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Jackson DJ, Bacharier LB, Mauger DT, Boehmer S, Beigelman A, Chmiel JF, Fitzpatrick AM, Gaffin JM, Morgan WJ, Peters SP, Phipatanakul W, Sheehan WJ, Cabana MD, Holguin F, Martinez FD, Pongracic JA, Baxi SN, Benson M, Blake K, Covar R, Gentile DA, Israel E, Krishnan JA, Kumar HV, Lang JE, Lazarus SC, Lima JJ, Long D, Ly N, Marbin J, Moy JN, Myers RE, Olin JT, Raissy HH, Robison RG, Ross K, Sorkness CA, Lemanske RF. Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations. N Engl J Med 2018; 378:891-901. [PMID: 29504498 PMCID: PMC5972517 DOI: 10.1056/nejmoa1710988] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Asthma exacerbations occur frequently despite the regular use of asthma-controller therapies, such as inhaled glucocorticoids. Clinicians commonly increase the doses of inhaled glucocorticoids at early signs of loss of asthma control. However, data on the safety and efficacy of this strategy in children are limited. METHODS We studied 254 children, 5 to 11 years of age, who had mild-to-moderate persistent asthma and had had at least one asthma exacerbation treated with systemic glucocorticoids in the previous year. Children were treated for 48 weeks with maintenance low-dose inhaled glucocorticoids (fluticasone propionate at a dose of 44 μg per inhalation, two inhalations twice daily) and were randomly assigned to either continue the same dose (low-dose group) or use a quintupled dose (high-dose group; fluticasone at a dose of 220 μg per inhalation, two inhalations twice daily) for 7 days at the early signs of loss of asthma control ("yellow zone"). Treatment was provided in a double-blind fashion. The primary outcome was the rate of severe asthma exacerbations treated with systemic glucocorticoids. RESULTS The rate of severe asthma exacerbations treated with systemic glucocorticoids did not differ significantly between groups (0.48 exacerbations per year in the high-dose group and 0.37 exacerbations per year in the low-dose group; relative rate, 1.3; 95% confidence interval, 0.8 to 2.1; P=0.30). The time to the first exacerbation, the rate of treatment failure, symptom scores, and albuterol use during yellow-zone episodes did not differ significantly between groups. The total glucocorticoid exposure was 16% higher in the high-dose group than in the low-dose group. The difference in linear growth between the high-dose group and the low-dose group was -0.23 cm per year (P=0.06). CONCLUSIONS In children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129 .).
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Lai PS, Kolde R, Franzosa EA, Gaffin JM, Baxi SN, Sheehan WJ, Gold DR, Gevers D, Xavier RJ, Phipatanakul W. The classroom microbiome and asthma morbidity in children attending 3 inner-city schools. J Allergy Clin Immunol 2018. [PMID: 29518428 DOI: 10.1016/j.jaci.2018.02.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dilley MA, Petty CR, Sheehan WJ, Gaffin JM, Hauptman M, Phipatanakul W. Adherence and stress in a population of inner-city children with asthma. Pediatr Allergy Immunol 2017; 28:610-612. [PMID: 28686791 PMCID: PMC5585050 DOI: 10.1111/pai.12756] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Gaffin JM, Petty CR, Hauptman M, Kang CM, Wolfson JM, Awad YA, Di Q, Lai PS, Sheehan WJ, Baxi S, Coull BA, Schwartz JD, Gold DR, Koutrakis P, Phipatanakul W. Modeling indoor particulate exposures in inner-city school classrooms. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2017; 27:451-457. [PMID: 27599884 PMCID: PMC5340641 DOI: 10.1038/jes.2016.52] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 04/09/2016] [Indexed: 05/24/2023]
Abstract
Outdoor air pollution penetrates buildings and contributes to total indoor exposures. We investigated the relationship of indoor to outdoor particulate matter in inner-city school classrooms. The School Inner City Asthma Study investigates the effect of classroom-based environmental exposures on students with asthma in the northeast United States. Mixed effects linear models were used to determine the relationships between indoor PM2.5 (particulate matter) and black carbon (BC), and their corresponding outdoor concentrations, and to develop a model for predicting exposures to these pollutants. The indoor-outdoor sulfur ratio was used as an infiltration factor of outdoor fine particles. Weeklong concentrations of PM2.5 and BC in 199 samples from 136 classrooms (30 school buildings) were compared with those measured at a central monitoring site averaged over the same timeframe. Mixed effects regression models found significant random intercept and slope effects, which indicate that: (1) there are important PM2.5 sources in classrooms; (2) the penetration of outdoor PM2.5 particles varies by school and (3) the site-specific outside PM2.5 levels (inferred by the models) differ from those observed at the central monitor site. Similar results were found for BC except for lack of indoor sources. The fitted predictions from the sulfur-adjusted models were moderately predictive of observed indoor pollutant levels (out of sample correlations: PM2.5: r2=0.68, BC; r2=0.61). Our results suggest that PM2.5 has important classroom sources, which vary by school. Furthermore, using these mixed effects models, classroom exposures can be accurately predicted for dates when central site measures are available but indoor measures are not available.
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Phipatanakul W, Koutrakis P, Coull BA, Kang CM, Wolfson JM, Ferguson ST, Petty CR, Samnaliev M, Cunningham A, Sheehan WJ, Gaffin JM, Baxi SN, Lai PS, Permaul P, Liang L, Thorne PS, Adamkiewicz G, Brennan KJ, Baccarelli AA, Gold DR. The School Inner-City Asthma Intervention Study: Design, rationale, methods, and lessons learned. Contemp Clin Trials 2017; 60:14-23. [PMID: 28619649 DOI: 10.1016/j.cct.2017.06.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/31/2017] [Accepted: 06/10/2017] [Indexed: 02/08/2023]
Abstract
Asthma is the most common chronic disease of childhood in the United States, causes significant morbidity, particularly in the inner-city, and accounts for billions of dollars in health care utilization. Home environments are established sources of exposure that exacerbate symptoms and home-based interventions are effective. However, elementary school children spend 7 to 12h a day in school, primarily in one classroom. From the observational School Inner-City Asthma Study we learned that student classroom-specific exposures are associated with worsening asthma symptoms and decline in lung function. We now embark on a randomized, blinded, sham-controlled school environmental intervention trial, built on our extensively established school/community partnerships, to determine the efficacy of a school-based intervention to improve asthma control. This factorial school/classroom based environmental intervention will plan to enroll 300 students with asthma from multiple classrooms in 40 northeastern inner-city elementary schools. Schools will be randomized to receive either integrated pest management versus control and classrooms within these schools to receive either air purifiers or sham control. The primary outcome is asthma symptoms during the school year. This study is an unprecedented opportunity to test whether a community of children can benefit from school or classroom environmental interventions. If effective, this will have great impact as an efficient, cost-effective intervention for inner city children with asthma and may have broad public policy implications.
