The role of acute and chronic stress in asthma attacks in children

The state of pediatric asthma in Chicago's Humboldt Park: a community-based study in two local elementary schools

BACKGROUND

Pediatric asthma is a serious public health problem in Chicago and has been designated a high priority concern by residents of Chicago's Humboldt Park, a diverse community area with a large number of Puerto Rican, African American, and Mexican American families.

METHODS

In May 2009, following the principles of community-based participatory research, a cross-sectional asthma screening survey was administered to adult caregivers of children attending two Humboldt Park elementary schools. Data were analyzed to determine the prevalence of diagnosed and probable asthma as well as the degree of asthma control among affected children; associations between asthma outcomes and mutable triggers were evaluated.

RESULTS

Surveys from 494 children were evaluated. Physician-diagnosed asthma was reported for 24.9% of children and probable asthma identified in an additional 16.2% of children. Asthma was poorly or moderately controlled in 60.0% of diagnosed children. Smoking occurred inside 25.0% of households and 75.0% of caregivers reported idling of vehicles in their community. Report of general stress among caregivers, stress due to community crime, and/or an inability to cope with everyday life were significantly and positively associated with poor asthma morbidity and control among affected children.

CONCLUSIONS

Despite high prevalence rates and poor asthma morbidity and control in Humboldt Park, the association of these measures with mutable variables is promising. A community-based asthma intervention to address the issues identified in this study is needed to affect positive change.

Epidemiology of asthma: risk factors for development

This comprehensive review of the recent literature was undertaken to determine the current state of knowledge of the risk factors involved in the development of asthma in order to focus investigations in a proposed new longitudinal birth cohort study. The origins of asthma appear to lie in the prenatal and early postnatal period, and renewed investigations in this period with long-term close follow-up and objective phenotypic characterization will help to unravel the role of the multiple putative environmental factors in the development of asthma. It is only after understanding these effects that one can hope to design rational prevention studies for asthma.

Decrease of CD4(+)FOXP3(+) T regulatory cells in the peripheral blood of human subjects undergoing a mental stressor

We have previously shown that acute psychological stress alerts the adaptive immune response causing an increase in antigen-experienced effector T cells in the peripheral blood. T regulatory cells (Tregs) play a central role in maintaining self-tolerance and controlling autoimmune responses. Here, we analyzed for the first time the behaviour of Tregs in the context of a stress-induced activation of the adaptive immune response. 31 healthy young males underwent a brief laboratory stressor and, in a crossover design, served as their own unstressed controls. We quantified effects of acute stress on CD4(+)FOXP3(+) T regulatory cells and other T cell subpopulations using flow cytometry. In addition, the expression of Treg-related effector molecules and stress hormone receptors were analyzed in the subjects' peripheral T cells. We confirmed our previous observation of a stress-induced decrease in CD45RA(+)CCR7(+) "naïve" and CD45RA(-)CCR7+ "central memory" T cells while CD45RA(-)-CCR7(-) "memory effector" and CD45RA(+)CCR7(-) "terminally differentiated" effector T cells remained stable or increased. Importantly, we found acute psychological stress to cause a concomitant decrease in CD4(+)FOXP3(+) Tregs and in CD4(+) T cells expressing Treg-related effector molecules cytotoxic T-lymphocyte antigen-4 (CTLA-4) and latency associated peptide (LAP). Finally, we observed beta(1)-adrenergic and glucorticoid alpha receptors to be overexpressed in Tregs, suggesting that these molecules might mediate stress-related effects on Tregs. In conclusion, inhibiting components of the adaptive immune response, like Tregs, are down-regulated during a stress-induced activation of the adaptive immune response. In situations of chronic stress, this scenario might result in an exacerbation of inflammatory conditions such as autoimmune diseases.

The association between community crime and childhood asthma prevalence in Chicago

BACKGROUND

Little attention has been given to exposure to crime as a possible socioenvironmental contributor to variability in urban childhood asthma prevalence.

OBJECTIVE

To determine the association of violent crime, property crime, and drug abuse violations with childhood asthma prevalence in Chicago.

METHODS

In 2003-2005, the Chicago Initiative to Raise Asthma Health Equity conducted an asthma screening survey of children in grades K to 8 attending Chicago public and Catholic schools. Crime data were obtained from the Chicago Police Department. In addition to simple regression analysis, multilevel logistic regression analysis was performed to estimate the effect of criminal activity on neighborhood asthma variance.

RESULTS

Of the surveys returned, 45,371 (93%) were geocoded into 247 neighborhoods. Neighborhoods were divided into quartile groups by mean asthma prevalence (9%, 12%, 17%, and 22%). Criminal activity (annual incidence per 100,000 people) was significantly higher (P < .001) in neighborhoods with a high asthma prevalence, especially drug abuse violations, which increased more than 6-fold (461 vs 2,921), and violent crimes, which increased more than 3-fold (448 vs 1,566). After adjusting for community race/ethnicity, only violent crime continued to be significantly associated with the neighborhood asthma prevalence (odds ratio, 1.27; 95% confidence interval, 1.04-1.55, P < .05). When considered alongside sociodemographic and individual characteristics, violence continued to contribute significantly (P < .05), explaining 15% of neighborhood variation in childhood asthma.

CONCLUSIONS

Evidence suggests an association between violent crime and childhood asthma prevalence in Chicago. A deeper understanding of the mechanisms that underlie this association may lend insight into potential interventions to address urban asthma.

Parent perceptions of neighborhood stressors are associated with general health and child respiratory health among low-income, urban families

BACKGROUND

This cross-sectional study examines parents' perceptions of their neighborhoods and general and respiratory health among low-income Chicago families. Asthma disproportionately affects nonwhite, urban, and low socioeconomic status (SES) populations, but Chicago's burden, and the national epidemic, are not well explained by known risk factors. Urban dwellers experience acute and chronic stressors that produce psychological distress and are hypothesized to impact health through biological and behavioral pathways. Identifying factors that covary with lower SES and minority-group status-e.g., stress-is important for understanding asthma's social patterning.

METHODS

We used survey data from 319 parents of children 5-13 years with asthma/respiratory problems and principal components analysis to create exposure variables representing parents' perceptions of two aspects of neighborhoods: collective efficacy ("CE") and physical/social order ("order"). Adjusted binomial regression models estimated risk differences (RDs) and 95% confidence intervals (CIs) for eight binary outcomes.

RESULTS

Magnitude was generally as expected, i.e., RD for low- versus high- (most favorable) exposure groups (RD(low v. high)) was larger than for the middle versus high contrast (RD(mid v. high)). "Parent general health" was strongly associated with "CE" (RD(low v. high) = 20.8 [95% CI: 7.8, 33.9]) and "order" (RD(mid v. high) = 11.4 [95% CI: 2.1, 20.7]), unlike "child general health," which had nearly null associations. Among respiratory outcomes, only "waking at night" was strongly associated with "CE" (RD(low v. high) = 16.7 [95% CI: 2.8, 30.6]) and "order" (RD(low v. high) = 22.2 [95% CI: 8.6, 35.8]). "Exercise intolerance" (RD(low v. high) = 15.8 [95% CI: 2.1, 29.5]) and "controllability" (RD(mid v. high) = 12.0 [95% CI: 1.8, 22.3]) were moderately associated with "order" but not with "CE," whereas "school absences," "rescue medication use," and "unplanned visits" had nearly null associations with both exposures.

