjects aged 6 to 20 years (139 subjects with asthma and 74 subjects without asthma) were genotyped for 12 single nucleotide polymorphisms (SNPs) in 3 vitamin D metabolism genes: VDR (vitamin D receptor), CYP24A1 (cytochrome P450 vitamin D 24-hydroxylase), and CYP2R1 (cytochrome P450 vitamin D 25-hydroxylase). In a case-control analysis, SNPs were studied for associations with an asthma diagnosis. Within the asthmatic cohort, SNPs were analyzed for associations with quantitative asthma characteristics. All analyses were adjusted for age, sex, and body mass index percentile.

RESULTS

Only the CYP2R1 SNP rs10766197 homozygous minor genotype was associated with asthma (P = 0.044). CYP24A1 SNP rs2248137 was associated with lower vitamin D levels (P = 0.006). Within the asthma cohort, multiple significant associations between SNPs and asthma characteristics were identified; VDR SNP rs2228570 was associated with the higher nighttime asthma morbidity scores (P = 0.04), lower baseline spirometric measures (P < 0.05), 1 or more positive aeroallergen skin test (P = 0.003), and increased immunoglobulin E levels (P < 0.001).

DISCUSSION

This pilot study demonstrates that variants in vitamin D metabolism genes are associated with quantitative asthma characteristics in young, urban AAs. The collection of these associations provides evidence for the need for a large population-based study of vitamin D-relevant SNPs in this cohort.

Secondhand smoke risk in infants discharged from an NICU: potential for significant health disparities?

INTRODUCTION

Secondhand smoke exposure (SHSe) threatens fragile infants discharged from a neonatal intensive care unit (NICU). Smoking practices were examined in families with a high respiratory risk infant (born at very low birth weight; ventilated > 12 hr) in a Houston, Texas, NICU. Socioeconomic status, race, and mental health status were hypothesized to be related to SHSe and household smoking bans.

METHODS

Data were collected as part of The Baby's Breath Project, a hospital-based SHSe intervention trial targeting parents with a high-risk infant in the NICU who reported a smoker in the household (N = 99). Measures of sociodemographics, smoking, home and car smoking bans, and depression were collected.

RESULTS

Overall, 26% of all families with a high-risk infant in the NICU reported a household smoker. Almost half of the families with a smoker reported an annual income of less than $25,000. 46.2% of families reported having a total smoking ban in place in both their homes and cars. Only 27.8% families earning less than $25,000 reported having a total smoking ban in place relative to almost 60% of families earning more (p < .01). African American and Caucasian families were less likely to have a smoking ban compared with Hispanics (p < .05). Mothers who reported no smoking ban were more depressed than those who had a household smoking ban (p < .02).

CONCLUSIONS

The most disadvantaged families were least likely to have protective health behaviors in place to reduce SHSe and, consequently, are most at-risk for tobacco exposure and subsequent tobacco-related health disparities. Innovative SHSe interventions for this vulnerable population are sorely needed.

Association of late-preterm birth with asthma in young children: practice-based study

OBJECTIVE

To evaluate the association of late-preterm birth with asthma severity among young children.

METHODS

A retrospective cohort study was performed with electronic health record data from 31 practices affiliated with an academic medical center. Participants included children born in 2007 at 34 to 42 weeks of gestation and monitored from birth to 18 months. We used multivariate logistic or Poisson models to assess the impact of late-preterm (34-36 weeks) and low-normal (37-38 weeks) compared with term (39-42 weeks) gestation on diagnoses of asthma and persistent asthma, inhaled corticosteroid use, and numbers of acute respiratory visits.

RESULTS

Our population included 7925 infants (7% late-preterm and 21% low-normal gestation). Overall, 8.3% had been diagnosed with asthma by 18 months. Compared with term gestation, late-preterm gestation was associated with significant increases in persistent asthma diagnoses (adjusted odds ratio [aOR]: 1.68), inhaled corticosteroid use (aOR: 1.66), and numbers of acute respiratory visits (incidence rate ratio: 1.44). Low-normal gestation was associated with increases in asthma diagnoses (aOR: 1.34) and inhaled corticosteroid use (aOR: 1.39).

CONCLUSION

Birth at late-preterm and low-normal gestational ages might be an important risk factor for the development of asthma and for increased health service use in early childhood.

A randomized controlled trial of parental asthma coaching to improve outcomes among urban minority children

OBJECTIVES

To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits.

