Chronic stress and asthma in adolescents

The effects of violence and related stress on asthma

In the United States, people living in deprived urban areas and persons in certain minoritized groups are often exposed to violence and affected with asthma, and epidemiologic studies have shown a link between exposure to violence (ETV) and asthma throughout the lifespan. Indeed, ETV at the individual, intrafamilial and community levels has been linked to asthma in children and adults. In this review, we discuss the evidence for a causal relation between ETV and asthma, emphasizing findings published in the last five years. Interpretation of the available evidence is limited by variable quality of the assessment of ETV or asthma, potential recall and selection bias, inability to estimate the relative contribution of various types of violence to the observed associations, lack of objective biomarkers of asthma or asthma endotypes, and inconsistent consideration of potential confounders or modifiers of the ETV-asthma link. Despite such limitations, the aggregate evidence from studies conducted in different locations and populations suggests that ETV affects asthma and asthma outcomes, and that this is explained by direct physiologic effects of violence-related distress and indirect effects (e.g., through risky health behaviors or co-morbidities). Thus, large prospective studies with careful assessment of specific types of ETV, key covariates and comorbidities (including mental illness), and asthma are needed to advance this field. Such research efforts should not preclude screening for maltreatment in children with asthma and ETV-related depression and anxiety in adolescents and adults with asthma. Further, vigorous policies are needed to curtail violence, as such policies could benefit patients with asthma while saving lives.

Asthma Knowledge, Self-Efficacy, and Self-Management Among Rural Adolescents with Poorly Controlled Asthma

Rural adolescents with asthma are a disparate group. Self-management is essential to asthma control. We describe asthma knowledge, self-efficacy, and self-management behaviors among 198 rural adolescents with poorly controlled asthma, exploring demographic differences; we also test the application of Social Cognitive Theory to asthma self-management examining if self-efficacy mediates associations between knowledge and self-management. Asthma knowledge and self-management were relatively poor in our sample, particularly among male and White adolescents; greater knowledge was significantly associated with better symptom prevention and management. Self-efficacy partially mediated the association between knowledge and symptom prevention, but not acute symptom management, suggesting that knowledge may not improve symptom prevention behaviors without confidence to implement such behaviors and that factors beyond knowledge and self-efficacy likely play a role in asthma self-management in this population. Addressing asthma knowledge and self-efficacy could improve self-management and, ultimately, enhance asthma control among rural adolescents with poorly controlled asthma.

Community violence and asthma: A review

Over the past 2 decades, epidemiologic studies have identified significant associations between exposure to violence, as a psychosocial stressor, and the incidence or exacerbation of asthma. Across diverse populations, study designs, and measures of community violence, researchers have consistently identified adverse associations. In this review, the published epidemiologic evidence is summarized with special attention to research published in the last 5 years and seminal papers. Hypothesized mechanisms for the direct effects of violence exposure and for how such exposure affects susceptibility to physical agents (eg, air pollution and extreme temperature) are discussed. These include stress-related pathways, behavioral mechanisms, and epigenetic mechanisms. Finally, clinical implications and recommendations are discussed.

Associations of advanced lung cancer inflammation index with all-cause and respiratory disease mortality in adults with asthma: NHANES, 1999-2018