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Phipatanakul W, Mauger DT, Sorkness RL, Gaffin JM, Holguin F, Woodruff PG, Ly NP, Bacharier LB, Bhakta NR, Moore WC, Bleecker ER, Hastie AT, Meyers DA, Castro M, Fahy JV, Fitzpatrick AM, Gaston BM, Jarjour NN, Levy BD, Peters SP, Teague WG, Fajt M, Wenzel SE, Erzurum SC, Israel E. Effects of Age and Disease Severity on Systemic Corticosteroid Responses in Asthma. Am J Respir Crit Care Med 2017; 195:1439-1448. [PMID: 27967215 PMCID: PMC5470749 DOI: 10.1164/rccm.201607-1453oc] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/13/2016] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Phenotypic distinctions between severe asthma (SA) and nonsevere asthma (NONSA) may be confounded by differential adherence or incorrect use of corticosteroids. OBJECTIVES To determine if there are persistent phenotypic distinctions between SA (as defined by 2014 American Thoracic Society/European Respiratory Society guidelines) and NONSA after intramuscular triamcinolone acetonide (TA), and to identify predictors of a corticosteroid response in these populations. METHODS A total of 526 adults age 18 years and older (315 SA) and 188 children age 6 to less than 18 years (107 SA) in the NHLBI Severe Asthma Research Program III were characterized before and 3 weeks after TA. The primary outcome for corticosteroid response was defined as greater than or equal to 10-point improvement in percent predicted FEV1. MEASUREMENTS AND MAIN RESULTS Adult asthma groups exhibited a small but significant mean FEV1% predicted improvement after TA (SA group mean difference, 3.4%; 95% confidence interval, 2.2-4.7%; P = 0.001), whereas children did not. Adult SA continued to manifest lower FEV1 and worse asthma control as compared with NONSA after TA. In children, after TA only prebronchodilator FEV1 distinguished SA from NONSA. A total of 21% of adults with SA and 20% of children with SA achieved greater than or equal to 10% improvement after TA. Baseline bronchodilator response and fractional exhaled nitric oxide had good sensitivity and specificity for predicting response in all groups except children with NONSA. CONCLUSIONS One in five patients with SA exhibit greater than or equal to 10% improvement in FEV1 with parenteral corticosteroid. Those likely to respond had greater bronchodilator responsiveness and fractional exhaled nitric oxide levels. In adults, differences in airflow obstruction and symptoms between SA and NONSA persist after parenteral corticosteroids, suggesting a component of corticosteroid nonresponsive pathobiology in adults with SA that may differ in children. Clinical trial registered with www.clinicaltrials.gov (NCT 01606826).
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Greenberg J, Prushinskaya O, Harris JD, Guidetti-Myers G, Steiding J, Sawicki GS, Gaffin JM. Utilization of a patient-centered asthma passport tool in a subspecialty clinic. J Asthma 2017; 55:180-187. [PMID: 28548904 DOI: 10.1080/02770903.2017.1323916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Despite available and effective tools for asthma self-assessment (Asthma Control Test, ACT) and self-management (Asthma Action Plan, AAP), they are underutilized in outpatient specialty clinics. We evaluated the impact of a patient-centered checklist, the Asthma Passport, on improving ACT and AAP utilization in clinic. METHODS This was a randomized, interventional quality-improvement project in which the Asthma Passport was distributed to 120 pediatric asthma patients over the duration of 16 weeks. The passport's checklist consisted of tasks to be completed by the patient/family, including completion of the ACT and AAP. We compared rates of completion of the ACT and AAP for those who received the passport versus the control group, and assessed patient/caregiver and provider satisfaction. RESULTS Based on electronic medical record data from 222 participants, the ACT completion rate was not significantly different between the passport and control groups, however, the AAP completion rate was significantly greater than control (30.0% vs. 17.7%, p = 0.04). When per-protocol analysis was limited to groups who completed and returned their passports, ACT and AAP completion rates were significantly greater than control (73.8% vs. 44.1% (p = 0.002) and 35.7% vs. 17.7% (p = 0.04), respectively). Nearly all participants reported high satisfaction with care, and surveyed providers viewed the passport favorably. CONCLUSIONS A patient-centered checklist significantly improved the completion rate of the AAP. For patient's who completed and returned the asthma passport, the ACT completion rate was also improved. Participants and providers reported high satisfaction with the checklist, suggesting that it can effectively promote asthma self-management and self-assessment without burdening clinicians or clinic workflow.
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Kopel LS, Petty CR, Gaffin JM, Sheehan WJ, Baxi SN, Kanchongkittiphon W, Fu C, Gold DR, Phipatanakul W. Caregiver stress among inner-city school children with asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1132-1134.e3. [PMID: 28433340 DOI: 10.1016/j.jaip.2017.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 02/03/2017] [Accepted: 02/21/2017] [Indexed: 10/19/2022]
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Gaffin JM, Hauptman M, Lai P, Petty CR, Wolfson JM, Kang CM, Sheehan WJ, Baxi SN, Bartnikas LM, Permaul P, Gold DR, Coull B, Koutrakis P, Phipatanakul W. Nitrogen Dioxide Exposure in School Classrooms Is Associated with Airflow Obstruction in Students with Asthma. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.570] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dilley MA, Sheehan WJ, Gaffin JM, Petty CR, Phipatanakul W. Adherence to Asthma Medications in a Population of Inner-City Children with Asthma. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sheehan WJ, Permaul P, Petty CR, Coull BA, Baxi SN, Gaffin JM, Lai PS, Gold DR, Phipatanakul W. Association Between Allergen Exposure in Inner-City Schools and Asthma Morbidity Among Students. JAMA Pediatr 2017; 171:31-38. [PMID: 27893060 PMCID: PMC5349325 DOI: 10.1001/jamapediatrics.2016.2543] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Home aeroallergen exposure is associated with increased asthma morbidity in children, yet little is known about the contribution of school aeroallergen exposures to such morbidity. OBJECTIVE To evaluate the effect of school-specific aeroallergen exposures on asthma morbidity among students, adjusting for home exposures. DESIGN, SETTING, AND PARTICIPANTS The School Inner-City Asthma Study was a prospective cohort study evaluating 284 students aged 4 to 13 years with asthma who were enrolled from 37 inner-city elementary schools in the northeastern United States between March 1, 2008, and August 31, 2013. Enrolled students underwent baseline clinical evaluations before the school year started and were then observed clinically for 1 year. During that same school year, classroom and home dust samples linked to the students were collected and analyzed for common indoor aeroallergens. Associations between school aeroallergen exposure and asthma outcomes during the school year were assessed, adjusting for home exposures. EXPOSURES Indoor aeroallergens, including rat, mouse, cockroach, cat, dog, and dust mites, measured in dust samples collected from inner-city schools. MAIN OUTCOMES AND MEASURES The primary outcome was maximum days in the past 2 weeks with asthma symptoms. Secondary outcomes included well-established markers of asthma morbidity, including asthma-associated health care use and lung function, measured by forced expiratory volume in 1 second. RESULTS Among 284 students (median age, 8 years [interquartile range, 6-9 years]; 148 boys and 136 girls), exposure to mouse allergen was detected in 441 (99.5%) of 443 school dust samples, cat allergen in 420 samples (94.8%), and dog allergen in 366 samples (82.6%). Levels of mouse allergen in schools were significantly higher than in students' homes (median settled dust level, 0.90 vs 0.14 µg/g; P < .001). Exposure to higher levels of mouse allergen in school (comparing 75th with 25th percentile) was associated with increased odds of having an asthma symptom day (odds ratio, 1.27; 95% CI, 1.05-1.54; P = .02) and 4.0 percentage points lower predicted forced expiratory volume in 1 second (95% CI, -6.6 to -1.5; P = .002). This effect was independent of allergic sensitization. None of the other indoor aeroallergens were associated with worsening asthma outcomes. CONCLUSIONS AND RELEVANCE In this study of inner-city students with asthma, exposure to mouse allergen in schools was associated with increased asthma symptoms and decreased lung function. These findings demonstrate that the school environment is an important contributor to childhood asthma morbidity. Future school-based environmental interventions may be beneficial for this important public health problem.
