Prevalence of asthma in a Portuguese countryside town: repercussions on absenteeism and self-concept.

Rosado-Pinto JE.

Immunoallergy Department, Dona Estefania Hospital, Rua Jacinta Marto, 1169-045 Lisbon, Portugal. luis.borrego netcabo.pt

BACKGROUND: Childhood asthma represents an increasing health problem and is the leading cause of hospital admission and absenteeism in children with chronic disease. It also compromises quality of life, eventually contributing to disturbances in self-concept. Self-concept is a recent and global perspective of "the self" and relates to skills, self-image and self-esteem. Little information is available on this topic and there are no data from Portuguese countryside towns. OBJECTIVE: The aim of this study was to determine the prevalence of asthma among all school children in the 5th and 6th grades in a Portuguese countryside town and to establish its possible correlation with absenteeism and self-concept. METHODS: In April 2002, two questionnaires were administered in the presence of the researcher to a group of 950 children attending different schools. The children completed the internationally renowned questionnaires: ISAAC and the Self-Concept Scale by Susan Harter. RESULTS: Our sample (n = 818) had a mean age of 11 years (10-15 years) and a male-to-female ratio of 1/1. The cumulative prevalence of asthma was 11.9 % and that of active asthma was 8.8 %; 63.9 % of asthmatics were male and 36.1 % were female. The mean age of asthmatics was 11.34 years and 74 % had active symptoms. Comparison of this group of 97 asthmatic children with the remaining children revealed a statistically significant correlation between the presence of asthma and school absenteeism (global: p = 0.04; gymnastics: 0.05). Regarding the Self-Concept Scale a statistically significant association was found between the presence of asthma and school achievement (p = 0.027), physical appearance (p = 0.015), behavior (p < 0.000) and self-esteem (p < 0.000). No statistically significant correlations were found in social acceptance (p = 0.289) or athletic competence (p = 0.085). Asthmatic boys had higher self-concept scores than girls, except in the domain of behavior. CONCLUSIONS: Twelve percent of the population studied was asthmatic. In asthmatic children, absenteeism was higher and self-concept was lower for almost all domains, except social acceptance and athletic achievement, probably due to overprotection.

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What is new with the beta2-agonists: issues in the management of asthma.

Kelly HW.

Department of Pediatrics, Pediatrics/Pulmonary, MSC10-5590, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. hwkelly salud.unm.edu

OBJECTIVE: To review the more recent literature addressing the issue of whether beta2-agonists can worsen asthma and/or increase the risk of severe exacerbations and death from asthma. DATA SOURCES: PubMed was searched (2001-December 2004), along with the Food and Drug Administration and Cochrane Library Web sites. In addition, the bibliographies of recent reviews of the subject were assessed. STUDY SELECTION AND DATA EXTRACTION: Randomized clinical trials, retrospective and prospective cohort studies, and meta-analyses published in the past 3 years were reviewed. Studies assessing the potential for beta2-agonists to worsen outcomes in asthma as well as long-term studies assessing asthma outcomes that included an arm with regular administration of short- or long-acting inhaled beta2-agonists (LABAs) were selected. Worsening asthma was defined as a decline in lung function, an increase in bronchial hyperresponsiveness, exacerbations, or death. Studies older than 3 years selected from the bibliographies of the primary articles that addressed background perspective were also included where appropriate. DATA SYNTHESIS: The studies fell into 3 primary categories with some overlap: those assessing toxicity of the S-enantiomer of albuterol, those evaluating the risk of specific genotypes regarding worsening asthma, and those assessing asthma outcomes with LABA therapy. CONCLUSIONS: The current data on the use of beta2-agonists continue to support the national and international guidelines for the treatment of asthma. That is, short-acting inhaled beta2-agonists should only be used as needed for symptoms and prevention of exercise-induced bronchospasm, and LABAs should only be used regularly as adjunctive therapy with inhaled corticosteroids in patients whose asthma is not controlled with low to medium doses of the inhaled corticosteroid.