CONCLUSIONS

More negative perceptions tended to be associated with higher risk of undesirable outcomes, adding to evidence that the social environment contributes to health and supporting research on stress' health impact among disadvantaged populations. Interventions must address not only traditional "environmental" factors, but also individuals' reactions to stress and attempt to mitigate effects of stressors while structural solutions to health inequities are sought.

Effects of examination stress on psychological responses, sleep and allergic symptoms in atopic and non-atopic students

BACKGROUND

Recent findings indicate that atopics may be more vulnerable to stress than non-atopics. However, the roles of psychological well-being and sleep in this presumed increased sensitivity are not known.

PURPOSE

To investigate the effects of a brief naturalistic stressor on psychological responses, sleep, and allergic symptoms and to compare those responses between atopic and non-atopic individuals.

METHODS

We assessed atopic and non-atopic students during a period without and during a period with examinations.

RESULTS

For both atopic and non-atopic students, tension, anxiety, and depression deteriorated in response to examination, as did sleep latency and sleep quality. Overall, atopics were more tense, had more anxiety, longer sleep latencies, and were less well rested than non-atopics. Non-atopic students rose from bed later during the examination period. In response to examination, atopic students reported increased frequency of stress behaviors (e.g., eating fast), while decreased stress behaviors were reported by non-atopic students. Allergic symptoms were not affected.

CONCLUSION

Atopic students were worse off in aspects of psychological well-being and sleep, but displayed only partly stronger responses to a stressor compared to non-atopic students. In spite of a broad negative response to examination, allergic symptoms were not affected.

Socioeconomic status associated with exhaled nitric oxide responses to acute stress in children with asthma

Although psychosocial stress has been linked to clinical asthma outcomes, controlled, laboratory paradigms that test associations between psychosocial stress and markers of airway inflammation in humans are lacking. There is also little known about how individual background characteristics may affect variability across individuals in asthma-relevant inflammatory and pulmonary responses to stress. The goals of this study were to investigate the effects of a laboratory stress paradigm on markers of airway inflammation and pulmonary function in children with asthma, and to determine why some children are more biologically responsive to stress. 38 children physician-diagnosed with asthma, and 23 healthy control children (M age=15 years) engaged in a conflict discussion task with a parent. Pulmonary function (FEV(1)) was measured before and immediately after the task. Airway inflammation (indicated by exhaled nitric oxide, FeNO) was measured before and 45 min after the task (to minimize effects from spirometry). Parents were interviewed about family socioeconomic status (SES: income and occupation). In children with asthma only, there was an inverse association of SES with change in FeNO levels in response to the conflict task, meaning that as SES declined, greater increases in FeNO were observed No changes in FEV(1) were found in response to the conflict task. This study suggests that lower SES children with asthma may be more vulnerable to heightened airway inflammation in response to stress.

Social stress and asthma: the role of corticosteroid insensitivity

Psychosocial stress alters susceptibility to infectious and systemic illnesses and may enhance airway inflammation in asthma by modulating immune cell function through neural and hormonal pathways. Stress activates the hypothalamic-pituitary-adrenal axis. Release of endogenous glucocorticoids, as a consequence, may play a prominent role in altering the airway immune homeostasis. Despite substantial corticosteroid and catecholamine plasma levels, chronic psychosocial stress evokes asthma exacerbations. Animal studies suggest that social stress induces corticosteroid insensitivity that in part may be a result of impaired glucocorticoid receptor expression and/or function. Such mechanisms likely promote and amplify airway inflammation in response to infections, allergen, or irritant exposure. This review discusses evidence of an altered corticosteroid responsive state as a consequence of chronic psychosocial stress. Elucidation of the mechanisms of stress-induced impairment of glucocorticoid responsiveness and immune homeostasis may identify novel therapeutic targets that could improve asthma management.

Modifiable risk factors for asthma morbidity in Bronx versus other inner-city children

BACKGROUND

Bronx children have higher asthma prevalence and asthma morbidity than other US children.

OBJECTIVE

To compare risk factors for asthma morbidity present in Bronx children with those of children from other US inner-city areas.

METHODS

Cross-sectional, multi-state study of 1772 children ages 5-11 yrs. old with persistent asthma. Parental responses to the Child Asthma Risk Assessment Tool for 265 Bronx children are compared with those of 1507 children from 7 other sites (1 Northeast, 2 South, 2 Midwest, 2 West).

RESULTS

Bronx children were significantly more likely to be sensitized to reported aeroallergens in their homes than were children from the other sites (86% vs. 58%; p < .001). More Bronx parents reported household cockroaches (65% v 20%; p < .001), mice (42% v 11%; p < .001), and rats (7% v 3%; p < .001); using a gas stove to heat the home (20% v 9%; p < .001); and visible mold (48% v 25%; p < .001). Bronx parents were more likely to report pessimistic beliefs about controlling asthma (63% v 26%; p < .001) and high parental stress (48% v 37%; p < .01).

CONCLUSIONS

Compared with other inner-city children with asthma, Bronx children are more likely to be exposed to household aeroallergens to which they are sensitized and have poor housing conditions. Their parents are more likely to report low expectations for asthma control and high levels of psychological stress. Interventions that address these identified needs may help to reduce the disproportionate burden of asthma morbidity experienced by Bronx children.

Airway cytokine responses to acute and repeated stress in a murine model of allergic asthma

Although stress is known to exacerbate asthma, the underlying mechanisms are unclear. Using a murine model of allergic asthma, Th1 (interleukin [IL]-2 and gamma-interferon [IFN-γ]) and Th2 (IL-4 and IL-5) airway cytokine responses and Th1:Th2 cytokine ratios to acute and repeated stress were examined in bronchoalveolar lavage fluid (BALF). Asthmatic mice showed significantly higher IL-4 level and Th2 predominance, compared with healthy mice. To acute stress, asthmatic mice significantly increased IL-4 but decreased IFN-γ levels favoring Th2 predominance, whereas healthy mice significantly decreased IL-4 level favoring Th1 predominance in BALF. To repeated stress, asthmatic mice significantly decreased IFN-γ, IL-4 and IL-5 levels overall favoring Th1 predominance, whereas healthy mice basically maintained the same response profile shown to acute stress. These findings suggest that a significant shift toward Th2 predominance in asthmatic mice under acute stress may be a mechanism underlying exacerbation of asthma.

