Qualitative study of young people's and parents' beliefs about childhood asthma.

Couriel J.

School of Nursing, Midwifery and Health Visiting, University of Manchester, Coupland 3 Building, Oxford Road, Manchester M13 9PL. peter.callery man.ac.uk

BACKGROUND: Asthma continues to be a common childhood chronic illness managed principally in primary care. Self-management requires co-ordinated efforts of young people, carers and health professionals. Non-compliance occurs even when parents are supervising care, suggesting that decisions are made on the basis of beliefs that contrast with professional advice. Health professionals therefore need to understand the views of parents (or other carers) and patients to promote good self-management. Little attention has been given to carers' and young people's perspectives on asthma. AIM: To gain insights into the beliefs of a group of 25 young people aged nine to 16 years old and their carers about asthma and its management. DESIGN OF STUDY: Qualitative study using conversational-style interviews. SETTING: Generally deprived urban areas of Greater Manchester. METHOD: Interviews were conducted with 25 young people with asthma and separately with their carers. The interviews were analysed using the principles and procedures of grounded theory. RESULTS: Carers reported assessing asthma symptoms through observed effects on the child and other family members, including emotions and behaviours that disrupted family life. Young people emphasised the effect of asthma on their everyday lives and in particular the extent to which they appeared different to their peers. Some young people reported continuing symptoms and restrictions of activity that differed widely from the reports of their carers. CONCLUSION: Differences between young people's and carers' criteria for assessment suggest explanations for some 'non-compliant' behaviour. Carers' assessment of asthma severity through the absence of acute attacks is consistent with managing asthma as intermittent acute episodes. Professionals should take account of differences between young people's, carers' and professionals' perceptions of asthma.

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Childhood asthma: proper managements do reduce severity.

Vangveeravong M.

Allergy Unit, Queen Sirikit National Institute of Child Health, Bangkok 10400, Thailand.

RATIONALE: Asthma is an increasing problem, both in children and adults which is due to an increase in environmental pollution. The current management of asthmatic patients is different from the previous decade as more understanding of the mechanism of asthma pathology is known. OBJECTIVES: To study the prevalence of hospitalized asthmatic patients of different age groups in the past decade and to compare the results of different treatments during each 5-year period, 1986-1990, 1991-1995 and 1997-2001. MATERIAL AND METHOD: A retrospective review of the Out-patient Department (OPD) and In-patient Department (IPD) cases of asthma patients, sorted by International Classification of Diseases (ICD 9 & 10) at the Queen Sirikit National Institute of Child Health (QSNICH), previously known as Children's Hospital was carried out. The patients were divided into 3 groups according to the 5-year period of admissions: 1986-1990, 1991-1995 and 1997-2001. Comparison of the prevalence, age distribution, management, severity and outcomes of the patients in different groups using the standard statistical package SPSS for windows. RESULTS: The prevalence of asthma increased from 7,476 OPD visits in 1986 to the peak of 15,576 visits in 1997 and about 13,000-14,000 stable visits from 1998 through 2001. About 2-3 per cent of these OPD cases were admitted to the hospital. After the hospital charts had been reviewed, 2,927 cases of true asthma cases (81.9%) were studied and they were divided into 3 groups, group 1, 2 and 3 consisting of 1,140, 716 and 1,071 patients, respectively. About 60-80 per cent of the admitted cases were children under 5 years old. With the different management of hospitalized cases between the 3 periods, a significant reduction in the readmission rate was outstanding from 14 per cent to 5 per cent and the maximum number of readmissions was reduced from 8 times to 5 times (the majority was 2 times). The length of stay and the percentage of complicated respiratory failure cases were not different. CONCLUSION: The asthma prevalence is increasing. Young children 0-2 years of age tend to have more severe diseases that need hospitalization. Current management, inhaled beta 2 agonists, together with anti-inflammatory drugs do reduce asthma severity to a certain degree. Early intervention of controller medications and regular follow-up care do reduce the readmissions. Further newer treatment of asthma is required for better outcomes of these asthmatic patients.