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Jhun I, Gaffin JM, Coull BA, Huffaker MF, Petty CR, Sheehan WJ, Baxi SN, Lai PS, Kang CM, Wolfson JM, Gold DR, Koutrakis P, Phipatanakul W. School Environmental Intervention to Reduce Particulate Pollutant Exposures for Children with Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:154-159.e3. [PMID: 27641483 PMCID: PMC5222771 DOI: 10.1016/j.jaip.2016.07.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/29/2016] [Accepted: 07/25/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Home-based interventions to improve indoor air quality have demonstrated benefits for asthma morbidity, yet little is known about the effect of environmental interventions in the school setting. OBJECTIVE We piloted the feasibility and effectiveness of a classroom-based air cleaner intervention to reduce particulate pollutants in classrooms of children with asthma. METHODS In this pilot randomized controlled trial, we assessed the effect of air cleaners on indoor air particulate pollutant concentrations in 18 classrooms (9 control, 9 intervention) in 3 urban elementary schools. We enrolled 25 children with asthma (13 control, 12 intervention) aged 6 to 10 years. Classroom air pollutant measurements and spirometry were completed once before and twice after randomization. Asthma symptoms were surveyed every 3 months. RESULTS Baseline classroom levels of fine particulate matter (particulate matter with diameter of <2.5 μm [PM2.5]) and black carbon (BC) were 6.3 and 0.41 μg/m3, respectively. When comparing the intervention to the control group, classroom PM2.5 levels were reduced by 49% and 42% and BC levels were reduced by 58% and 55% in the first and second follow-up periods, respectively (P < .05 for all comparisons). When comparing the children randomized to intervention and control classrooms, there was a modest improvement in peak flow, but no significant changes in forced expiratory volume in 1 second (FEV1) and asthma symptoms. CONCLUSIONS In this pilot study, a classroom-based air cleaner intervention led to significant reductions in PM2.5 and BC. Future large-scale studies should comprehensively evaluate the effect of school-based environmental interventions on pediatric asthma morbidity.
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Dilley MA, Sheehan WJ, Petty CR, Gaffin JM, Hauptman M, Phipatanakul W. Comparison of treatment modalities for inpatient asthma exacerbations among US pediatric hospitals. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:855-857.e1. [PMID: 27888031 DOI: 10.1016/j.jaip.2016.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/04/2016] [Accepted: 10/07/2016] [Indexed: 01/14/2023]
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Sheehan WJ, Mauger DT, Paul IM, Moy JN, Boehmer SJ, Szefler SJ, Fitzpatrick AM, Jackson DJ, Bacharier LB, Cabana MD, Covar R, Holguin F, Lemanske RF, Martinez FD, Pongracic JA, Beigelman A, Baxi SN, Benson M, Blake K, Chmiel JF, Daines CL, Daines MO, Gaffin JM, Gentile DA, Gower WA, Israel E, Kumar HV, Lang JE, Lazarus SC, Lima JJ, Ly N, Marbin J, Morgan WJ, Myers RE, Olin JT, Peters SP, Raissy HH, Robison RG, Ross K, Sorkness CA, Thyne SM, Wechsler ME, Phipatanakul W. Acetaminophen versus Ibuprofen in Young Children with Mild Persistent Asthma. N Engl J Med 2016; 375:619-30. [PMID: 27532828 PMCID: PMC5085065 DOI: 10.1056/nejmoa1515990] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies have suggested an association between frequent acetaminophen use and asthma-related complications among children, leading some physicians to recommend that acetaminophen be avoided in children with asthma; however, appropriately designed trials evaluating this association in children are lacking. METHODS In a multicenter, prospective, randomized, double-blind, parallel-group trial, we enrolled 300 children (age range, 12 to 59 months) with mild persistent asthma and assigned them to receive either acetaminophen or ibuprofen when needed for the alleviation of fever or pain over the course of 48 weeks. The primary outcome was the number of asthma exacerbations that led to treatment with systemic glucocorticoids. Children in both groups received standardized asthma-controller therapies that were used in a simultaneous, factorially linked trial. RESULTS Participants received a median of 5.5 doses (interquartile range, 1.0 to 15.0) of trial medication; there was no significant between-group difference in the median number of doses received (P=0.47). The number of asthma exacerbations did not differ significantly between the two groups, with a mean of 0.81 per participant with acetaminophen and 0.87 per participant with ibuprofen over 46 weeks of follow-up (relative rate of asthma exacerbations in the acetaminophen group vs. the ibuprofen group, 0.94; 95% confidence interval, 0.69 to 1.28; P=0.67). In the acetaminophen group, 49% of participants had at least one asthma exacerbation and 21% had at least two, as compared with 47% and 24%, respectively, in the ibuprofen group. Similarly, no significant differences were detected between acetaminophen and ibuprofen with respect to the percentage of asthma-control days (85.8% and 86.8%, respectively; P=0.50), use of an albuterol rescue inhaler (2.8 and 3.0 inhalations per week, respectively; P=0.69), unscheduled health care utilization for asthma (0.75 and 0.76 episodes per participant, respectively; P=0.94), or adverse events. CONCLUSIONS Among young children with mild persistent asthma, as-needed use of acetaminophen was not shown to be associated with a higher incidence of asthma exacerbations or worse asthma control than was as-needed use of ibuprofen. (Funded by the National Institutes of Health; AVICA ClinicalTrials.gov number, NCT01606319.).
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Gaffin JM, Zhou JS, Cai Q, Petty CR, Fu C, Sheehan WJ, Baxi S, Bailey A, Gold DR, Phipatanakul W. Utility of a portable hand-held forced expiratory volume in 1 second meter for monitoring asthma in an inner-city school setting. Ann Allergy Asthma Immunol 2016; 117:323-4. [PMID: 27424126 DOI: 10.1016/j.anai.2016.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/15/2016] [Accepted: 06/19/2016] [Indexed: 10/21/2022]
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Kanchongkittiphon W, Gaffin JM, Kopel L, Petty CR, Bollinger ME, Miller RL, Perzanowski M, Matsui EC, Phipatanakul W. Association of FEF25%-75% and bronchodilator reversibility with asthma control and asthma morbidity in inner-city children with asthma. Ann Allergy Asthma Immunol 2016; 117:97-9. [PMID: 27236218 DOI: 10.1016/j.anai.2016.04.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/24/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
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Levy S, Dedeoglu F, Gaffin JM, Garvey KC, Harstad E, MacGinnitie A, Rufo PA, Huang Q, Ziemnik RE, Wisk LE, Weitzman ER. A Screening Tool for Assessing Alcohol Use Risk among Medically Vulnerable Youth. PLoS One 2016; 11:e0156240. [PMID: 27227975 PMCID: PMC4882018 DOI: 10.1371/journal.pone.0156240] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 05/11/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND In an effort to reduce barriers to screening for alcohol use in pediatric primary care, the National Institute on Alcoholism and Alcohol Abuse (NIAAA) developed a two-question Youth Alcohol Screening Tool derived from population-based survey data. It is unknown whether this screening tool, designed for use with general populations, accurately identifies risk among youth with chronic medical conditions (YCMC). This growing population, which comprises nearly one in four youth in the US, faces a unique constellation of drinking-related risks. METHOD To validate the NIAAA Youth Alcohol Screening Tool in a population of YCMC, we performed a cross-sectional validation study with a sample of 388 youth ages 9-18 years presenting for routine subspecialty care at a large children's hospital for type 1 diabetes, persistent asthma, cystic fibrosis, inflammatory bowel disease, or juvenile idiopathic arthritis. Participants self-administered the NIAAA Youth Alcohol Screening Tool and the Diagnostic Interview Schedule for Children as a criterion standard measure of alcohol use disorders (AUD). Receiver operating curve analysis was used to determine cut points for identifying youth at moderate and highest risk for an AUD. RESULTS Nearly one third of participants (n = 118; 30.4%) reported alcohol use in the past year; 86.4% (106) of past year drinkers did not endorse any AUD criteria, 6.8% (n = 8) of drinkers endorsed a single criterion, and 6.8% of drinkers met criteria for an AUD. Using the NIAAA tool, optimal cut points found to identify youth at moderate and highest risk for an AUD were ≥ 6 and ≥12 drinking days in the past year, respectively. CONCLUSIONS The NIAAA Youth Alcohol Screening Tool is highly efficient for detecting alcohol use and discriminating disordered use among YCMC. This brief screen appears feasible for use in specialty care to ascertain alcohol-related risk that may impact adversely on health status and disease management.