Social and environmental stressors in the home and childhood asthma

BACKGROUND

Both physical environmental factors and chronic stress may independently increase susceptibility to asthma; however, little is known on how these different risks may interact. The authors examined the relationship between maternal intimate partner violence (IPV), housing quality and asthma among children in the Fragile Families and Child Wellbeing Study (N=2013).

METHODS

Maternal reports of IPV were obtained after the child's birth and at 12 and 36 months. At the 36-month assessment, interviewers rated indoor housing conditions, regarding housing deterioration (ie, peeling paint, holes in floor, broken windows) and housing disarray (ie, dark, cluttered, crowded or noisy house). At the same time, mothers reported on housing hardships (ie, moving repeatedly, and hardships in keeping house warm). Maternal-report of physician-diagnosed asthma by age 36 months which was active in the past year was the outcome.

RESULTS

Asthma was diagnosed in 10% of the children. In an adjusted analysis, an increased odds of asthma was observed in children of mothers experiencing IPV chronically (OR 1.8, 95% CI 1.0 to 3.5) and in children experiencing housing disarray (OR 1.5, 95% CI 1.1 to 2.0) compared with those not exposed to these risks. In stratified analyses, a greater effect of IPV on asthma was noted among children living in disarrayed or deteriorated housing or among children whose mothers were experiencing housing hardship.

CONCLUSIONS

IPV and housing disarray are associated with increased early childhood asthma. Exposure to cumulative or multiple stressors (ie, IPV and poor housing quality) may increase children's risk of developing asthma more than a single stressor.

Neuroticism, extraversion, stressful life events and asthma: a cohort study of middle-aged adults

BACKGROUND

Stressful life events can trigger asthma exacerbations, but could also contribute to the development of incident asthma. However, only few studies have investigated the association between stressful life events and adult asthma prospectively. Likewise, stress-related personality traits (e.g. neuroticism and extraversion) may increase asthma risk, but this has been examined in only one prospective study. We therefore aimed to investigate the association between neuroticism, extraversion, stressful life events and incident asthma.

METHODS

A population-based sample of 5114 middle-aged adults completed questionnaires between 1992 and 1995. Among those alive in 2002/2003, 4010 (83%) were followed-up by questionnaires. Exposures of interest included neuroticism, extraversion and three stressful life events (unemployment, having broken off a life partnership and death of a close person). Associations with incident asthma were estimated by multivariable risk ratios (RR) and 95% confidence intervals (95% CI) using Poisson regression.

RESULTS

High vs low neuroticism predisposed to developing asthma (RR = 3.07, 95% CI = 1.71-5.48), but high extraversion did not (RR = 1.30, 95% CI = 0.79-2.15). Having broken off a life partnership significantly increased asthma risk (RR = 2.24, 95% CI = 1.20-4.21) in contrast to death of a close person (RR = 1.06, 95% CI = 0.64-1.75) or unemployment (RR = 1.65, 95% CI = 0.72-3.78).

CONCLUSIONS

High levels of neuroticism may increase the risk of asthma in middle-aged adults. Having broken off a life partnership was the only stressful event, which was associated with incident asthma. Synthesized with evidence from earlier studies, this could reflect that interpersonal conflicts may increase asthma risk, possibly along an immunological pathway.

A framework for examining social stress and susceptibility to air pollution in respiratory health

OBJECTIVE

There is growing interest in disentangling the health effects of spatially clustered social and physical environmental exposures and in exploring potential synergies among them, with particular attention directed to the combined effects of psychosocial stress and air pollution. Both exposures may be elevated in lower-income urban communities, and it has been hypothesized that stress, which can influence immune function and susceptibility, may potentiate the effects of air pollution in respiratory disease onset and exacerbation. In this paper, we attempt to synthesize the relevant research from social and environmental epidemiology, toxicology, immunology, and exposure assessment to provide a useful framework for environmental health researchers aiming to investigate the health effects of environmental pollution in combination with social or psychological factors.

DATA SYNTHESIS

We review the existing epidemiologic and toxicologic evidence on synergistic effects of stress and pollution, and then describe the physiologic effects of stress and key issues related to measuring and evaluating stress as it relates to physical environmental exposures and susceptibility. Finally, we identify some of the major methodologic challenges ahead as we work toward disentangling the health effects of clustered social and physical exposures and accurately describing the interplay among these exposures.

CONCLUSIONS

There is still tremendous work to be done toward understanding the combined and potentially synergistic health effects of stress and pollution. As this research proceeds, we recommend careful attention to the relative temporalities of stress and pollution exposures, to nonlinearities in their independent and combined effects, to physiologic pathways not elucidated by epidemiologic methods, and to the relative spatial distributions of social and physical exposures at multiple geographic scales.

Parental stress increases the effect of traffic-related air pollution on childhood asthma incidence

Exposure to traffic-related pollution (TRP) and tobacco smoke have been associated with new onset asthma in children. Psychosocial stress-related susceptibility has been proposed to explain social disparities in asthma. We investigated whether low socioeconomic status (SES) or high parental stress modified the effect of TRP and in utero tobacco smoke exposure on new onset asthma. We identified 2,497 children aged 5-9 years with no history of asthma or wheeze at study entry (2002-2003) into the Children's Health Study, a prospective cohort study in southern California. The primary outcome was parental report of doctor-diagnosed new onset asthma during 3 years of follow-up. Residential exposure to TRP was assessed using a line source dispersion model. Information about maternal smoking during pregnancy, parental education (a proxy for SES), and parental stress were collected in the study baseline questionnaire. The risk of asthma attributable to TRP was significantly higher for subjects with high parental stress (HR 1.51 across the interquartile range for TRP; 95% CI 1.16-1.96) than for subjects with low parental stress (HR 1.05, 95% CI 0.74-1.49; interaction P value 0.05). Stress also was associated with larger effects of in utero tobacco smoke. A similar pattern of increased risk of asthma was observed among children from low SES families who also were exposed to either TRP or in utero tobacco smoke. These results suggest that children from stressful households are more susceptible to the effects of TRP and in utero tobacco smoke on the development of asthma.

Perception of neighborhood safety and reported childhood lifetime asthma in the United States (U.S.): a study based on a national survey

Background

Recent studies have emphasized the role of psychosocial stressors as a determinant of asthma, and neighborhoods can be a potential source of such stressors. We investigated the association between parental perception of neighborhood safety and reported lifetime asthma among children.

Methodology/Principal Findings

Data for the study came from the 2003–04 National Survey of Children Health (NSCH); a nationally representative cross-sectional sample of children aged 0–17 years. Demographic, socioeconomic and behavioral covariates were included in the study. Models were estimated after taking account of weighting and complex survey design. Parental report of whether the child has ever been diagnosed with asthma by a physician was used to define the outcome. Parental report of perception of neighborhood safety was the main exposure. In unadjusted models, the odds ratio (OR) for reporting asthma associated with living in neighborhoods that were perceived to be sometimes or never safe was 1.36 (95% confidence intervals [CI] 1.21, 1.53) compared to living in neighborhoods that were perceived to be always safe. Adjusting for covariates including exposure to second hand tobacco smoke, mother's self-rated health, child's physical activity and television viewing attenuated this association (OR 1.25, 95% CI 1.08, 1.43). In adjusted models, the increased odds ratio for reporting asthma was also higher among those who perceived neighborhoods as being usually safe (OR 1.15 95% CI 1.06, 1.26), as compared to always safe, suggestive of a dose-response relationship, with the differentials for usually safe and never safe being statistically significant (p = 0.009).