The Advanced Lung Cancer Inflammation Index (ALI) represents both the inflammatory and nutritional status of the host, but its link with mortality in asthma patients is uncertain. The purpose of this study was to look at the relationship between ALI levels and all-cause and respiratory disease mortality in asthmatic patients. We conducted our research using cohort data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018. The National Death Index was used to calculate mortality until December 31, 2019. The study employed multivariate logistic regression to look into the relationship between ALI levels and asthma prevalence. Weighted Kaplan-Meier and multivariate-adjusted Cox analyses were utilized for investigating the relationship between ALI levels and all-cause and respiratory disease mortality in individuals with asthma. A restricted cubic spline (RCS) analysis was used to assess their nonlinear relationship. Subgroup and sensitivity analyses were also performed to evaluate the robustness of the results that were obtained. We enrolled 40,497 people in our study, and 5,469 of them had asthma, representing a 14% prevalence. A median follow-up of 11.19 (9.38, 14.29) years revealed 109 fatalities from respiratory diseases and 724 deaths from all causes. After correcting for several covariates, there was no longer any link (P-trend = 0.2) between ALI levels and the prevalence of asthma. When compared to the lowest quartile, the highest quartile of ALI levels was substantially linked to a lower risk of mortality from respiratory diseases and all causes (all P-trend < 0.001). In the RCS regression model, the relationship between ALI level and both all-cause and respiratory disease mortality in asthmatic participants was nonlinear, with P for nonlinearity of 0.006 and 0.015, respectively. We also discovered that the probability of mortality from respiratory disease decreased progressively to a nadir at an ALI level of 109.13 and then increased as the ALI level increased. Multiple subgroup and sensitivity analyses revealed that ALI was consistently related to lower all-cause and respiratory disease mortality in asthma patients. Our findings suggest that ALI is associated with a reduced risk of all-cause and respiratory disease mortality in asthma patients.

Effects of changes in daily life attributed to COVID-19 on allergic diseases among Korean adolescents

OBJECTIVE

The daily lives of adolescents have changed significantly because of COVID-19 pandemic. We investigated the effects of changes in daily life attributed to COVID-19 on allergic diseases among Korean adolescents.

METHODS

Data from the 2021 Korea Youth Risk Behavior Survey were used. In total, 54,848 survey participants were included in the analysis. Allergic diseases included allergic rhinitis, atopic dermatitis, and asthma. Changes attributed to COVID-19 included family economic difficulties, physical activity, breakfast skipping frequency, alcohol consumption, smoking, and depressive moods. Chi-square tests and multiple logistic regression analyses were conducted to examine the impact of changes in daily life attributed to COVID-19 on allergic diseases.

RESULTS

Among the Korean adolescents surveyed, 29.8% experienced a deterioration in their economic status due to COVID-19, 49.1% reported decreased physical activity, 2.8% reported increased alcohol consumption, 1.0% reported an increase in their smoking behavior, and 36.9% reported an increase in depressive moods. Those diagnosed with atopic dermatitis, allergic rhinitis, or asthma within the previous 12 months accounted for 17.1%, 6.2%, and 1.0% of the population, respectively. Adolescents who were significantly affected by COVID-19 in their daily lives were frequently diagnosed with allergic diseases within the last 12 months.

CONCLUSION

Changes in daily life due to COVID-19, including decreased physical activity and increased depressive mood, were common in adolescents and were associated with an increased prevalence of allergic diseases. Since changes in daily life due to the pandemic may increase the burden of allergic disease, additional interventions for disease management should be considered.

The Climate-Asthma Connection: Examining the Influence of Climate Change Anxiety on Asthma Control and Quality of Life: A Multi-National Study

AIMS

This study aims to identify the impact of climate change anxiety and asthma control on asthmatics' quality of life and examine the moderating role of climate change anxiety in this linkage.

METHOD

A multi-national cross-sectional study was conducted in four Arabian countries on 1266 asthmatics selected by convenience sampling. Data were collected from November 2023 to February 2024 using a climate anxiety scale, mini-asthma quality of life questionnaire, and an asthma control questionnaire.

RESULTS

Climate anxiety was higher among middle-aged participants, as well as those with longer disease durations and previous hospitalisations. Climate anxiety showed strong negative correlations with asthma control (r = -0.704, p ≤ 0.05) and asthma quality of life (r = - 0.638, p ≤ 0.05). Climate anxiety and asthma control are powerful predictors of quality of life among asthmatics. Climate anxiety moderates the relationship between asthma control and quality of life, making it less positive (B = -0.094, p > 0.001). Covariates such as gender, age, comorbidities, employment status, disease duration, and previous hospitalisation showed significant associations with asthma quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Assessment and mitigation of climate anxiety among asthmatics is a key strategy for controlling asthma and improving the quality of life. So, nurses must incorporate climate anxiety assessment into the care plan for asthmatics.