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[Relationships between melatonin and cortisol and the status of disease in patients with bronchial asthma]

[Article in Chinese]

Zhou JN.

School of Life Science, University of Science and Technology of China, Hefei 230026, China.

OBJECTIVE: The aim of the study was to elucidate the interaction and clinical significance between melatonin and cortisol and the status of disease in patients with bronchial asthma. METHODS: Ten mild persistent and 10 moderate-to-severe persistent asthma patients were recruited to participate in the study. Fifteen normal subjects served as contrds Salivary free melatonin and cortisol were measured simultaneously by radioimmunoassay in all subjects, and 8 salivary samples were collected in a series during a 24-hour period in each subject. The intensity of light was restricted to natural light at room during the daytime and less than 50 lux at night. RESULTS: The results showed that salivary free melatonin levels were significantly lower in mild (15.5 +/- 5.3) micro g/L and moderate-to-severe (7.1 +/- 2.5) micro g/L persistent asthma patients as compared to control subjects (28.9 +/- 8.7) micro g/L (F = 4.47, P < 0.05; F = 7.61, P < 0.01, respectively). The results also showed that salivary free cortisol levels were significantly lower in mild (3.1 +/- 0.5) micro g/L and moderate-to-severe (4.2 +/- 0.5) micro g/L persistent asthma patients as compared to control subjects (5.9 +/- 0.7) micro g/L (F = 10.45, P < 0.01; F = 5.21, P < 0.05, respectively). The amplitude of salivary free cortisol level was reduced in mild and moderate-to-severe persistent asthma patients, and salivary cortisol peak level was significantly delayed in mild and moderate-to-severe persistent asthma patients (P < 0.05, P < 0.01, respectively). There were no significant correlations between the salivary free melatonin and cortisol levels in control and mild persistent asthma patients (r = 0.174, P = 0.057; r = -0.138, P = 0.221, respectively). However, a significant negative correlation was found between the salivary free melatonin and cortisol levels in moderate-to-severe persistent asthma patients (r = -0.275, P = 0.013). CONCLUSIONS: There were lower salivary free melatonin and cortisol levels in asthmatic patients. A significant negative correlation was found between melatonin and cortisol levels in moderate-to-severe persistent asthma patients. Furthermore, the reciprocal inhibition of melatonin and cortisol was closely associated with the status of disease in asthmatic patients.

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Gastroesophageal reflux in bronchial asthma patients. A clinical note.

Abdulrahman IS.

Department of Physiology, King Faisal University, Dammam, Kingdom of Saudi Arabia.

OBJECTIVE: The objective is to correlate the symptoms of gastroesophageal reflux with the results of esophageal reflux with the results of esophageal pH metry in asthmatic patients. METHODS: A prospective study was carried out in King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia (KSA), during the period January 2000 through to February 2001, whereby 50 patients (34 females and 16 females) with primary diagnosis of bronchial asthma were consecutively enrolled, their mean age + SD was 38.01 + 9.8 years. Twenty-two subjects who were not suffering from asthma or gastroesophageal reflux (GER) (13 females and 9 males) constituted the control group. A questionnaire was administered to all participants and demographic data; asthma and GER symptoms were obtained. Esophageal manometry was performed, whereby the location, length and resting pressure of the lower esophageal sphincter (LES) were determined, pH catheter was inserted nasogastrically, and ambulatory pH data over 24 hours were collected. Pulmonary function tests were also performed. RESULTS: Twenty-two (44%) patients with asthma had a Demeester score greater than 14.7 and were therefore diagnosed as having pathological GER. Accordingly, the asthma patients were divided into 2 groups, asthma patients with GER (n=22) and those without GER (n=28). Multiple logistic regression analysis revealed that age did not significantly influence occurrence of GER, but it indicated that hoarseness of voice and nocturnal symptoms were significant predictors for the presence of GER in asthmatic patients, hence, the probability of having GER in an asthma patient is nearly 8 times if he/she has nocturnal symptoms and about 7 times if they have hoarseness of voice. However 36.4% of asthmatic patients diagnosed by esophageal ph metry as having GER did not complain of heartburn and hoarseness of voice; such as the reflux was silent. CONCLUSION: The frequency of GER among 50 patients with asthma reporting to KFHU, Al-Khobar, KSA is 44%. The presence of nocturnal symptoms and hoarseness of voice are significant clinical predictors of GER in asthmatic patients. Patients with difficult to treat asthma should be subjected to esophageal pH metry since a substantial proportion of them may have silent reflux.