Conclusion

Psychosocial stressors may be important risk factors that may impact the pathogenesis of asthma and/or contribute to asthma morbidity by triggering exacerbations through neuroimmunologic mechanisms, as well as social mechanisms.

Asthma disparities in urban environments

Asthma continues to disproportionately affect minority and low-income groups, with African American and Latino children who live in low-socioeconomic-status urban environments experiencing higher asthma morbidity and mortality than white children. This uneven burden in asthma morbidity has been ever increasing despite medical advancement. Many factors have contributed to these disparities in the areas of health care inequities, which result in inadequate treatment; poor housing, which leads to increased exposure to asthma allergens; and social and psychosocial stressors, which are often unappreciated. Interventions to reduce individual areas of disparities have had varying successes. Because asthma is a complex disease that affects millions of persons, multifaceted comprehensive interventions that combine all evidence-based successful strategies are essential to finally closing the gap in asthma morbidity.

Depressed children with asthma evidence increased airway resistance: "vagal bias" as a mechanism?

BACKGROUND

Depression is prevalent in pediatric asthma, and implicated in asthma morbidity and mortality. Pathways linking stress, depression, and asthma are unknown.

OBJECTIVES

To examine, under controlled laboratory conditions, pathways by which depressive states affect airway function via autonomic dysregulation.

METHODS

Participants were 171 children with asthma, age 7 to 17 years, presenting to an emergency department for asthma exacerbation. Forty-five children with asthma and high depressive symptoms (D) were contrasted with 45 with low/no depressive symptoms (ND). Depressive symptoms, asthma disease severity, vagal and sympathetic reactivity to film stressors, airflow (FEV1), and airway resistance were compared between the groups. A subgroup with greater airway reactivity (nonmedicated FEV1<80% predicted) was also studied. Correlations among variables were examined for the entire sample.

RESULTS

Groups did not differ in demographics, disease severity, medications, or adherence. The D group with FEV1<80% predicted showed greater airway resistance throughout all conditions (P = .03), and vagal bias in the film stressors. The D group's vagal response was significant for the sad stimuli: family distress/loss (P = .03), dying (P = .003), and death (P = .03). The ND group showed sympathetic activation to sad stimuli: lonely (P = .04) and dying (P = .04). Depressive symptoms were correlated with respiratory resistance (r = .43; P = .001) and vagal bias in scene 3 (r = .24; P = .03), and vagal bias (scene 3) was correlated with postmovie airway resistance (r = 0.39; P = .004).

CONCLUSIONS

Children with asthma and depressive symptoms manifest vagal bias when emotionally stressed. Those with depressive symptoms and FEV1<80% manifest greater airway resistance. Depression, vagal bias, and airway resistance were intercorrelated for the full sample.

How stress and anxiety can alter immediate and late phase skin test responses in allergic rhinitis

Allergic rhinitis (AR) is the fifth most common chronic disease, and the association between allergic disorders and anxiety is well-documented. To investigate how anxiety and stressors modulate skin prick test (SPT) responses and associated inflammatory responses, 28 men and women with AR were selected by clinical history and skin test responses. The participants were admitted twice to a hospital research unit for 4h in a crossover trial. Changes in SPT wheals were assessed before and after a standardized laboratory speech stressor, as well as again the following morning; skin responses assessed twice during a lab session without a stressor and again the following morning served as the contrast condition. Anxiety heightened the magnitude of allergen-induced wheals following the stressor. As anxiety increased, SPT wheal diameters increased after the stressor, compared to a slight decrease following the control task. Anxiety also substantially enhanced the effects of stress on late phase responses: even skin tests performed the day after the stressor reflected the continuing impact of the speech stressor among the more anxious participants. Greater anxiety was associated with more IL-6 production by Con A-stimulated leukocytes following the stressor compared to the control visit. The data suggest that stress and anxiety can enhance and prolong AR symptoms.

Addressing asthma health disparities: a multilevel challenge

Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups.

Double-exposure to acute stress and chronic family stress is associated with immune changes in children with asthma

OBJECTIVE

To understand how psychological stress heightens risk for asthma flare-ups, we examined the relationship between acute stress, chronic family stress, and the production of asthma-related cytokines.

METHODS

Seventy-one children with asthma and 76 medically healthy children completed interviews regarding life stress, and peripheral blood samples were collected. After mononuclear cells had been mitogenically stimulated, production of the cytokines interleukin (IL)-4, IL-5, IL-13, and IFN-gamma was measured. All measurements were repeated every 6 months for 2 years. Children reported on their asthma symptoms for 14 days after each study visit.

RESULTS

Children with asthma who had higher levels of chronic family stress showed increased production of IL-4, IL-5, and IFN-gamma at times when they had experienced an acute event compared with times when they had not. These stress-related changes did not occur in asthmatic children with lower levels of chronic family stress, or in healthy controls. The combination of acute and chronic stress was also associated with increased asthma symptoms.

CONCLUSION

These findings suggest that acute negative life events have a particularly strong impact among a subgroup of children with asthma who are under high chronic family stress. The heightened inflammatory profile in this group suggests an explanation for why children experiencing life stressors are at greater risk for asthma exacerbations.

Asthma, obesity, and eating behaviors according to the diagnostic and statistical manual of mental disorders IV in a large population-based sample of adolescents

BACKGROUND

Obesity is related to asthma, but factors influencing this relation have not been clearly defined.

OBJECTIVE

This study was designed to assess the role of eating behaviors and weight concerns in the association between obesity and asthma.

DESIGN

A population-based sample of 11,710 adolescents, recruited from 186 secondary schools of 8 educational districts in France, completed a self-administered standardized questionnaire including DSM IV (Diagnostic and Statistical Manual of Mental Disorders) questions on eating disorders.

RESULTS

Obesity (body mass index >/=95th percentile according to age and sex) was associated with asthma in girls (odds ratio: 1.48; 95% CI: 1.05, 2.08) but not in boys (odds ratio: 1.07; 95% CI: 0.75, 1.54). Both obese and asthmatic adolescents were more likely to have abnormal eating behaviors and weight concerns (P < 0.05). In an adjusted polytomous logistic model with 4 categories based on the presence and/or the absence of asthma and obesity as the dependent variable, the odds ratio for weight concerns increased from a minimum value for asthmatic nonobese adolescents (odds ratio: <1.5; P < 0.03) to a maximum value for asthmatic obese adolescents (odds ratio: >6.3; P < 0.001) with nonasthmatic, nonobese adolescents as the reference group. Similar patterns were observed for overweight.