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Lai PS, Sheehan WJ, Gaffin JM, Petty CR, Coull BA, Gold DR, Phipatanakul W. School Endotoxin Exposure and Asthma Morbidity in Inner-city Children. Chest 2016; 148:1251-1258. [PMID: 26087201 DOI: 10.1378/chest.15-0098] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Endotoxin exposure is associated with airway inflammation. Children spend 6 to 8 h/d in school, yet the effect of school-specific endotoxin exposure on asthma morbidity is not well understood. METHODS In this longitudinal cohort study, 248 students with asthma, from 38 inner-city schools, underwent baseline phenotyping and follow-up. Clinical outcomes were evaluated throughout the academic school year and linked to classroom-specific dust and air endotoxin levels as well as home dust endotoxin levels. The primary outcome was maximum asthma symptom-days per 2-week period. RESULTS Classrooms had higher settled dust endotoxin levels compared with homes (14.3 endotoxin unit/mg vs 11.3 endotoxin unit/mg; P = .02). Airborne endotoxin levels exceeding recommended occupational exposure limits for adults were recorded in 22.0% of classrooms. Classroom air endotoxin levels were independently associated with increased maximum symptom-days in children with nonatopic asthma, but not in those with atopic asthma (interaction P = .03). Adjusting for home exposures, classroom endotoxin exposure was independently associated with a dose-dependent increase in asthma symptom-days for children with nonatopic asthma (adjusted incidence rate ratio, 1.16 [95% CI, 1.03-1.31]; P = .02). In these subjects, maximum symptom-days increased by 1.3 days for each 14-day period when comparing students in classrooms with the lowest endotoxin levels compared with average measured levels. CONCLUSIONS Inner-city children with asthma are exposed to high levels of airborne endotoxin at school, resulting in increased asthma symptoms in children with nonatopic asthma. Mitigation of school-related exposures may represent a strategy to decrease asthma morbidity in this population. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01756391; URL: www.clinicaltrials.gov.
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Gaffin JM. Postnatal environmental tobacco smoke exposure is associated with objective markers of atopy in preschool-aged children. EVIDENCE-BASED MEDICINE 2015; 20:219. [PMID: 26374387 PMCID: PMC4886653 DOI: 10.1136/ebmed-2014-110134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Bacharier LB, Guilbert TW, Mauger DT, Boehmer S, Beigelman A, Fitzpatrick AM, Jackson DJ, Baxi SN, Benson M, Burnham CAD, Cabana M, Castro M, Chmiel JF, Covar R, Daines M, Gaffin JM, Gentile DA, Holguin F, Israel E, Kelly HW, Lazarus SC, Lemanske RF, Ly N, Meade K, Morgan W, Moy J, Olin T, Peters SP, Phipatanakul W, Pongracic JA, Raissy HH, Ross K, Sheehan WJ, Sorkness C, Szefler SJ, Teague WG, Thyne S, Martinez FD. Early Administration of Azithromycin and Prevention of Severe Lower Respiratory Tract Illnesses in Preschool Children With a History of Such Illnesses: A Randomized Clinical Trial. JAMA 2015; 314:2034-2044. [PMID: 26575060 PMCID: PMC4757487 DOI: 10.1001/jama.2015.13896] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Many preschool children develop recurrent, severe episodes of lower respiratory tract illness (LRTI). Although viral infections are often present, bacteria may also contribute to illness pathogenesis. Strategies that effectively attenuate such episodes are needed. OBJECTIVE To evaluate if early administration of azithromycin, started prior to the onset of severe LRTI symptoms, in preschool children with recurrent severe LRTIs can prevent the progression of these episodes. DESIGN, SETTING, AND PARTICIPANTS A randomized, double-blind, placebo-controlled, parallel-group trial conducted across 9 academic US medical centers in the National Heart, Lung, and Blood Institute's AsthmaNet network, with enrollment starting in April 2011 and follow-up complete by December 2014. Participants were 607 children aged 12 through 71 months with histories of recurrent, severe LRTIs and minimal day-to-day impairment. INTERVENTION Participants were randomly assigned to receive azithromycin (12 mg/kg/d for 5 days; n = 307) or matching placebo (n = 300), started early during each predefined RTI (child's signs or symptoms prior to development of LRTI), based on individualized action plans, over a 12- through 18-month period. MAIN OUTCOMES AND MEASURES The primary outcome measure was the number of RTIs not progressing to a severe LRTI, measured at the level of the RTI, that would in clinical practice trigger the prescription of oral corticosteroids. Presence of azithromycin-resistant organisms in oropharyngeal samples, along with adverse events, were among the secondary outcome measures. RESULTS A total of 937 treated RTIs (azithromycin group, 473; placebo group, 464) were experienced by 443 children (azithromycin group, 223; placebo group, 220), including 92 severe LRTIs (azithromycin group, 35; placebo group, 57). Azithromycin significantly reduced the risk of progressing to severe LRTI relative to placebo (hazard ratio, 0.64 [95% CI, 0.41-0.98], P = .04; absolute risk for first RTI: 0.05 for azithromycin, 0.08 for placebo; risk difference, 0.03 [95% CI, 0.00-0.06]). Induction of azithromycin-resistant organisms and adverse events were infrequently observed. CONCLUSIONS AND RELEVANCE Among young children with histories of recurrent severe LRTIs, the use of azithromycin early during an apparent RTI compared with placebo reduced the likelihood of severe LRTI. More information is needed on the development of antibiotic-resistant pathogens with this strategy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01272635.