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Early effects of Asthma Prevention Program on asthma diagnosis and hospitalization in urban population of Poland.

Stelmach I.

Regional Health Insurance Fund, Lodz, Poland.

BACKGROUND: Asthma is one of the commonest public health problems in Poland and the commonest chronic disorder in children. Lodz Regional Health Insurance Fund was a sponsor of the Prevention Asthma Program in 2000-03, directed at increasing early detection and providing optimal treatment of allergies by specialists in children. METHODS: All funds were divided between 127 primary and 12 specialized care centres participated in the programme. Primary care centre goals were: anamnestic information, mapping of allergy-causing factors, repeated auscultation of the lungs, bronchial dilation test, peak expiratory flow (PEF) measurement at the clinic and at home for 2 weeks. After preliminary diagnosis patients have been send to specialized centres. Specialized care centre goals were as follows: skin testing, spirometry, repeated bronchial dilation test, determination of eosinophilic white blood cells and eosinophil cationic protein (ECP) in blood. RESULTS: Increasing trend of new asthma diagnosis, expressed per 1000 inhabitants, was observed from 0.99 in 2000 to 2.19 in 2003. In the first year of Asthma Prevention Program, we observed more hospital episodes because of asthma exacerbation in comparison with year 1999 but from the second year of programme we showed systematically decreasing number of hospital episodes as a result of asthma exacerbation from 1.48 in 2000 to 0.84 in 2003. We found significantly decreasing trend in duration of hospitalization due to asthma exacerbation (P = 0.001). CONCLUSIONS: Effects of this programmes are: early identification of allergic diseases, mainly asthma, reduced number and shorter duration of hospitalization because of asthma exacerbation and establishing new Asthma Schools Education.

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The influence of neighborhood environment on the incidence of childhood asthma: a multilevel approach.

Yunginger J.

Department of Pediatric and Adolescent Medicine, Division of Community Pediatric and Adolescent Medicine, Mayo Clinic, Baldwin building 3B, 200 1st Street, SW, Rochester, MN 55905, USA. juhn.young mayo.edu

Some ecological analyses suggest an influence of neighborhood environment on asthma outcomes. However, no previous study has applied a multilevel approach to assess an ecological effect of neighborhood environment on the incidence of childhood asthma accounting for individual risk factors. This study assessed the influence of neighborhood and individual-level factors on the incidence of childhood asthma among all children born in Rochester, Minnesota, between 1976 and 1979. We identified asthmatics among all children born in Rochester, between 1976 and 1983. We applied a multilevel survival model with the frailty term to assess the effects of neighborhood characteristics, such as mean family income per census tract (n = 16) from the 1980 census report and the status of whether a census tract faces intersections with major highways or railroads, on asthma incidence. The relative risks (RR) of neighborhood socioeconomic status (SES), the status of whether census tracts face intersections with highways or railroads and the variance of random effect of census tracts were calculated adjusting individual-level covariates for asthma, including gender, birth weight, mother's age at birth and parental educational level at birth. We found that the RR of developing asthma among children living in census tracts facing intersections with highways or railroads was 1.6 (95% CI: 1.1-2.2) compared to those who lived in census tracts not facing intersections, adjusting individual- and neighborhood-level covariates. The variance of the frailty term attributable to census tracts was small (0.0085) and was modified (from 0.004 to 0.0085, 112% change) by adding neighborhood covariates. The overall effects of individual-level factors on asthma incidence were independent of neighborhood environment. The influence of neighborhood environment on childhood asthma in a non-inner-city setting, like Rochester, Minnesota, was small to modest. Incorporating pertinent neighborhood-level covariates into multilevel models needs to be considered in assessing the random effect of clusters.

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Prevalence of gastroesophageal reflux in difficult asthma: relationship to asthma outcome.