CONCLUSIONS

Our data suggest that, besides well-known factors such as genetic background, direct mechanical effects, and reduced physical activity, abnormal eating behaviors and weight concerns might intervene in the relation between obesity and asthma. Psychosocial dimension has to be considered to disentangle the complex relation between obesity and asthma in adolescence in view of prevention.

The role of neuro-immune cross-talk in the regulation of inflammation and remodelling in asthma

Despite recent advances in the development of anti-asthmatic medication, asthma continues to be a major health problem worldwide. The symptoms of asthmatic patients include wheezing, chest tightness, cough and shortness of breath, which, together with airway hyperresponiveness, previously have been attributed to a dysfunction of airway nerves. However, research in the last two decades identified Th2-sensitization and the subsequent allergic reaction to innocuous environmental antigens as a basic immunological mechanism leading to chronic airway inflammation. Recent evidence suggests that the development of allergic asthma is influenced by events and circumstances in early childhood and even in utero. Allergen, ozone or stress exposure, as well as RSV infection in early life could be able to induce irreversible changes in the developing epithelial-mesenchymal trophic unit of the airways. The co-existence of chronic inflammation and neural dysfunction have recently drawn attention to the involvement of interaction pathways between the nervous and the immune system in the airways. Intensive basic research has accumulated morphological as well as functional evidence for the interaction between nerves and immune cells. Neuropeptides and neurotrophins have come into focus of attention as the key mediators of neuro-immune interactions, which lead to the development of several pharmacological compounds specifically targeting these molecules. This review will integrate our current knowledge on the involvement of neuro-immune pathways in asthma on the cellular and molecular level. It will summarize the results of pharmacological studies addressing the potential of neuropeptides and neurotrophins as novel therapeutic targets in asthma.

Effect of relaxation-breathing training on anxiety and asthma signs/symptoms of children with moderate-to-severe asthma: a randomized controlled trial

BACKGROUND

Emotional stress triggers and exacerbates asthma in children. Reducing anxiety in adults by relaxation-breathing techniques has been shown in clinical trials to produce good asthma outcomes. However, more evidence is needed on using this intervention with asthmatic children.

OBJECTIVE

To evaluate the effectiveness of combined self-management and relaxation-breathing training for children with moderate-to-severe asthma compared to self-management-only training.

DESIGN

Two-group experimental design.

SETTING AND PARTICIPANTS

Pediatric outpatient clinic of a medical center in central Taiwan. Participants were 48 children, ages 6-14 years, with moderate-to-severe asthma and their parents.

METHODS

Participants were randomly assigned to an experimental or comparison group and matched by gender, age, and asthma severity. Both groups participated in an asthma self-management program. Children in the experimental group were also given 30 min of training in a relaxation-breathing technique and a CD for home practice. Data on anxiety levels, self-perceived health status, asthma signs/symptoms, peak expiratory flow rate, and medication use were collected at baseline and at the end of the 12-week intervention. Effects of group, time, and group-time interaction were analyzed using the Mixed Model in SPSS (12.0).

RESULTS

Anxiety (especially state anxiety) was significantly lower for children in the experimental group than in the comparison group. Differences in the other four physiological variables were also noted between pre- and post-intervention, but these changes did not differ significantly between groups.

CONCLUSIONS

A combination of self-management and relaxation-breathing training can reduce anxiety, thus improving asthmatic children's health. These results can serve as an evidence base for psychological nursing practice with asthmatic children.

Health psychology: developing biologically plausible models linking the social world and physical health

Research over the past several decades has documented psychosocial influences on the development and progression of several major medical illnesses. The field is now increasingly focused on identifying the biological and behavioral mechanisms underlying these effects. This review takes stock of the knowledge accumulated in the biological arena to date and highlights conceptual and methodological approaches that have proven especially productive. It emphasizes the value of a disease-centered approach that "reverse engineers" adverse health outcomes into their specific biological determinants and then identifies psychologically modulated neuroendocrine and immunologic dynamics that modulate those pathological processes at the cellular and molecular levels.

Parental support and cytokine activity in childhood asthma: the role of glucocorticoid sensitivity

BACKGROUND

Stress is known to worsen the course of asthma, but the underlying mechanisms are poorly understood. This problem is especially difficult because stress elicits secretion of cortisol, a hormone that dampens airway inflammation and ameliorates asthma symptoms.

OBJECTIVE

This article proposes that stress affects asthma by inducing resistance to the anti-inflammatory properties of glucocorticoids. To evaluate this hypothesis, we examine whether a particular kind of stress in children's lives, not feeling supported or understood by parents, is associated with in vitro measures of lymphocyte resistance to glucocorticoids and indices of eosinophil mobilization and activation.

METHODS

Children with asthma (n = 67) and medically healthy children (n = 76) completed standardized questionnaires about support from their parents. PBMCs were collected and incubated with a mitogen cocktail in the presence of physiologic concentrations of hydrocortisone. Production of IL-5, IL-13, and IFN-gamma was measured by means of ELISA. Circulating eosinophils were enumerated with a hematology analyzer, and the extent of their activation was indexed by means of ELISA for eosinophil cationic protein.

RESULTS

To the extent that children with asthma perceived low support from their parents, children were more resistant to hydrocortisone's anti-inflammatory effects on IL-5 and IFN-gamma production and had higher circulating levels of eosinophil cationic protein. These associations were independent of socioeconomic conditions, cigarette exposure, disease severity, and medication use.

CONCLUSIONS

These patterns suggest the hypothesis that strained parent-child relations, and perhaps stress more generally, brings about adverse outcomes in asthma by diminishing cortisol's ability to regulate cytokine activity and subsequent airway inflammation.

Dysregulation of the stress response in asthmatic children

The stress system co-ordinates the adaptive responses of the organism to stressors of any kind. Inappropriate responsiveness may account for increased susceptibility to a variety of disorders, including asthma. Accumulated evidence from animal models suggests that exogenously applied stress enhances airway reactivity and increases allergen-induced airway inflammation. This is in agreement with the clinical observation that stressful life events increase the risk of a new asthma attack. Activation of the hypothalamic-pituitary-adrenal (HPA) axis by specific cytokines increases the release of cortisol, which in turn feeds back and suppresses the immune reaction. Data from animal models suggest that inability to increase glucocorticoid production in response to stress is associated with increased airway inflammation with mechanical dysfunction of the lungs. Recently, a growing body of evidence shows that asthmatic subjects who are not treated with inhaled corticosteroids (ICS) are likely to have an attenuated activity and/or responsiveness of their HPA axis. In line with this concept, most asthmatic children demonstrate improved HPA axis responsiveness on conventional doses of ICS, as their airway inflammation subsides. Few patients may experience further deterioration of adrenal function, a phenomenon which may be genetically determined.