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Gaffin JM, Landrum A, Petty CR, Baxi S, Sheehan WJ, Phipatanakul W. Black and Hispanic perceptions of asthma medication in the School Inner-City Asthma Study. Ann Allergy Asthma Immunol 2015; 114:533-4. [PMID: 25868711 PMCID: PMC4449786 DOI: 10.1016/j.anai.2015.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/22/2015] [Indexed: 10/23/2022]
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Rao DR, Sordillo JE, Kopel LS, Gaffin JM, Sheehan WJ, Hoffman E, Ozonoff A, Gold DR, Phipatanakul W. Association between allergic sensitization and exhaled nitric oxide in children in the School Inner-City Asthma Study. Ann Allergy Asthma Immunol 2015; 114:256-257.e1. [PMID: 25595887 DOI: 10.1016/j.anai.2014.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 11/04/2014] [Accepted: 12/08/2014] [Indexed: 11/20/2022]
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Friedlander JL, Sheehan WJ, Baxi SN, Kopel LS, Gaffin JM, Ozonoff A, Fu C, Gold DR, Phipatanakul W. Food allergy and increased asthma morbidity in a School-based Inner-City Asthma Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 1:479-84. [PMID: 24058900 DOI: 10.1016/j.jaip.2013.06.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Children with asthma have increased prevalence of food allergies. The relationship between food allergy and asthma morbidity is unclear. OBJECTIVE We aimed to investigate the presence of food allergy as an independent risk factor for increased asthma morbidity by using the School Inner-City Asthma Study, a prospective study that evaluates risk factors and asthma morbidity among urban children. METHODS We prospectively surveyed, from inner-city schools, 300 children with physician-diagnosed asthma, followed by clinical evaluation. Food allergies were reported, which included symptoms experienced within 1 hour of food ingestion. Asthma morbidity, pulmonary function, and resource utilization were compared between children with food allergies and those without. RESULTS Seventy-three of 300 children with asthma (24%) surveyed had physician-diagnosed food allergy, and 36 (12%) had multiple food allergies. Those with any food allergy independently had increased risk of hospitalization (OR [odds ratio] 2.35 [95% CI, 1.30-4.24]; P = .005) and use of controller medication (OR 1.99 [95% CI, 1.06-3.74]; P = .03). Those with multiple food allergies also had an independently higher risk of hospitalization in the past year (OR 4.10 [95% CI, 1.47-11.45]; P = .007), asthma-related hospitalization (OR 3.52 [95% CI, 1.12-11.03]; P = .03), controller medication use (OR 2.38 [95% CI, 1.00-5.66]; P = .05), and more provider visits (median, 4.5 vs 3.0; P = .008). Furthermore, lung function was significantly lower (percent predicted FEV1 and FEV1/FVC ratios) in both food allergy category groups. CONCLUSIONS Food allergy is highly prevalent in inner-city school-aged children with asthma. Children with food allergies have increased asthma morbidity and health resource utilization with decreased lung function, and this association is stronger in those with multiple food allergies.
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Kanchongkittiphon W, Mendell MJ, Gaffin JM, Wang G, Phipatanakul W. Indoor environmental exposures and exacerbation of asthma: an update to the 2000 review by the Institute of Medicine. ENVIRONMENTAL HEALTH PERSPECTIVES 2015; 123:6-20. [PMID: 25303775 PMCID: PMC4286274 DOI: 10.1289/ehp.1307922] [Citation(s) in RCA: 240] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 10/09/2014] [Indexed: 05/18/2023]
Abstract
BACKGROUND Previous research has found relationships between specific indoor environmental exposures and exacerbation of asthma. OBJECTIVES In this review we provide an updated summary of knowledge from the scientific literature on indoor exposures and exacerbation of asthma. METHODS Peer-reviewed articles published from 2000 to 2013 on indoor exposures and exacerbation of asthma were identified through PubMed, from reference lists, and from authors' files. Articles that focused on modifiable indoor exposures in relation to frequency or severity of exacerbation of asthma were selected for review. Research findings were reviewed and summarized with consideration of the strength of the evidence. RESULTS Sixty-nine eligible articles were included. Major changed conclusions include a causal relationship with exacerbation for indoor dampness or dampness-related agents (in children); associations with exacerbation for dampness or dampness-related agents (in adults), endotoxin, and environmental tobacco smoke (in preschool children); and limited or suggestive evidence for association with exacerbation for indoor culturable Penicillium or total fungi, nitrogen dioxide, rodents (nonoccupational), feather/down pillows (protective relative to synthetic bedding), and (regardless of specific sensitization) dust mite, cockroach, dog, and dampness-related agents. DISCUSSION This review, incorporating evidence reported since 2000, increases the strength of evidence linking many indoor factors to the exacerbation of asthma. Conclusions should be considered provisional until all available evidence is examined more thoroughly. CONCLUSION Multiple indoor exposures, especially dampness-related agents, merit increased attention to prevent exacerbation of asthma, possibly even in nonsensitized individuals. Additional research to establish causality and evaluate interventions is needed for these and other indoor exposures.
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Kopel LS, Gaffin JM, Ozonoff A, Rao DR, Sheehan WJ, Friedlander JL, Permaul P, Baxi SN, Fu C, Subramanian SV, Gold DR, Phipatanakul W. Perceived neighborhood safety and asthma morbidity in the school inner-city asthma study. Pediatr Pulmonol 2015; 50:17-24. [PMID: 24421055 PMCID: PMC4096619 DOI: 10.1002/ppul.22986] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 12/11/2013] [Indexed: 11/09/2022]
Abstract
AIM The aim of this study was to investigate whether neighborhood safety as perceived by primary caregivers is associated with asthma morbidity outcomes among inner-city school children with asthma. METHODS School children with asthma were recruited from 25 inner-city schools between 2009 and 2012 for the School Inner-City Asthma Study (N = 219). Primary caregivers completed a baseline questionnaire detailing their perception of neighborhood safety and their children's asthma symptoms, and the children performed baseline pulmonary function tests. In this cross-sectional analysis, asthma control was compared between children whose caregivers perceived their neighborhood to be unsafe versus safe. RESULTS After adjusting for potential confounders, those children whose primary caregivers perceived the neighborhood to be unsafe had twice the odds of having poorly controlled asthma (odds ratio [OR] adjusted = 2.2, 95% confidence interval [CI] = 1.2-3.9, P = 0.009), four times the odds of dyspnea and rescue medication use (OR adjusted = 4.7; 95% CI = 1.7-13.0, P = 0.003, OR adjusted = 4.0; 95% CI = 1.8-8.8, P < 0.001, respectively), three times as much limitation in activity (OR adjusted = 3.2; 95% CI = 1.4-7.7, P = 0.008), and more than twice the odds of night-time symptoms (OR adjusted = 2.2; 95% CI = 1.3-4.0, P = 0.007) compared to participants living in safe neighborhoods. There was no difference in pulmonary function test results between the two groups. CONCLUSIONS Primary caregivers' perception of neighborhood safety is associated with childhood asthma morbidity among inner-city school children with asthma. Further study is needed to elucidate mechanisms behind this association, and future intervention studies to address social disadvantage may be important.
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Gaffin JM, Kanchongkittiphon W, Phipatanakul W. Reprint of: Perinatal and early childhood environmental factors influencing allergic asthma immunopathogenesis. Int Immunopharmacol 2014; 23:337-46. [PMID: 25308874 DOI: 10.1016/j.intimp.2014.09.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/03/2014] [Accepted: 06/03/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND The prevalence of asthma has increased dramatically over the past several decades. While hereditary factors are highly important, the rapid rise outstrips the pace of genomic variation. Great emphasis has been placed on potential modifiable early life exposures leading to childhood asthma. METHODS We reviewed the recent medical literature for important studies discussing the role of the perinatal and early childhood exposures and the inception of childhood asthma. RESULTS AND DISCUSSION Early life exposure to allergens (house dust mite (HDM), furred pets, cockroach, rodent and mold), air pollution (nitrogen dioxide (NO2), ozone (O3), volatile organic compounds (VOCs), and particulate matter (PM)) and viral respiratory tract infections (Respiratory syncytial virus (RSV) and human rhinovirus (hRV)) has been implicated in the development of asthma in high risk children. Conversely, exposure to microbial diversity in the perinatal period may diminish the development of atopy and asthma symptoms.