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Prospective study of acetaminophen use and newly diagnosed asthma among women.

Camargo CA Jr.

Division of General Medicine, Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York 10032, USA. rgb9 columbia.edu

Acetaminophen decreases glutathione levels in the lung, which may predispose to oxidative injury and bronchospasm. Acetaminophen use has been associated with asthma in cross-sectional studies and a birth cohort. We hypothesized that acetaminophen use would be associated with newly diagnosed adult-onset asthma in the Nurses' Health Study, a prospective cohort study of 121,700 women. Participants were first asked about frequency of acetaminophen use in 1990. Cases with asthma were defined as those with a new physician diagnosis of asthma between 1990 and 1996 plus reiteration of the diagnosis and controller medication use. Proportional hazard models included age, race, socioeconomic status, body mass index, smoking, other analgesic use, and postmenopausal hormone use. During 352,719 person-years of follow-up, 346 participants reported a new physician diagnosis of asthma meeting diagnostic criteria. Increasing frequency of acetaminophen use was positively associated with newly diagnosed asthma (p for trend = 0.006). The multivariate rate ratio for asthma for participants who received acetaminophen for more than 14 days per month was 1.63 (95% confidence interval, 1.11-2.39) compared with nonusers. It would be premature to recommend acetaminophen avoidance for patients with asthma, but further research on pulmonary responses to acetaminophen is necessary to confirm or refute these findings and to identify subgroups whose asthma may be modified by acetaminophen.

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Development of the asthma control test: a survey for assessing asthma control.

Pendergraft TB.

Asthma and allergy Associates and Research Center, Colorado Springs, USA.

BACKGROUND: Asthma guidelines indicate that the goal of treatment should be optimum asthma control. In a busy clinic practice with limited time and resources, there is need for a simple method for assessing asthma control with or without lung function testing. OBJECTIVES: The objective of this article was to describe the development of the Asthma Control Test (ACT), a patient-based tool for identifying patients with poorly controlled asthma. METHODS: A 22-item survey was administered to 471 patients with asthma in the offices of asthma specialists. The specialist's rating of asthma control after spirometry was also collected. Stepwise regression methods were used to select a subset of items that showed the greatest discriminant validity in relation to the specialist's rating of asthma control. Internal consistency reliability was computed, and discriminant validity tests were conducted for ACT scale scores. The performance of ACT was investigated by using logistic regression methods and receiver operating characteristic analyses. RESULTS: Five items were selected from regression analyses. The internal consistency reliability of the 5-item ACT scale was 0.84. ACT scale scores discriminated between groups of patients differing in the specialist's rating of asthma control (F = 34.5, P <.00001), the need for change in patient's therapy (F = 40.3, P <.00001), and percent predicted FEV(1) (F = 4.3, P =.0052). As a screening tool, the overall agreement between ACT and the specialist's rating ranged from 71% to 78% depending on the cut points used, and the area under the receiver operating characteristic curve was 0.77. CONCLUSION: Results reinforce the usefulness of a brief, easy to administer, patient-based index of asthma control.

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Distinguishing severe asthma phenotypes: role of age at onset and eosinophilic inflammation.

Wenzel SE.

National Jewish Medical and Research Center and the University of Colorado Health Sciences Center, Denver, Colorado 80206, USA.