IMPACT

Climate change is a global concern, and insights into how climate-related psychological stressors exacerbate asthma symptoms and overall health outcomes are necessary. The findings provide actionable data for healthcare professionals to underscore the need for integrated healthcare approaches considering environmental and psychological factors.

REPORTING METHOD

This study adheres to strengthening the reporting of observational studies in epidemiology (STROBE) statement.

PATIENT OR PUBLIC CONTRIBUTION

Clients with asthma across multiple nationalities actively contributed to our paper.

Rate of Asthma Prescriptions for Children and Adolescents During the 2018 Floods in Japan

BACKGROUND AND OBJECTIVES

Victims of natural disasters are exposed to air pollution, changes in living conditions, and physical/emotional stress, which leads to exacerbation of asthma. The study aimed to examine the association between being victims of a natural disaster and asthma medication prescriptions among children and adolescents by comparing those affected and unaffected by the 2018 Japan floods.

METHODS

Within the most severely impacted regions, a 1-year postdisaster retrospective cohort study was conducted on the basis of the National Health Insurance Claims Database. Participants aged 0 to 19 years with no record of asthma treatment in the year preceding the disaster were included in the analysis. The cumulative incidence of newly prescribed asthma inhalers in the 12 months after the disasters was compared between victims and nonvictims using survival analysis. To test the robustness, a difference-in-differences analysis was performed, including participants with a history of asthma prescriptions.

RESULTS

Of the 1 073 170 participants included in the study, 4425 (0.40%) were assigned to the victim group. Of these, 287 individuals (6.5%) from the victim group and 59 469 individuals (5.6%) from the nonvictim group were newly prescribed asthma inhalers within the year after the floods. Survival analysis revealed that victims were more prone to receiving inhaler prescriptions compared with nonvictims (adjusted hazard ratio 1.30; 95% confidence interval 1.16-1.46). Consistent results were obtained from the difference-in-differences analysis.

CONCLUSIONS

The 2018 Japan floods increased the demand for asthma inhalers among flood victims, underscoring the general implication that natural disasters can increase the incidence of asthma.

'Ask a hundred people, you get a hundred definitions': A comparison of lay and expert understanding of stress and its associations with health

The understanding an individual holds about stress can influence their appraisal of it and have implications for subsequent health, yet knowledge of such understanding is scarce. This study explored discrepancies between lay and expert understanding of stress and links made between stress and health. Twenty-six lay members of the local community aged 18-62 years, and seven expert stress researchers, participated in individual semi-structured interviews. Thematic analysis of the two datasets was conducted separately, then findings compared to identify similarities and differences between lay and scientific understanding. Whilst many similarities were identified, we found three important discrepancies: (i) Lay participants demonstrated a strong awareness of the indirect effects of stress on health via health behaviours; (ii) compared to experts, lay participants showed less awareness of a direct path between stress and physical health; (iii) lay participants showed less understanding of social determinants of stress and collective measures for stress management that went beyond individual responsibility. Discrepancies identified serve to highlight potential misunderstandings in lay conceptualisation of stress and its links with health. These findings have potential to facilitate the work of practitioners who serve as intermediaries to translate scientific knowledge into therapeutic benefit, through improved awareness and communication surrounding stress understanding.

Clinical Subtypes of Neutrophilic Asthma: A Cluster Analysis From Australasian Severe Asthma Network

BACKGROUND

Clinical heterogeneity may exist within asthma subtypes defined by inflammatory markers. However, the heterogeneity of neutrophilic asthma (NA) remains largely unexplored.

OBJECTIVE

To explore potential clusters and the stability of NA.

METHODS

Participants with NA from the Australasian Severe Asthma Network underwent a multidimensional assessment. They were then asked to participate in a 12-month longitudinal cohort study. We explored potential clusters using a hierarchical cluster analysis and validated the differential future risk of asthma exacerbations in the identified clusters. A decision tree analysis was developed to predict cluster assignments. Finally, the stability of prespecified clusters was examined within 1 month.