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Gaffin JM, Kanchongkittiphon W, Phipatanakul W. Perinatal and early childhood environmental factors influencing allergic asthma immunopathogenesis. Int Immunopharmacol 2014; 22:21-30. [PMID: 24952205 DOI: 10.1016/j.intimp.2014.06.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/03/2014] [Accepted: 06/03/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND The prevalence of asthma has increased dramatically over the past several decades. While hereditary factors are highly important, the rapid rise outstrips the pace of genomic variation. Great emphasis has been placed on potential modifiable early life exposures leading to childhood asthma. METHODS We reviewed the recent medical literature for important studies discussing the role of the perinatal and early childhood exposures and the inception of childhood asthma. RESULTS AND DISCUSSION Early life exposure to allergens (house dust mite (HDM), furred pets, cockroach, rodent and mold), air pollution (nitrogen dioxide (NO(2)), ozone (O(3)), volatile organic compounds (VOCs), and particulate matter (PM)) and viral respiratory tract infections (Respiratory syncytial virus (RSV) and human rhinovirus (hRV)) has been implicated in the development of asthma in high risk children. Conversely, exposure to microbial diversity in the perinatal period may diminish the development of atopy and asthma symptoms.
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Kanchongkittiphon W, Gaffin JM, Phipatanakul W. The indoor environment and inner-city childhood asthma. Asian Pac J Allergy Immunol 2014; 32:103-10. [PMID: 25003723 PMCID: PMC4110514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 03/21/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Exposure to indoor pollutants and allergens has been speculated to cause asthma symptoms and exacerbations and influence the risk of developing asthma. The aim of this article is to review the medical literature regarding the role of the indoor environment on inner-city childhood asthma. DATA SOURCES A literature search was performed in PubMed. Studies focusing on inner-city indoor allergen, childhood asthma, and environmental controls were included. RESULTS The prevalence of asthma in children is increasing especially in inner-city area. Exposure to high levels of indoor allergens and pollutants has been related to asthma development. Studies have shown that mouse, cockroach, pets, dust mite, mold, tobacco smoke, endotoxin and nitrogen dioxide are the important exposures. Recent studies have shown that indoor environmental control is beneficial in reducing asthma morbidity and development. CONCLUSIONS Inner-city children are exposed to various indoor allergens and pollutants that may lead to asthma development and exacerbation of existing asthma. Multifaceted environmental controls are beneficial in improving asthma symptom and maybe a viable prevention strategy. Further prospective studies of environmental intervention are needed to further identify effective strategies to improve and prevent asthma symptoms in inner-city children.
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Permaul P, Sheehan WJ, Petty C, Baxi SN, Gaffin JM, Kopel LS, Kanchongkittiphon W, Fu C, Gold DR, Phipatanakul W. Allergic Inflammation and Health Outcomes Of Comorbid Asthma and Obesity In Inner-City Black and Hispanic Schoolchildren. J Allergy Clin Immunol 2014. [DOI: 10.1016/j.jaci.2013.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kanchongkittiphon W, Gaffin JM, Kopel LS, Sheehan WJ, Baxi SN, Permaul P, Gold DR, Phipatanakul W. The Association Of Spirometry With Asthma Control and Asthma Morbidity In Inner City Schoolchildren With Asthma. J Allergy Clin Immunol 2014. [DOI: 10.1016/j.jaci.2013.12.861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gaffin JM, Phipatanakul W. Beta-2-Adrenergic Receptor Methylation Influences Asthma Phenotype in The School Inner City Asthma Study. ACTA ACUST UNITED AC 2014; 1. [PMID: 25590045 DOI: 10.14800/rci.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Asthma is the most common chronic illness of childhood and inner city residents suffer a disproportionately high rate of asthma diagnosis and asthma morbidity. The School Inner City Asthma Study investigates the school classroom based environmental exposures that may lead to asthma morbidity in inner city school children with asthma. Within this cohort, we investigated the role of methylation at the promoter region of the beta-2-adrenergic receptor in relation to asthma morbidity. We found that high levels of methylation in the region studied was significantly associated with decreased report of dyspnea and trended towards significance for lower levels of asthma symptoms and airway obstruction. This Research Highlight discusses the findings of the recent study and the investigators' active research endeavors.
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Gaffin JM, Raby BA, Petty CR, Hoffman EB, Baccarelli AA, Gold DR, Phipatanakul W. β-2 adrenergic receptor gene methylation is associated with decreased asthma severity in inner-city schoolchildren: asthma and rhinitis. Clin Exp Allergy 2014; 44:681-9. [PMID: 24131275 PMCID: PMC3989375 DOI: 10.1111/cea.12219] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 08/26/2013] [Accepted: 09/24/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND Genetic variation in the β-2 adrenergic receptor gene (ADRB2) has been implicated in asthma severity and control with conflicting results. Epigenetic variation in the ADRB2 may play an important role in asthma phenotype. OBJECTIVE We aimed to evaluate whether DNA methylation of ADRB2 is associated with asthma phenotypes in inner-city school-aged children. METHODS Multiple CpG sites in the promoter region of ADRB2 gene were analysed in 177 children enrolled in the School Inner-City Asthma Study. Blood- or saliva-derived DNA was measured by bisulphite-polymerase chain reaction pyrosequencing assay. Average percentage DNA methylation across the sites was evaluated for association with asthma severity (report of dyspnoea, night-time symptoms, rescue medication use, and baseline spirometry) and morbidity (school absences and unscheduled healthcare visits). Three clades composed of highly correlated methylation sites within the methylated segment of ADRB2 were further analysed. RESULTS Methylation of individual sites generally ranged from 0% to 6% with average percentage methylation across sites of 2.4%. Univariate analyses strongly favoured the association of higher percentage methylation with lower asthma severity measured by report of dyspnoea. Furthermore, there was a non-significant trend towards less rescue medication use, night-time symptoms, school absences, activity limitation due to asthma, and improved lung function measurements with increased methylation. Multivariate analysis demonstrated methylation of ADRB2 gene significantly associated with less dyspnoea (odds ratio (OR) 0.2, 95% confidence interval (CI), 0.1-0.6, P = 0.002). Each of the three clades of methylation sites showed a strong, but not statistically significant, effect on decreased dyspnoea. CONCLUSIONS AND CLINICAL RELEVANCE DNA methylation in the ADRB2 gene is associated with decreased asthma symptom severity, suggesting a role for methylation in asthma phenotypes.