Heaney LG.

Regional Respiratory Centre, Level 8, Belfast City Hospital, Lisburn Rd, Belfast, BT97AB, UK.

STUDY OBJECTIVES: To determine the prevalence of gastroesophageal reflux disease (GERD)-both symptoms and objective evidence-using 24-h dual-probe pH monitoring in difficult asthma, and the relationship between the presence and treatment of GERD to clinical outcome. DESIGN AND SETTING: As part of a systematic evaluation protocol, 68 subjects with difficult-to-control asthma attending a difficult asthma clinic were referred for dual-probe ambulatory pH esophageal monitoring. RESULTS: Esophageal probe data were available in 52 patients (76%) with difficult asthma. The prevalence of GERD/GERD-associated asthma symptoms was 75% (39 of 52 patients; 95% confidence interval [CI], 63 to 84.7%). The prevalence of GERD as evidenced by an abnormal pH profile at the distal esophageal probe was 55% (29 of 52 patients; 95% CI, 40 to 69%). The prevalence of GERD at the proximal probe was 34.6% (18 of 52 patients; 95% CI, 23.6 to 51%). The prevalence of GERD was similar in asthmatic subjects who responded to intervention and those who remained difficult to control (therapy resistant). Asymptomatic GERD was present in 9.6% (5 of 52 patients); 16% of cough episodes correlated with acid reflux. CONCLUSIONS: In difficult-to-control asthma, GERD is common, but identification and treatment of GERD do not appear to relate to improvement in asthma control in this population.

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Maternal and grandmaternal smoking patterns are associated with early childhood asthma.

Gilliland FD.

Department of Preventive Medicine, USC Keck School of Medicine, 1540 Alcazar St, CHP 236, Los Angeles, CA 90033, USA.

OBJECTIVE: To investigate the associations of maternal and grandmaternal smoking before, during, and after pregnancy with childhood asthma. DESIGN, SETTING, AND PARTICIPANTS: We conducted a case-control study nested within the Children's Health Study in southern California. The case patients consisted of 338 children with asthma that had been diagnosed in the first 5 years of life, and 570 control subjects were countermatched on in utero exposure to maternal smoking within grade, sex, and community of residence. MEASUREMENTS: Detailed maternal and household smoking histories and other asthma risk factor information was obtained by telephone interview. RESULTS: The participation rates were 72.3% and 82.5%, respectively, for control subjects and case patients. In utero exposure to maternal smoking was associated with increased risk for asthma diagnosed in the first 5 years of life (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.0 to 2.3), and for persistent asthma (OR, 1.5; 95% CI, 1.0 to 2.3). The associations did not differ in children with early transient asthma compared to those with early persistent asthma. Relative to never-smokers, children whose mothers smoked throughout the pregnancy had an elevated risk of asthma in the first 5 years of life (OR, 1.6; 95% CI, 1.0 to 2.6). Children of mothers who quit smoking prior to the pregnancy showed no increased risk (OR, 0.9; 95% CI, 0.5 to 1.5). We were unable to assess the association of smoking cessation during pregnancy because very few mothers were reported to have done so (15%). Asthma risk did not increase in a monotonic pattern with smoking intensity during pregnancy. Postnatal secondhand smoke exposure was not independently associated with asthma. Grandmaternal smoking during the mother's fetal period was associated with increased asthma risk in her grandchildren (OR, 2.1; 95% CI, 1.4 to 3.2). CONCLUSIONS: Maternal and grandmaternal smoking during pregnancy may increase the risk of childhood asthma.

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Regular use of corticosteroids and low use of short-acting beta2-agonists can reduce asthma hospitalization.

Dosman JA.