DESIGN

Randomized controlled trial.

SETTING

Urban tertiary care children's hospital.

PARTICIPANTS

Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care.

INTERVENTION

Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group).

MAIN OUTCOME MEASURES

The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment.

RESULTS

We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27).

CONCLUSION

This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00149500.

Resilience in low-socioeconomic-status children with asthma: adaptations to stress

BACKGROUND

Low socioeconomic status (SES) is a strong predictor of many health problems, including asthma impairment; however, little is understood about why some patients defy this trend by exhibiting good asthma control despite living in adverse environments.

OBJECTIVE

This study sought to test whether a psychological characteristic, the shift-and-persist strategy (dealing with stressors by reframing them more positively while at the same time persisting in optimistic thoughts about the future), protects low-SES children with asthma.

METHODS

One hundred twenty-one children aged 9 to 18 years with a physician's diagnosis of asthma were recruited from medical practices and community advertisements (mean age, 12.6 years; 67% male; 61% white). Shift-and-persist scores and asthma inflammation (eosinophil counts and stimulated IL-4 cytokine production) were assessed at baseline, and asthma impairment (daily diary measures of rescue inhaler use and school absences) and daily peak flow were monitored at baseline and at a 6-month follow-up.

RESULTS

Children who came from low-SES backgrounds but who engaged in shift-and-persist strategies displayed less asthma inflammation at baseline (β = 0.19, P < .05), as well as less asthma impairment (reduced rescue inhaler use and fewer school absences; β = 0.32, P < .01) prospectively at the 6-month follow-up period. In contrast, shift-and-persist strategies were not beneficial among high-SES children with asthma.

CONCLUSION

An approach that focuses on the psychological qualities that low-SES children develop to adapt to stressors might represent a practical and effective starting point for reducing health disparities. Moreover, the approaches that are effective in low-SES communities might be different from those that are optimal in a high-SES context.

Associations between genetic variants in vitamin D metabolism and asthma characteristics in young African Americans: a pilot study

INTRODUCTION

Low vitamin D levels have been associated with asthma severity in children. Young, urban African Americans (AAs) have high rates of hypovitaminosis D and asthma. Our objective was to determine associations between variants in vitamin D metabolism genes and asthma characteristics in a pilot study of young urban AAs.

MATERIALS AND METHODS

Two urban AA cohorts of subjects aged 6 to 20 years (139 subjects with asthma and 74 subjects without asthma) were genotyped for 12 single nucleotide polymorphisms (SNPs) in 3 vitamin D metabolism genes: VDR (vitamin D receptor), CYP24A1 (cytochrome P450 vitamin D 24-hydroxylase), and CYP2R1 (cytochrome P450 vitamin D 25-hydroxylase). In a case-control analysis, SNPs were studied for associations with an asthma diagnosis. Within the asthmatic cohort, SNPs were analyzed for associations with quantitative asthma characteristics. All analyses were adjusted for age, sex, and body mass index percentile.

RESULTS

Only the CYP2R1 SNP rs10766197 homozygous minor genotype was associated with asthma (P = 0.044). CYP24A1 SNP rs2248137 was associated with lower vitamin D levels (P = 0.006). Within the asthma cohort, multiple significant associations between SNPs and asthma characteristics were identified; VDR SNP rs2228570 was associated with the higher nighttime asthma morbidity scores (P = 0.04), lower baseline spirometric measures (P < 0.05), 1 or more positive aeroallergen skin test (P = 0.003), and increased immunoglobulin E levels (P < 0.001).

DISCUSSION

This pilot study demonstrates that variants in vitamin D metabolism genes are associated with quantitative asthma characteristics in young, urban AAs. The collection of these associations provides evidence for the need for a large population-based study of vitamin D-relevant SNPs in this cohort.

Disproportionate exposures in environmental justice and other populations: the importance of outliers

We examined traditional environmental justice populations and other groups whose exposure to contaminants is often disproportionately high. Risk assessment methods may not identify these populations, particularly if they are spatially dispersed. We suggest using a National Health and Nutrition Examination Survey approach to oversample minority communities and develop methods for assessing exposure at different distances from pollution sources; publishing arithmetic and geometric means and full distributions for minority populations; and paying particular attention to high-end exposures. Means may sufficiently characterize populations as a whole but are inadequate in identifying vulnerable groups and subgroups. The number of individuals above the 95th percentile of any distribution may be small and unrepresentative, but these outliers are the ones who need to be protected.