Food allergen sensitization in inner-city children with asthma.

Sampson HA.

Division of Allergy and Immunology, Department of Pediatrics, Mount Sinai Hospital, New York, NY, USA.

BACKGROUND: Asthma continues to be an increasing cause of morbidity in the pediatric population, and studies have shown an association between food sensitivity and asthma. OBJECTIVE: We investigated the degree of food allergen sensitization in inner-city patients with asthma. METHODS: Five hundred four random serum samples from the National Cooperative Inner City Asthma Study were evaluated for specific IgE (UniCap) to 6 common food allergens (egg, milk, soy, peanut, wheat, and fish). Statistical analyses were performed to determine food sensitization prevalence and its association with asthma morbidity. RESULTS: Forty-five percent of patients had evidence of sensitization (food-specific IgE > or = 0.35 kU/L) to at least 1 food. Nineteen percent had IgE levels at > or = 50% positive predictive value for clinical reactivity to at least 1 food, with 4% of patients having levels > 95% positive predictive value for food allergy. Children sensitized to foods had higher rates of asthma hospitalization (P < .01) and required more steroid medications (P = .025). Sensitization to foods also correlated with sensitization to more indoor and outdoor aeroallergens (P < .001). CONCLUSION: Food allergen sensitization is highly prevalent in the inner-city population with asthma, and it is associated with increased asthma healthcare and medication use. Therefore, food allergen sensitivity may be a marker for increased asthma severity.

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Time trends in obesity among adults with asthma in the United States: findings from three national surveys.

Mannino DM.

Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA. eford cdc.gov

Obesity may affect the respiratory health of people with asthma. Because the temporal trends in the prevalence of obesity among people with asthma have not been described in the United States, our objective was to describe these trends. Using data from National Health and Nutrition Examination Survey (NHANES) I (1971-1975), II (1976-1980), and III (1988-1994), the authors examined changes in the prevalence of obesity during the period covered by these surveys. The age-adjusted prevalence of current asthma was 3.5% for NHANES I, 3.1% for NHANES II, and 5.2% in NHANES III. Among people with current asthma, age-adjusted mean body mass index increased from 26.1 kg/m2 in the NHANES I to 28.0 kg/m2 in NHANES III, and the age-adjusted prevalence of obesity increased from 21.3 to 32.8%. Among people without asthma, age-adjusted mean body mass index increased from 25.4 kg/m2 in NHANES I to 26.6 kg/m2 in NHANES III, and the prevalence of obesity increased from 14.6 to 22.8%. These results show that people with asthma are far more likely to be obese than people who do not have asthma. Because excess weight may adversely affect the respiratory health of people with asthma, weight management for overweight and obese patients with asthma may be an important component in the medical care of these patients.

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Asthma development with obesity exposure: observations from the cohort of the National Health and Nutrition Evaluation Survey Epidemiologic Follow-up Study (NHEFS).

Rhoads GG.

Institute of Health, Healthcare and Aging Research, Rutgers University, New Brunswick, New Jersey 08901-1293, USA. astanley rci.rutgers.edu

Results of cross-sectional studies suggest an association between body mass index and asthma. However, it is not clear whether the occurrence of asthma precedes increased body mass index or vice versa. From 1971 to 1975, the First National Health and Nutrition Examination Survey collected height and weight data and information about doctor-diagnosed asthma from 14,407 subjects aged 25-74. In 1982 through 1985, information was again obtained on doctor-diagnosed asthma with a follow-up rate of 84.8%. We took this opportunity to examine the relationship between body mass index (BMI) and asthma in this cohort. Subjects with subnormal BMI and subjects admitting current or history of doctor-diagnosed asthma were excluded from the cohort. Mean follow-up was 10 years (range 6.7-13 years). Analyses were adjusted for race and gender. Logistic regression analysis was conducted with asthma as the dependent variable and BMI modeled as a categorical independent variable (BMI groups). At baseline and at follow-up, increasing BMI was associated with increased prevalence of asthma. During the observation interval, however, no increased incidence of asthma associated with increasing BMI was noted. In comparison with normal BMI, the relative risk (RR) for development of doctor-diagnosed asthma in elevated BMI was 1.0 (95% confidence interval 0.9-1.2), for markedly elevated BMI was 1.0 (0.8-1.3), and for severely elevated BMI was 1.1 (0.8-1.5). Race did not affect this relationship. African Americans had an increased risk of asthma, but the risk was unassociated with increasing BMI. Gender did not affect this relationship. The disease burden of asthma appeared in normal weight and slightly overweight women rather than obese and markedly obese women. These results suggest that asthma development may be a point on the trajectory of chronic obesity disease or asthma appears with obesity as a concurrent disorder.