Measuring respiratory health in longitudinal social science surveys

Objectively assessing respiratory health in longitudinal social science surveys would involve collecting pulmonary function measures on research participants, either in clinic settings or at home. These measures include indicators of volume (e.g., maximal amount of air blown in the first second of a forced exhalation) and airflow (maximal speed air is exhaled during a forced exhalation). Equipment options include office spirometry, portable spirometry, or home peak flow monitoring. Each option has different equipment and personnel costs. The types of research questions that could be answered using pulmonary function measures in longitudinal household surveys are quite broad, ranging from effects of socioeconomic status and race/ethnicity on respiratory health to social/environmental factors that contribute to respiratory health to the long-term social and economic consequences of respiratory health problems. Currently, such data are lacking. Given the potential payoffs in scientific knowledge, adding these measures to population-based surveys merits serious consideration.

The relationship of household routines to morbidity outcomes in childhood asthma

PURPOSE

The major purpose of this study was to explore the effect of routines on asthma management and morbidity outcomes for children with asthma and their parents.

DESIGN AND METHODS

This study is a secondary data analysis in a sample of 150 children, which was originally used for an intervention study.

RESULTS

Parents who had fewer routines in their homes had lower quality-of-life scores and higher burden of asthma scores when compared to parents in households with more routines. More routines were associated with improved asthma morbidity outcomes as measured by nurse rankings of routines.

PRACTICE IMPLICATIONS

Assisting families to establish routines may result in improved asthma morbidity outcomes.

Environmental noise and asthma in children: sex-specific differences

OBJECTIVE

There is evidence that stress increases the risk of asthma. Chronic noise exposure is known to act as an unspecific stressor, but little is known about its effect on the risk of asthma in children. The aim of this study was to compare subjectively reported noise annoyance in 12-year-old asthmatic and non-asthmatic children with special regard to sex-specific differences.

SUBJECTS AND METHODS

In a German multi-center birth cohort study we assessed the annoyance by different sources of environmental noise, doctor-diagnosed asthma, and potential confounders by questionnaire. The comparisons between asthmatic and non-asthmatic children were stratified by sex.

RESULTS

A total of 336 boys and 316 girls were included in the analysis. Prevalence of doctor-diagnosed asthma was 13% in boys and 5% in girls; 73% of the boys and 74% of the girls reported at least some degree of noise annoyance during the day and night time. In girls, asthma was associated with a significantly increased total noise annoyance at night (adjusted odds ratio aOR 1.5, 95%CI 1.1;2.1), for noise within the home/apartment (aOR 3.5, 95%CI 1.5;8.0), and in or around the house (aOR 3.3, 95%CI 1.7;6.3). No statistical significant effects were seen in boys.

CONCLUSIONS

Noise annoyance, particularly at night or caused by domestic sources, is associated with increased asthma prevalence in girls but not boys. Further research is needed to identify underlying mechanisms of these sex-specific differences.

Maternal transmission of asthma risk

Maternal asthma significantly increases the risk of asthma in offspring, but the mechanisms remain poorly defined. We review animal models used to study the maternal effect, focusing on a murine model developed in our laboratory. Mother mice rendered allergic to ovalbumin produce offspring that are more susceptible to allergic sensitization, seen as airway hyperresponsiveness and allergic airway inflammation after a sensitization protocol, which has minimal effects on newborns from normal mothers. Mechanistic analyses identify a role for interleukin-4 (based on pre-mating injection of neutralizing antibodies), dendritic cells and allergen-specific T cells (based on adoptive transfer experiments). Other maternal exposures (e.g. pollutant exposure and non-pulmonary allergy) can increase asthma susceptibility in offspring. This observation implies that the maternal transmission of asthma represents a final common pathway to various types of inflammatory stimuli. Identification of the shared molecular mechanisms in these models may allow better prevention and therapy. Current knowledge, gaps in knowledge and future directions are discussed.

Does the social environment contribute to asthma?

The impact of the social environment on asthma has recently begun to receive increasing attention. This article reviews the current literature to investigate the impact of the social environment at three levels-the neighborhood level, the peer level, and the family level-and to explore pathways through which the social environment "gets under the skin" to impact asthma onset and morbidity. Research to date suggests that adverse social conditions at the neighborhood and family levels impact asthma morbidity through direct effects on physiologic systems as well as by altering health behaviors. The impact on asthma of social networks, such as friendships, is less clear and will need to be investigated further. Future research will need to take into account the impact of the social environment to develop more comprehensive models of asthma pathogenesis.

A functional genomic fingerprint of chronic stress in humans: blunted glucocorticoid and increased NF-kappaB signaling

BACKGROUND

Chronic stressors are known to increase vulnerability to medical illness, but the mechanisms underlying this phenomenon are poorly understood.

METHODS

To identify transcriptional control pathways that are modified by chronic stress, we conducted genomewide expression microarrays on familial caregivers of brain-cancer patients (n = 11) and matched control subjects (n = 10). Analyses were conducted on peripheral blood monocytes, which are cells that have the ability to initiate and maintain many inflammatory responses. Salivary cortisol was collected over the course of 3 days as volunteers went about normal activities.

RESULTS

Caregivers' patterns of cortisol secretion were similar to those of matched control subjects. However, their monocytes showed diminished expression of transcripts bearing response elements for glucocorticoids, and heightened expression of transcripts with response elements for NF-kappaB, a key pro-inflammatory transcription factor. Caregivers also showed relative elevations in the inflammatory markers C-reactive protein and interleukin-1 receptor antagonist.

CONCLUSIONS

These findings suggest that even in the absence of excess adrenocortical output, stress brings about functional resistance to glucocorticoids in monocytes, which enables activation of pro-inflammatory transcription control pathways. This persistent activation of inflammatory mechanisms may contribute to stress-related morbidity and mortality.

Chronic traffic-related air pollution and stress interact to predict biologic and clinical outcomes in asthma

BACKGROUND

Previous research has documented effects of both physical and social environmental exposures on childhood asthma. However, few studies have considered how these two environments might interact to affect asthma.

OBJECTIVE

This study aimed to test interactions between chronic exposure to traffic-related air pollution and chronic family stress in predicting biologic and clinical outcomes in children with asthma.

METHOD

Children with asthma (n = 73, 9-18 years of age) were interviewed about life stress, and asthma-relevant inflammatory markers [cytokine production, immunoglobulin E (IgE), eosinophil counts] were measured. Parents reported on children's symptoms. Children completed daily diaries of symptoms and peak expiratory flow rate (PEFR) measures at baseline and 6 months later. Exposure to traffic-related air pollution was assessed using a land use regression model for nitrogen dioxide concentrations.

RESULTS

NO(2) by stress interactions were found for interleukin-5 (beta for interaction term = -0.31, p = 0.02), IgE (interaction beta = -0.29, p = 0.02), and eosinophil counts (interaction beta = -0.24, p = 0.04). These interactions showed that higher chronic stress was associated with heightened inflammatory profiles as pollution levels decreased. Longitudinally, NO(2) by stress interactions emerged for daily diary symptoms (interaction beta = -0.28, p = 0.02), parent-reported symptoms (interaction beta = -0.25, p = 0.07), and PEFR (interaction beta = 0.30, p = 0.03). These interactions indicated that higher chronic stress was associated with increases over time in symptoms and decreases over time in PEFR as pollution levels decreased.