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Gaffin JM, Bouzaher A, McCown M, Larabee Tuttle K, Israel E, Phipatanakul W. Rethinking the prevalence of exercise-induced bronchoconstriction in patients with asthma. Ann Allergy Asthma Immunol 2013; 111:567-8. [PMID: 24267370 DOI: 10.1016/j.anai.2013.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 09/27/2013] [Accepted: 10/10/2013] [Indexed: 11/18/2022]
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Permaul P, Sheehan WJ, Baxi SN, Gaffin JM, Fu C, Petty CR, Gold DR, Phipatanakul W. Predictors of indoor exposure to mouse allergen in inner-city elementary schools. Ann Allergy Asthma Immunol 2013; 111:299-301.e1. [PMID: 24054369 DOI: 10.1016/j.anai.2013.07.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/16/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
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Permaul P, Petty CR, Sheehan WJ, Baxi SN, Gaffin JM, Kopel LS, Kanchongkittiphan W, Bailey A, Fu C, Gold DR, Phipatanakul W. Mouse Allergen Exposure in Urban Schools and Its Effect On Childhood Asthma Morbidity. J Allergy Clin Immunol 2013. [DOI: 10.1016/j.jaci.2012.12.1167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Baxi SN, Petty CR, Fu C, Sheehan WJ, Permaul P, Kopel L, Kanchongkittiphon W, Gaffin JM, Rogers CA, Muilenberg ML, Gold DR, Phipatanakul W. Classroom Fungal Spore Exposure and Asthma Morbidity in Inner-City School Children. J Allergy Clin Immunol 2013. [DOI: 10.1016/j.jaci.2012.12.875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rao DR, Gaffin JM, Baxi SN, Sheehan WJ, Hoffman EB, Phipatanakul W. The utility of forced expiratory flow between 25% and 75% of vital capacity in predicting childhood asthma morbidity and severity. J Asthma 2012; 49:586-92. [PMID: 22742446 PMCID: PMC3398223 DOI: 10.3109/02770903.2012.690481] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The forced expiratory volume in 1 second (FEV(1)) felt to be an objective measure of airway obstruction is often normal in asthmatic children. The forced expiratory flow between 25% and 75% of vital capacity (FEF(25-75)) reflects small airway patency and has been found to be reduced in children with asthma. The aim of this study was to determine whether FEF(25-75) is associated with increased childhood asthma severity and morbidity in the setting of a normal FEV(1), and to determine whether bronchodilator responsiveness (BDR) as defined by FEF(25-75) identifies more childhood asthmatics than does BDR defined by FEV(1). METHODS The Boston Children's Hospital Pulmonary Function Test database was queried and the most recent spirometry result was retrieved for 744 children diagnosed with asthma between 10 and 18 years of age between October 2000 and October 2010. Electronic medical records in the 1 year prior and the 1 year following the date of spirometry were examined for asthma severity (mild, moderate, or severe) and morbidity outcomes for the three age, race, and gender-matched subgroups: Group A (n = 35) had a normal FEV(1), FEV(1)/forced vital capacity (FVC), and FEF(25-75); Group B (n = 36) had solely a diminished FEV(1)/FVC; and Group C (n = 37) had a normal FEV(1), low FEV(1)/FVC, and low FEF(25-75). Morbidity outcomes analyzed included the presence of hospitalization, emergency department visit, intensive care unit admission, asthma exacerbation, and systemic steroid use. RESULTS Subjects with a low FEF(25-75) (Group C) had nearly 3 times the odds ratio (OR) (OR = 2.8, p < .01) of systemic corticosteroid use and 6 times the OR of asthma exacerbations (OR = 6.3, p > .01) compared with those who had normal spirometry (Group A). Using FEF(25-75) to define BDR identified 53% more subjects with asthma than did using a definition based on FEV(1). CONCLUSIONS A low FEF(25-75) in the setting of a normal FEV(1) is associated with increased asthma severity, systemic steroid use, and asthma exacerbations in children. In addition, using the percent change in FEF(25-75) from baseline may be helpful in identifying BDR in asthmatic children with a normal FEV(1).
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Rork JF, Sheehan WJ, Gaffin JM, Timmons KG, Sidbury R, Schneider LC, Phipatanakul W. Parental response to written eczema action plans in children with eczema. ACTA ACUST UNITED AC 2012; 148:391-2. [PMID: 22431785 DOI: 10.1001/archdermatol.2011.2267] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Cortot CF, Sheehan WJ, Permaul P, Friedlander JL, Baxi SN, Gaffin JM, Dioun AF, Hoffman EB, Schneider LC, Phipatanakul W. Role of specific IgE and skin-prick testing in predicting food challenge results to baked egg. Allergy Asthma Proc 2012; 33:275-81. [PMID: 22584194 DOI: 10.2500/aap.2012.33.3544] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Previous studies suggest that children with egg allergy may be able to tolerate baked egg. Reliable predictors of a successful baked egg challenge are not well established. We examined egg white-specific IgE levels, skin-prick test (SPT) results, and age as predictors of baked egg oral food challenge (OFC) outcomes. We conducted a retrospective chart review of children, aged 2-18 years, receiving an egg white-specific IgE level, SPT, and OFC to baked egg from 2008 to 2010. Fifty-two oral baked egg challenges were conducted. Of the 52 challenges, 83% (n = 43) passed and 17% (n = 9) failed, including 2 having anaphylaxis. Median SPT wheal size was 12 mm (range, 0-35 mm) for passed challenges and 17 mm (range, 10-30 mm) for failed challenges (p = 0.091). The negative predictive value for passing the OFC was 100% (9 of 9) if SPT wheal size was <10 mm. Median egg white-specific IgE was 2.02 kU/L (range, <0.35-13.00 kU/L) for passed challenges and 1.52 kU/L (range, 0.51-6.10 kU/L) for failed challenges (p = 0.660). Receiver operating characteristic (ROC) curve analysis for SPT revealed an area under the curve (AUC) of 0.64. ROC curve analysis for egg white-specific IgE revealed an AUC of 0.63. There was no significant difference in age between patients who failed and those who passed (median = 8.8 years versus 7.0 years; p = 0.721). Based on our sample, SPT, egg white-specific IgE and age are not good predictors of passing a baked egg challenge. However, there was a trend for more predictability with SPT wheal size.
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Gaffin JM, Spergel JM, Boguniewicz M, Eichenfield LF, Paller AS, Fowler JF, Dinulos JG, Tilles SA, Schneider LC, Phipatanakul W. Effect of cat and daycare exposures on the risk of asthma in children with atopic dermatitis. Allergy Asthma Proc 2012; 33:282-8. [PMID: 22584195 DOI: 10.2500/aap.2012.33.3572] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Atopic dermatitis (AD) in young children is often followed by the development of asthma (atopic march). The role of environmental exposures is unclear in this high-risk population. We aimed to determine the predictive relationship between indoor allergen exposures, particularly pets, rodents, and cockroaches, to the development of asthma in a prospective pediatric cohort. Children with AD and a family history of allergy were followed prospectively with questionnaire ascertainment of environmental exposure to cats, dogs, cockroaches, rats, and mice. Asthma was diagnosed by study physicians based on caregiver reports of symptoms continually assessed over the course of the study period. Fifty-five of the 299 children developed asthma by the end of the study. Cat exposure had a strong and independent effect to reduce the risk of developing asthma across all analyses (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.53). Dog, mouse, rat, and cockroach exposures did not significantly influence the development of asthma. Daycare exposure had the largest risk reduction for the development of asthma (OR, 0.08; 95% CI, 0.03-0.19). Maternal asthma (OR, 2.93; 95% CI, 1.29-6.67), baseline body mass index (OR, 1.23; 95% CI, 1.08-1.42), and specific immunoglobulin E to house-dust mix at 3 years were each independent risk factors for the development of asthma. In children with AD, cat and daycare exposure may reduce the risk of developing early childhood asthma.
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Sheehan WJ, Hoffman EB, Fu C, Baxi SN, Bailey A, King EM, Chapman MD, Lane JP, Gaffin JM, Permaul P, Gold DR, Phipatanakul W. Endotoxin exposure in inner-city schools and homes of children with asthma. Ann Allergy Asthma Immunol 2012; 108:418-22. [PMID: 22626594 DOI: 10.1016/j.anai.2012.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/30/2012] [Accepted: 04/02/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endotoxins are stimulators of the immune system and, despite their potential to protect against allergy, have been associated with early wheezing and asthma morbidity. OBJECTIVE To compare inner-city school endotoxin exposure with home endotoxin exposure in children with asthma. METHODS Students with asthma were recruited from 12 urban elementary schools. Settled and airborne dust samples, linked to enrolled students, were collected from school classrooms, gymnasiums, and cafeterias twice during the academic year. For comparison, settled dust was collected once from the bedrooms of students with asthma. RESULTS Two hundred twenty-nine school settled dust samples and 118 bedroom settled dust samples were collected and analyzed for endotoxin. The median endotoxin concentration for school samples was 13.4 EU/mg (range, 0.7-360.7 EU/mg) and for home samples was 7.0 EU/mg (range = LLOD-843.0 EU/mg). The median concentration within each individual school varied from 6.6 EU/mg to 24.0 EU/mg. One hundred four students with asthma had matched classroom and bedroom endotoxin exposure measurements performed in the same season and demonstrated significantly higher concentrations of endotoxin in the students' classrooms (mean log value, 1.13 vs 0.99, P = .04). The median of the classrooms was 12.5 EU/mg compared with their bedrooms, with a median of 7.0 EU/mg. Within the school environment, no significant difference was seen between the fall and spring samples (mean log value 1.14 vs 1.09; P = .35). CONCLUSION Inner-city children with asthma were exposed to higher concentrations of endotoxin in their classrooms as compared with their bedrooms. Further studies are needed to evaluate school endotoxin exposure as a factor in asthma morbidity.