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Predictors for typical asthma onset from cough variant asthma.

Ogawa H.

Respiratory Medicine, Cellular Transplantation Biology, Kanazawa Graduate University School of Medicine, Kanazawa, Japan. fujimura med3.m.kanazawa-u.ac.jp

Cough variant asthma is recognized to be a precursor of asthma or preasthmatic state because nearly 30% patients with cough variant asthma develop typical asthma within several years. However, predictors for risk of typical asthma onset from cough variant asthma are unknown. Forty-one patients with cough variant asthma (median age 50 years, 13 men and 28 women), who had undertaken spirometry, bronchial reversibility test, methacholine provocation test, measurements of peripheral blood eosinophil count, serum total IgE, and specific IgE to common allergens, and induced sputum eosinophil count at presentation, were followed up with special emphasis on typical asthma onset during 1 year or more (median 4 years, range 1-12.4). Long-term inhaled corticosteroids (ICS) were taken in 27 patients. Univariate and multivariate logistic analyses were performed to determine the predictors for typical asthma onset. Asthma onset was recognized in 7 patients. Bronchial hyperresponsiveness, peripheral blood eosinophil count, and no use of ICS were significant predictors for the typical asthma onset by univariate analysis. However, only bronchial hyperresponsiveness was the significant predictor when multivariate analysis was used (adjusted OR 0.028, 95% CI 0.001-0.783, p = 0.0355). Bronchial hyperresponsiveness may be the most important predictor for risk of typical asthma onset from cough variant asthma.

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Soluble CTLA-4 in sera of patients with bronchial asthma.

Zhong XN.

Department of Pulmonary Medicine, First Affiliated Hospital, Guangxi Medical University, Guangxi, PR China. hzshi 163.net

Cytotoxic lymphocyte associated antigen-4 (CTLA-4) is a homologue of CD28, which plays a critical role in the down-regulation of antigen-activated immune response. The aim of the present study was to investigate the concentrations of soluble CTLA-4 in sera of patients with bronchial asthma and the correlation between soluble CTLA-4 concentrations and some clinical measures of asthma. The concentrations of serum soluble CTLA-4 in 31 atopic asthmatics, 20 non-atopic asthmatics, and 28 non-atopic normal control volunteers were determined by ELISA technique, and the relationship between serum soluble CTLA-4 concentrations in asthmatics and airway responsiveness, pulmonary function, blood white cell counts and differentials, respectively, were analyzed. Serum soluble CTLA-4 concentrations in both atopic asthmatics (20.2 +/- 5.4 microg/L) and non-atopic asthmatics (19.2 +/- 6.2 microg/L) were all higher than that in normal controls (1.8 +/- 0.8 microg/L, p = 0.04 and 0.014, respectively). There was no difference in serum soluble CTLA-4 concentrations between atopic and non-atopic asthmatics (p = 0.877). The serum soluble CTLA-4 concentrations in the asthmatics statistically correlated with forced expiratory volume in one second (r = -0.410, p = 0.027), percentage of predicted peak expiratory flow (r = -0.449, p = 0.015), and PaCO2 (r = 0.555, p = 0.002), respectively. Our data also showed that the concentration of soluble CTLA-4 was significantly related to blood lymphocyte numbers. The serum soluble CTLA-4 protein level was significantly elevated in patients with asthma. This level correlated with the severity of asthma. Our data also showed that the concentration of soluble CTLA-4 was significantly related to blood lymphocyte numbers.

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Physiological changes at altitude in nonasthmatic and asthmatic subjects.

Pare PD.

Sir Winston Churchill Secondary School, University of British Columbia, McDonald Research Laboratories/ iCAPTURE Centre, St Paul's Hospital, Vancouver, Canada.

Exercised-induced asthma is not due to exercise itself per se, but rather is due to cooling and/or drying of the airway because of the increased ventilation that accompanies exercise. Travel to high altitudes is accompanied by increased ventilation of cool, often dry, air, irrespective of the level of exertion, and by itself, this could represent an 'exercise' challenge for asthmatic subjects. Exercise-induced bronchoconstriction was measured at sea level and at various altitudes during a two-week trek through the Himalayas in a group of nonasthmatic and asthmatic subjects. The results of this study showed that in mild asthmatics, there was a significant reduction in peak expiratory flow at very high altitudes. Contrary to the authors' hypothesis, there was not a significant additional decrease in peak expiratory flow after exercise in the asthmatic subjects at high altitude. However, there was a significant fall in arterial oxygen saturation postexercise in the asthmatic subjects, a change that was not seen in the nonasthmatic subjects. These data suggest that asthmatic subjects develop bronchoconstriction when they go to very high altitudes, possibly via the same mechanism that causes exercise-induced asthma.