CONCLUSIONS

The physical and social environments interacted in predicting both biologic and clinical outcomes in children with asthma, suggesting that when pollution exposure is more modest, vulnerability to asthma exacerbations may be heightened in children with higher chronic stress.

Violence, abuse, and asthma in Puerto Rican children

RATIONALE

Puerto Ricans have the highest prevalence of and morbidity from asthma of all ethnic groups in the United States. One potential contributor to the high burden of asthma in Puerto Rican children is exposure to stress and violence.

OBJECTIVES

To examine whether exposure to stress and violence is associated with an increased risk of asthma among Puerto Rican children.

METHODS

This study was a population-based probability sample of children in the San Juan and Caguas metropolitan areas in Puerto Rico. Information was collected in a household survey of 1,213 children and their primary caretakers.

MEASUREMENTS AND MAIN RESULTS

The prevalence of lifetime physician-diagnosed asthma was 39.6%. In the year before the survey, 14% of children had witnessed an act of violence, 7% had been victims of violence, and 6% had been victims of physical or sexual abuse. Although stressful life events and exposure to neighborhood violence were not associated with asthma, a history of physical or sexual abuse was associated with approximately twice the odds of current asthma (odd ratio [OR], 2.52; 95% confidence interval [CI], 1.27-5.00), health care use for asthma (OR, 1.95; 95% CI, 0.96-3.96), and medication use for asthma (OR, 2.35; 95% CI, 1.05-5.26).

CONCLUSIONS

Physical or sexual abuse is associated with high asthma morbidity among Puerto Rican children. To our knowledge, this is the first report of an association between childhood abuse and asthma. Our findings highlight the importance of screening for asthma among victims of childhood abuse, and to be aware of the possibility of physical or sexual abuse among children with asthma.

Asma, competência social e transtornos comportamentais em crianças e adolescentes

O objetivo deste estudo foi avaliar competência social e transtornos comportamentais em crianças com asma. Participaram 62 crianças (sete a 16 anos) com asma moderada e grave e um grupo controle, cujos pais responderam à versão brasileira do Child Behavior Checklist. Houve associação entre asma e déficit na competência social global (p=0,000), na competência social associada a atividades (p=0,001) e associada à escola (p=0,010). A gravidade da asma não se mostrou associada à competência social. Houve associação entre transtornos comportamentais e asma, principalmente transtornos internalizantes, como ansiedade e depressão, que não se mostraram associados ao gênero, idade e tipo de asma. Concluiu-se que crianças com asma apresentaram mais alterações na competência social global e competência social relacionada a atividades e escola, quando comparadas ao grupo controle. Apresentaram, ainda, mais transtornos globais e internalizantes, que podem prejudicar seu desenvolvimento, qualidade de vida e o manejo adequado da doença.

Parental stress and childhood wheeze in a prospective cohort study

BACKGROUND

Although studies indicate that psychological stress is linked with asthma morbidity, it is unknown whether stress is associated with the incidence of asthma symptoms.

METHOD

In a cohort of 5- to 6-year-old school children participating in the southern California Children's Health Study, we evaluated parent-reported wheeze in the child using a standardized questionnaire and perceived parental stress at study entry. Wheeze in the child was evaluated one year later. Analyses were restricted to children without asthma at study entry (N = 2,888, of whom 286 had wheeze at follow-up).

RESULTS

There was an increase in wheeze across an interquartile range of parent stress (odds ratio [OR] 1.18; 95% confidence interval [CI] 0.99, 1.42). Parent stress was associated with wheeze among children with no parental asthma (OR 1.24; CI 0.99, 1.55) and among boys (OR 1.34; CI 1.04, 1.74), but not among girls or children with parental asthma. Among boys with no parental asthma there was a strong dose-response relationship, and in the top quartile of stress the OR was 2.76 (CI 1.39, 5.51) compared to the bottom quartile.

CONCLUSION

Parental stress increases the risk of childhood wheeze among children with no parental history of asthma, especially among boys. These results suggest that the influence of psychosocial factors on asthma, such as stress and social environment, deserve increased attention.

Parent psychological states predict changes in inflammatory markers in children with asthma and healthy children

Previous research has shown that parent mental health is associated with asthma morbidity in children. However, the biological pathways explaining these relationships are not known. The present study tested whether parent psychological characteristics could predict longitudinal changes in inflammatory markers in children with asthma and a comparison group of healthy children. For this, 33 healthy children (17 m/16 f; 13.5 years) and 50 children with asthma (37 m/13 f; 13.3 years) were assessed at two time points on average 208 days apart. Parent depression (CES-D) and perceived stress (PSS) were assessed at baseline, child depression (CDI) and anxiety (RCMAS) at follow-up. Asthma-relevant inflammatory markers eosinophil cationic protein (ECP) and stimulated interleukin-4 (IL-4) production were measured at baseline and at follow-up. Hierarchical regression analyses controlling for asthma severity and medication use revealed that higher levels of parental perceived stress at baseline were associated with greater increases over time in children's IL-4 production (beta=.29, p=.019) as well as ECP release (beta=.27, p=.004). Additionally, higher levels of parental depression at baseline were associated with increases in ECP over time (beta=.19, p=.046). There was no evidence that these associations were mediated by child depression or anxiety. These results demonstrate that parental stress and depression at baseline predict increases in children's inflammatory profiles over a six month period. This pattern appeared in both children with asthma and healthy children, and was not due to effects on child psychological states. These changes in inflammatory makers may represent one biological mechanism underlying the association between parental distress and child asthma morbidity.

Psychological factors in asthma

Asthma has long been considered a condition in which psychological factors have a role. As in many illnesses, psychological variables may affect outcome in asthma via their effects on treatment adherence and symptom reporting. Emerging evidence suggests that the relation between asthma and psychological factors may be more complex than that, however. Central cognitive processes may influence not only the interpretation of asthma symptoms but also the manifestation of measurable changes in immune and physiologic markers of asthma. Furthermore, asthma and major depressive disorder share several risk factors and have similar patterns of dysregulation in key biologic systems, including the neuroendocrine stress response, cytokines, and neuropeptides. Despite the evidence that depression is common in people with asthma and exerts a negative impact on outcome, few treatment studies have examined whether improving symptoms of depression do, in fact, result in better control of asthma symptoms or improved quality of life in patients with asthma.

Review of the literature: integrating psychoneuroimmunology into pediatric chronic illness interventions

OBJECTIVE

Provide an orientation to psychoneuroimmunology, a rationale for including assessments of immune function in intervention studies of pediatric chronic illness, review the current literature, and provide recommendations for future research.

METHODS

Using electronic searches and previous reviews, selected and reviewed published studies in which immunological changes related to psychological interventions were assessed in pediatric samples.