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Phipatanakul W, Bailey A, Hoffman EB, Sheehan WJ, Lane JP, Baxi S, Rao D, Permaul P, Gaffin JM, Rogers CA, Muilenberg ML, Gold DR. The school inner-city asthma study: design, methods, and lessons learned. J Asthma 2011; 48:1007-14. [PMID: 22010992 DOI: 10.3109/02770903.2011.624235] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Children spend a significant amount of time in school. Little is known about the role of allergen exposure in school environments and asthma morbidity. OBJECTIVES The School Inner-City Asthma Study (SICAS) is a National Institutes of Health (NIH)-funded prospective study evaluating the school/classroom-specific risk factors and asthma morbidity among urban children. METHODS/RESULTS This article describes the design, methods, and important lessons learned from this extensive investigation. A single center is recruiting 500 elementary school-aged children, all of whom attend inner-city metropolitan schools. The primary hypothesis is that exposure to common indoor allergens in the classroom will increase the risk of asthma morbidity in children with asthma, even after controlling for home allergen exposures. The protocol includes screening surveys of entire schools and baseline eligibility assessments obtained in the spring prior to the academic year. Extensive baseline clinical visits are being conducted among eligible children with asthma during the summer prior to the academic school year. Environmental classroom/school assessments including settled dust and air sampling for allergen, mold, air pollution, and inspection data are collected twice during the academic school year and one home dust sample linked to the enrolled student. Clinical outcomes are measured every 3 months during the academic school year. CONCLUSION The overall goal of SICAS is to complete the first study of its kind to better understand school-specific urban environmental factors on childhood asthma morbidity. We also discuss the unique challenges related to school-based urban research and lessons being learned from recruiting such a cohort.
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Gaffin JM, Sheehan WJ, Morrill J, Cinar M, Borras Coughlin IM, Sawicki GS, Twarog FJ, Young MC, Schneider LC, Phipatanakul W. Tree nut allergy, egg allergy, and asthma in children. Clin Pediatr (Phila) 2011; 50:133-9. [PMID: 21098525 PMCID: PMC3070157 DOI: 10.1177/0009922810384720] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Children with food allergies often have concurrent asthma. OBJECTIVE The authors aimed to determine the prevalence of asthma in children with food allergies and the association of specific food allergies with asthma. METHODS Parental questionnaire data regarding food allergy, corroborated by allergic sensitization were completed for a cohort of 799 children with food allergies. Multivariate regression analysis tested the association between food allergy and reported asthma. RESULTS In this cohort, the prevalence of asthma was 45.6%. After adjusting for each food allergy, environmental allergies, and family history of asthma, children with egg allergy (odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.3-3.2; P < .01) or tree nut allergy (OR = 2.0; 95% CI = 1.1-3.6; P = .02) had significantly greater odds of report of asthma. CONCLUSION There is a high prevalence of asthma in the food-allergic pediatric population. Egg and tree nut allergy are significantly associated with asthma, independent of other risk factors.
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Issa-El-Khoury K, Bayuk JL, Patil S, Ling M, Long A, Hesterberg P, Ling M, Patil S, Banerji A, Rork JF, Sheehan WJ, Gaffin JM, Timmons KG, Sidbury R, Schneider LC, Phipatanakul W, Cortot CF, Sheehan WJ, Baxi SN, Dioun AF, Schneider LC, Phipatanakul W. Research abstracts presented at the Fall Meeting of the New England Society of Allergy, October 23-24, 2010, Woodstock, Vermont. Allergy Asthma Proc 2011; 32:80-81. [PMID: 29165195 DOI: 10.2500/108854111794365133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gaffin JM, Israel E, Phipatanakul W. The effect of prophylactic palivizumab on recurrent wheezing in children with an atopic family history. J Allergy Clin Immunol 2010; 127:292-3; author reply 293. [PMID: 21093033 DOI: 10.1016/j.jaci.2010.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 09/30/2010] [Indexed: 11/28/2022]
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Gaffin JM, Shotola NL, Martin TR, Phipatanakul W. Clinically useful spirometry in preschool-aged children: evaluation of the 2007 American Thoracic Society Guidelines. J Asthma 2010; 47:762-7. [PMID: 20653495 DOI: 10.3109/02770903.2010.485664] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
RATIONALE In 2007 the American Thoracic Society (ATS) recommended guidelines for acceptability and repeatability for assessing spirometry in preschool children. The authors aim to determine the feasibility of spirometry among children in this age group performing spirometry for the first time in a busy clinical practice. METHODS First-time spirometry for children age 4 to 5 years old was selected from the Children's Hospital Boston Pulmonary Function Test (PFT) database. Maneuvers were deemed acceptable if ( 1 ) the flow-volume loop showed rapid rise and smooth descent; ( 2 ) the back extrapolated volume (V(be)), the volume leaked by a subject prior to the forced maneuver, was ≤ 80 ml and 12.5% of forced vital capacity (FVC); and ( 3 ) cessation of expiratory flow was at a point ≤ 10% of peak expiratory flow rate (PEFR). Repeatability was determined by another acceptable maneuver with forced expiratory volume in t seconds (FEV(t)) and FVC within 10% or 0.1 L of the best acceptable maneuver. Post hoc analysis compared spirometry values for those with asthma and cystic fibrosis to normative values. RESULTS Two hundred and forty-eight preschool children performed spirometry for the first time between August 26, 2006, and August 25, 2008. At least one technically acceptable maneuver was found in 82.3% (n = 204) of the tests performed. Overall, 54% of children were able to perform acceptable and repeatable spirometry based on the ATS criteria. Children with asthma or cystic fibrosis did not have spirometry values that differed significantly from healthy controls. However, up to 29% of the overall cohort displayed at least one abnormal spirometry value. CONCLUSIONS Many preschool-aged children are able to perform technically acceptable and repeatable spirometry under normal conditions in a busy clinical setting. Spirometry may be a useful screen for abnormal lung function in this age group.
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Wickner PG, Cahill K, Cheifetz A, Sheikh J, Gaffin JM, Sheehan WJ, Morrill J, Sawicki G, Twarog F, Cinar M, Young M, Schneider LC, Phipatanakul W, Permaul P, Stutius LM, Sheehan WJ, Rangsithienchai PA, Walter JE, Young M, Twarog F, Schneider LC, Phipatanakul W, Sheehan WJ, Rangsithienchai PA, Baxi S, Phipatanakul W, Van Stee V, Bielory L, Wheeler J, Robertson D, Bayuk J, Accetta D, Chong H, Wolf R, Kim S, Long A. Research abstracts presented at the New England Society of Allergy, Fall Meeting, Brewster, Massachusetts, October 20, 2008. Allergy Asthma Proc 2009. [DOI: 10.2500/aap.2009.30.3213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gaffin JM, Phipatanakul W. Montelukast as Monotherapy for Pediatric Asthma. MP MEDYCYNA PRAKTYCZNA. PEDIATRIA 2009; 3:20-23. [PMID: 24009473 PMCID: PMC3760433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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