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Correlates of quality of life in patients with asthma.

Van Ganse E.

Centre Hospitalier Universitaire de Lyon, Lyon, France.

BACKGROUND: Health-related quality of life (HRQOL) is a major outcome in asthma, but the relationships among HRQOL, characteristics of asthma, type of supervision, and sociodemographic characteristics of patients have not been thoroughly explored. OBJECTIVE: To identify major correlates of HRQOL in a survey of patients with asthma. METHODS: Patients with asthma were identified by their usual caregivers, either general practitioners or respiratory physicians. In a standardized interview, data were collected on patients' sociodemographic characteristics, medical history, medical resource use in the past 12 months, and asthma QOL. Intensity of asthma therapy was evaluated from the use of inhaled controllers and oral corticosteroids in the past 12 months, and number of asthma attacks during the same period was used as an indicator of level of asthma symptoms. RESULTS: Ninety-nine patients with asthma were identified (median age, 36 years; 62.6% women). In multivariate analysis, major correlates for lower HRQOL scores were having at least 5 asthma attacks and the number of medical visits in the past 12 months (P < .001 for both). Other significant positive associations were unemployment (P = .01) and female sex (P = .05), but not intensity of therapy, age, or type of asthma supervision (general practitioner vs respiratory physician). CONCLUSIONS: In this survey, HRQOL scores seem to be primarily related to asthma symptoms, as indicated by the number of attacks experienced by the patients and the frequency of medical contacts in a previous period. The relationships among HRQOL, therapy, and the determinants of control should be investigated in prospective studies.

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Development of a Rural Asthma Management Model, RAMM.

Oerlemans M.

Collaborative Health, Education & Research Centre, Bendigo, Victoria, Australia. acrombie bendigohealth.org.au

INTRODUCTION: The prevalence of asthma in Australia is increasing and places a significant cost burden on the community as well as reducing individuals' quality of life. In the late 1990s, asthma was the sixth National Health Priority in Australia and the prevalence of asthma in the Loddon Mallee region (LMR) of Victoria was approximately 1% higher than the State average. Four LMR local government areas had close to double the State average hospital admission ratios for asthma. AIM: The aim of this project was to develop a Regional Asthma Management Model (RAMM) and strategies for its implementation throughout the LMR, as a tool to implement a major health priority of both the Victorian State and Australian Commonwealth governments: to improve health outcomes for people with asthma. METHODS: A literature review was undertaken to identify best practice in asthma management for use as the basis of questions in workbooks designed to profile and compare current asthma management practice in the LMR. The workbooks were sent to all acute hospitals, community health centres and asthma educators in the LMR. The completed workbooks were returned and respondents elaborated on the workbook data at one of five subregional workshops. A survey was also undertaken to identify the range of asthma management strategies currently used by regional general practitioners (GPs) and to invite their views on ways to improve asthma management in the region. To gain consumer input into the RAMM a semi-structured group interview was held in an urban area and individual interviews were held in two rural areas in the region. A multidisciplinary reference group provided guidance to the project and a documentation design team was convened. RESULTS: Of the 19 workbooks sent to individual acute hospitals, 15 (78.9%) were completed and returned; 13 of 14 workbooks (92.8%) sent to individual community health centres were completed and returned. Fourteen of 15 asthma educators identified in the LMR were employed in the acute hospitals and community health centres that returned the workbooks; one asthma educator worked privately. Of the 215 GP surveys distributed, 38 surveys (17.6%) were returned. The majority of this small sample of GPs supported developing a uniform regional approach to asthma management based on NAC guidelines. Consumers interviewed suggested treating doctors, and/or EDs provide patients and carers with written instructions regarding acute asthma attacks and advice on management strategies for the ensuing 24-48 hours. A regional profile of asthma management practice was produced and compared with identified best practice. Gaps in practice and services were identified and responsive recommendations formulated. The National Asthma Campaign (NAC) guidelines were used as the basis for RAMM documentation, a package which consisted of a Regional Asthma Clinical Pathway and Emergency Department (ED) Package. CONCLUSION: The RAMM developed during the project provides documentation to assist best-practice asthma management by regional EDs and acute hospitals. The methodology and outcomes of the RAMM reflect the geography of the region, with multiple service providers from different locations managing a person with asthma across the primary, secondary and tertiary continuum. The RAMM methodology has the potential to be applied to other diseases and to other rural environments. Although the RAMM was designed for rural areas it could be easily adapted to suit the metropolitan environment. Implementation and evaluation of RAMM documentation is in progress.

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