RESULTS

Eight studies were identified and included in the review. These utilized a range of interventions (e.g., disclosure and hypnosis) and included a variety of pediatric samples (e.g., those with asthma, HIV infection, or lupus).

CONCLUSIONS

Results suggest that psychological intervention can influence immune function in pediatric samples. Recommendations for advancing our knowledge by studying populations for whom the immune system plays an active role in disease pathophysiology, measuring disease-relevant immune mediators, studying pediatric patients under times of stress, and focusing on interventions aimed at altering the stress system are provided.

Inner-city asthma: the role of the community

Asthma morbidity and mortality are disproportionately high in low-income minority populations. Variations in environmental exposures, stress, and access to appropriate health care all contribute to these disparities. The complex nature of asthma with strong contributions from environmental, psychosocial, and biological factors suggest that community-based approaches focused on the unique needs of high-risk populations may be effective. The few previous randomized trials suggest that case management with professionals and/or community health educators may reduce asthma morbidity. Health-educator programs should be lodged in stable infrastructures with training and funding for community health workers to obtain long-term sustainability. Factors not amenable to individual intervention, however, such as poor condition of homes, outdoor pollution, and lack of access to appropriate care, will require collaborative efforts of community groups, academic professionals, public agencies, and health-care providers.

The potential for reducing asthma disparities through improved family and social function and modified health behaviors

The National Workshop To Reduce Asthma Disparities assembled a multidisciplinary group comprised of scientists, clinicians, and community representatives to examine factors related to asthma disparities. Attention was given to the importance of discerning family, social, and behavioral factors that facilitate or impede the use of health-care services suitable to the medical status of an individual. This review highlights select biopsychosocial factors that contribute to these disparities, the manner in which they may contribute or protect persons affected by asthma, and recommended directions for future research.

A bidirectional relationship between psychosocial factors and atopic disorders: a systematic review and meta-analysis

OBJECTIVE

There is growing epidemiological literature focusing on the bidirectional association between psychosocial factors and atopic disorders, but no efforts to quantify the relationship systematically have been published.

METHODS

We searched Medline, PsycINFO, Web of Science, and PubMed up to June 2007. The studies included were prospective cohort studies investigating the influence of psychosocial factors on atopic disorders and the effect of atopic disorders on mental health. Two investigators independently extracted data and determined study quality.

RESULTS

There were 43 studies (in 22 articles), of which 34 evaluated the effect of psychosocial factors on atopic disorders and 9 evaluated the effect of atopic disorders on mental health. The major atopic disease assessed in these studies was asthma (90.7%) with allergic rhinitis, 4.7%; atopic dermatitis, 2.3%; and food allergies, 2.3%. The overall meta-analysis exhibited a positive association between psychosocial factors and future atopic disorder (correlation coefficient (r) as combined size effect .024; 95% confidence interval, 0.014-0.035; p < .001) as well as between atopic disorders and future poor mental health (r = .044, 95% confidence interval, 0.021-0.067, p < .001). More notably, the subgroup meta-analysis on the healthy and atopic disorder populations showed psychosocial factors had both an etiological and prognostic effect on atopic disorders.

CONCLUSIONS

The current review revealed a robust relationship between psychosocial factors and atopic disorders. This supports the use of psychological in addition to conventional physical and pharmacological interventions, in the successful prevention and management of atopic disorders.

Chronic stress, salivary cortisol, and alpha-amylase in children with asthma and healthy children

The present study examined whether chronic stress is related to daily life levels of salivary alpha-amylase (sAA), a marker for sympathetic activity, and cortisol in healthy children versus children with asthma. Children's sAA and cortisol levels were measured repeatedly over 2 days. Chronic stress measures included interviews with children about chronic home life stress and interviews with parents about one marker of socioeconomic status, parental education. Among children with asthma, higher chronic stress was associated with lower daily sAA output, while among healthy children, higher chronic stress was associated with flatter cortisol slopes. In conclusion, chronically stressed children with asthma showed lower salivary alpha-amylase output, indicating lower sympathetic activity, and implying a possible mechanism for increased susceptibility to symptom exacerbations. In contrast, higher cortisol levels in healthy children with chronic stress may indicate, for example, an increased risk for infectious diseases. This dichotomy emphasizes the different biological effects of chronic stress depending on illness status.

[Therapeutic education in asthma management]

All guidelines, protocols and recommendations underline the importance of therapeutic education as a key element in asthma management and control. Considerable evidence supports the efficacy and effectiveness of this measure. Health personnel, as well as patients and their parents, can and should be educated with two main objectives: to achieve the best possible quality of life and to allow self control of the disease. These goals can be attained through an educational process that should be individually tailored, continuous, progressive, dynamic, and sequential. The process poses more than a few difficulties involving patients, health professionals, and the health systems. Knowledge of the various psychological factors that can be present in asthmatic patients, as well as the factors related to the highly prevalent phenomenon of non-adherence, is essential. Awareness of the factors influencing physician-patient-family communication is also highly important to achieve the objectives set in therapeutic education. The educational process helps knowledge and abilities to be acquired and allows attitudes and beliefs to be modified. Patients and caregivers should be provided with an individual written action plan based on symptoms and/or forced expiratory volume in 1 second. Periodic follow-up visits are also required.

With an attack I associate it more with going into hospital: understandings of asthma and psychosocial stressors; are they related to use of services?

Asthma is still a major cause of morbidity and mortality. Patients who use hospital services frequently tend to have more severe asthma and lack formal support. Attitudes to self-management also tend to differ and qualitative studies of frequent attenders have identified differing views of the appropriateness of service use between patients and their physicians. We undertook a qualitative study of patients with severe asthma admitted and not admitted to hospital in a 12-month period in the UK. The aim of the study was to investigate the relationship between perception of life events, psychosocial factors, coping and asthma admission in these two groups of patients. We interviewed 50 patients (aged 16 and over) admitted to two large teaching hospitals in London with asthma exacerbations, 25 patients with similar levels of asthma severity (step 3 or higher of the British Thoracic Society guidelines) sampled in General Practice and 19 general practitioners (GPs). Data were analysed using an adapted framework analysis. Patients admitted to hospital reported high levels of psychosocial problems and life events but tended to make few connections between these and their asthma attacks or their ability to manage their asthma. Patients reporting frequent hospital use tended to value professionals working in hospitals while reporting poor relationships with GPs; views that appeared related to delays in seeking help from primary care. Among GPs, knowledge of patients having attended hospital was generally poor, although they appeared more aware of those who were high users of General Practice (whether they were high attenders at hospital or not). GPs perceived stressful life events in patients with asthma to compound existing dispositions and be related to poor control and poor adherence. These findings suggest that vulnerable patient groups often face poor material circumstances and chaotic lives, impacting on their capacity to manage their illness and on their ability to derive benefit from primary care. Policy interventions aimed at reducing 'unnecessary' admissions will need to be tailored to the psychosocial circumstances and health beliefs of vulnerable patient groups.