Department of Public Health Sciences, University of Alberta, 13-106B Clinical Sciences Building, Edmonton, AL, Canada, T6G 2G3. sentil ualberta.ca

OBJECTIVES: Inhaled corticosteroids (ICS) and inhaled short-acting beta(2)-agonists (ISABA) are the most commonly used medications for management of asthma. Increased asthma morbidity and mortality have been reported with excess use of ISABA in several studies. In these studies, authors have used different indicators to control for the potential confounding by asthma severity. The objective of this study was to determine the effect of ICS use on the association between use of ISABA and first hospitalization for asthma after controlling for several indicators of asthma severity. DESIGN: An inceptional cohort study using Saskatchewan Health databases. SETTING: The Province of Saskatchewan, Canada. PARTICIPANTS: A total of 29,957 persons aged 5 to 54 years who had at least five asthma-related visits to physicians between 1991 and 2000. RESULTS: Among the subjects with increased asthma severity, indicated by one or more average number of asthma-related physician visits per 3 months during the follow-up, high use of ISABA was a risk factor for hospitalization when no ICS were used (rate ratio [RR], 2.16; 95% confidence interval [CI], 1.51 to 2.95). There was a beneficial effect of ISABA when there was low use of ICS (RR, 0.65; 95% CI, 0.42 to 0.93) or high use of ICS (RR, 0.23; 95% CI, 0.12 to 0.41). Among the subjects with less severe asthma, indicated by less than one asthma-related physician visits per 3 months, on average, during the follow-up, the risk of hospitalization was even greater for high use of ISABA when no ICS were used (RR, 10.06; 95% CI, 6.99 to 14.47). This was reduced but not abolished when there was low use of ICS (RR, 3.24; 95% CI, 2.29 to 4.59) and negated altogether by high use of ICS (RR, 1.10; 95% CI, 0.39 to 3.12). CONCLUSION: Among both severe and less severe asthma groups, high use of ISABA was associated with an increased risk of asthma hospitalization in the absence of any use of ICS, which was progressively reduced with low and high use of ICS. This finding was independent of asthma severity and could result from lack of control through over reliance on ISABA in asthma management.

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Sensitization to Aspergillus antigens and occurrence of allergic bronchopulmonary aspergillosis in patients with asthma.

Shah A.

Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, PO Box: 2101, Delhi 110 007, India.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA), which is predominantly a disease of asthmatic subjects, is caused by hypersensitivity to Aspergillus antigens. Screening for Aspergillus sensitization in asthmatic subjects could identify those who are at risk for ABPA. Few studies have shown that fungal sensitization could be an important risk factor for asthma severity. We sought to determine the frequency of sensitization to Aspergillus antigens in asthmatic subjects and its effect on disease severity. We also determined the occurrence of ABPA in these subjects. DESIGN: Prospective study of consecutive patients with asthma. SETTING: Tertiary university referral hospital, outpatient department. PATIENTS AND METHODS: One hundred five asthmatic subjects and 26 volunteers underwent skin testing with aeroallergens, including Aspergillus, serum precipitins against Aspergillus antigens, and specific IgG against Aspergillus fumigatus, total serum IgE levels, and routine blood and radiologic investigations. ABPA was diagnosed when all eight major criteria were fulfilled. RESULTS: Thirty patients (28.5%) had a positive skin reactivity to Aspergillus antigens. Eleven patients (10.4%) had positive specific reactions to IgG, and 8 patients (7.6%) demonstrated positive reactions to serum precipitins. Eight of these 30 patients (26.6%) received diagnoses of ABPA, which was 7.6% of the total. None of the control subjects were sensitized to Aspergillus antigens. The patients were classified into the following four groups: negative skin test results; positive reactions to aeroallergens other than Aspergillus; positive reactions to aeroallergens including Aspergillus antigens; and patients with ABPA. Based on clinical and serologic parameters, patients with Aspergillus-sensitive asthma and ABPA had a significantly more severe form of the disease. CONCLUSIONS: Sensitization to the mold Aspergillus increases the severity of asthma. ABPA should be excluded in all patients with Aspergillus-sensitive asthma.

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