BACKGROUND: Asthma is a heterogeneous process, yet little is understood regarding phenotypes. OBJECTIVE: To determine whether phenotypic differences exist between early-onset, severe asthma as compared with late-onset disease and whether the presence or absence of eosinophilia influences the phenotypes. METHODS: Cross-sectional analysis of integrated clinical, physiologic, and pathologic data collected from 80 subjects with severe asthma. Subjects were divided into those with asthma onset before age 12 years (n = 50) versus after age 12 (n = 30) and by the presence or absence of lung eosinophils. RESULTS: Subjects with early-onset, severe asthma had significantly more allergen sensitivity (skin test positivity, 98% vs 76%, P <.007) and more allergic symptoms (P values all <or=.02) than subjects with late-onset asthma. In contrast, subjects with late-onset asthma had lower lung function (P values =.05 to.07) than early-onset, despite a shorter (P <.0001) duration of illness. Both groups had a high degree of general asthma symptoms, but those with persistent eosinophils from either age at onset group had significantly more (multiple P values <.05). Similarly, the presence of eosinophils in either age at onset group was associated with the lowest lung function (P <or=.02). Although late-onset asthma was associated with the highest numbers of lung eosinophils (P <.007), only early-onset severe asthma was associated with a lymphocytic/mast cell inflammatory process. Finally, subjects with late-onset asthma without eosinophils had no subepithelial basement membrane thickening, suggesting a different pathologic process. CONCLUSIONS: Differentiating severe asthma by age at onset and presence or absence of eosinophils identifies phenotypes of asthma, which could benefit subsequent genetic and therapeutic studies.

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Analysis of prevalence, triggers, risk factors and the related socio-economic effects of childhood asthma in the Student Lung Health Survey (SLHS) database, Canada 1996.

Li FC.

Centre for Chronic Disease Prevention and Control, Population and Public Health Branch, Health Canada, 120 Colonnade Road, Ottawa, Ontario, Canada K1A 0K9. Frank_Mo hc-sc.gc.ca

The purpose of this study was to provide information to improve the management of childhood asthma in Canada. The Student Lung Health Survey (SLHS) was conducted as a stratified and multi-staged cluster survey across Canada in 1996. It included a total of 136 public, private and separate schools in nine health units. The target study population was schoolchildren aged 5 to 19 years. Among all 5-19 years old students, the prevalence of asthma was 13.0%, with the prevalence for males being higher than for females, the adjusted Odds Ratio (OR) was 1.17, (95% CI 1.14-1.19) for males, in comparison with females. The prevalence in the 15-19 age group was higher than that in the 5-9 and 10-14 age group in females, but it was higher in the 5-9 and 10-14 age group than in the 15-19 age group in males. The mean delay from the onset of symptoms to time of first diagnosis was 1, 0.4 and 0.3 years for the 1-4, 5-9 and 10-14 age group respectively. However, there was no delay in the 15-19 group. The prevalence of asthma in Prince Edward Island (17.9%), Halifax (17.1%), and Kingston (16.1%) was higher than that in Saskatoon (10.0%). Sherbrooke (9.7%) and Kelowna (11.9%). The proportion of asthma for students who smoked more than 11 cigarettes per day (OR = 1.41), were exposed to passive smoke in home (OR = 7.29), in car (OR = 4.71), and in school (OR = 4.24) or had a family income less than CAN$40,000 (OR = 1.19), was significantly higher than groups without those factors. Risk factors and socio-economic status such as living conditions and environment, pets or plants in the home, parental education levels also affected the morbidity of asthma. The results of the SLHS study demonstrated the serious burden of childhood asthma, and asthma triggers, living and environmental conditions and lifestyle influence the prevalence and the effects of childhood asthma diagnosis, treatment, and education in Canada. Asthma is still a serious chronic condition for students and it influences their academic performance and their quality of life. The diagnostic methods and the practice guidelines for asthma control are useful for preventing and controlling asthma. These findings provide indications of interventions are being used for the control of asthma in Canada.

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