RESULTS

Three clusters were identified in 149 patients with NA. Cluster 1 (n = 99; 66.4%) was characterized by female-predominant nonsmokers with well-controlled NA, cluster 2 (n = 16; 10.7%) by individuals with comorbid anxiety/depressive symptoms with poorly controlled NA, and cluster 3 by older male smokers with late-onset NA. Cluster 2 had a greater proportion of participants with severe exacerbations (P = .005), hospitalization (P = .010), and unscheduled visits (P = .013) and a higher number of emergency room visits (P = .039) than that of the other two clusters. The decision tree assigned 92.6% of participants correctly. Most participants (87.5%; n = 7) in cluster 2 had a stable NA phenotype, whereas participants of clusters 1 and 3 had variable phenotypes.

CONCLUSIONS

We identified three clinical clusters of NA, in which cluster 2 represents an uncontrolled and stable NA subtype with an elevated risk of exacerbations. These findings have clinical implications for the management of NA.

Sleep, brain systems, and persistent stress in early adolescents during COVID-19: Insights from the ABCD study

PURPOSE

The first year of the COVID-19 pandemic constituted a major life stress event for many adolescents, associated with disrupted school, behaviors, social networks, and health concerns. However, pandemic-related stress was not equivalent for everyone and could have been influenced by pre-pandemic factors including brain structure and sleep, which both undergo substantial development during adolescence. Here, we analyzed clusters of perceived stress levels across the pandemic and determined developmentally relevant pre-pandemic risk factors in brain structure and sleep of persistently high stress during the first year of the COVID-19 pandemic.

METHODS

We investigated longitudinal changes in perceived stress at six timepoints across the first year of the pandemic (May 2020-March 2021) in 5559 adolescents (50 % female; age range: 11-14 years) in the United States (U.S.) participating in the Adolescent Brain Cognitive Development (ABCD) study. In 3141 of these adolescents, we fitted machine learning models to identify the most important pre-pandemic predictors from structural MRI brain measures and self-reported sleep data that were associated with persistently high stress across the first year of the pandemic.

RESULTS

Patterns of perceived stress levels varied across the pandemic, with 5 % reporting persistently high stress. Our classifiers accurately detected persistently high stress (AUC > 0.7). Pre-pandemic brain structure, specifically cortical volume in temporal regions, and cortical thickness in multiple parietal and occipital regions, predicted persistent stress. Pre-pandemic sleep difficulties and short sleep duration were also strong predictors of persistent stress, along with more advanced pubertal stage.

CONCLUSIONS

Adolescents showed variable stress responses during the first year of the COVID-19 pandemic, and some reported persistently high stress across the whole first year. Vulnerability to persistent stress was evident in several brain structural and self-reported sleep measures, collected before the pandemic, suggesting the relevance of other pre-existing individual factors beyond pandemic-related factors, for persistently high stress responses.

Adverse Events during Adulthood, Child Maltreatment, and Asthma among British Adults in the UK Biobank

Rationale: Intimate partner violence and child maltreatment have been separately associated with asthma in adults. No study has concurrently examined of adulthood adverse events (including, but not limited to, intimate partner violence) and child maltreatment on asthma in adults. Objectives: To concurrently examine of adulthood adverse events and child maltreatment on asthma in adults. Methods: This was a cross-sectional study of adulthood adverse events and child maltreatment on current asthma in 87,891 adults 40-69 years old who participated in the UK Biobank. Adulthood adverse events were assessed using questions adapted from a national crime survey. Child maltreatment was ascertained using the Childhood Trauma Screener questionnaire. Current asthma was defined as physician-diagnosed asthma and current wheeze and was further classified as noneosinophilic or eosinophilic according to eosinophil count (<300 vs. ⩾300 cells per microliter). Results: In a multivariable analysis, participants who reported two or more types of adulthood adverse events had 1.19-1.45 times significantly higher odds of asthma than those who did not, whereas participants who reported two or more types of child maltreatment had 1.25-1.59 significantly higher odds of asthma than those who reported no child maltreatment. After stratification by sex, similar results were obtained for child maltreatment in women and men, whereas adulthood adverse events were only significantly associated with asthma in women. Similar findings were observed in analyses that were restricted to never-smokers and former smokers with <10 pack-years of smoking and in analyses of noneosinophilic and eosinophilic asthma. Conclusions: In a cohort of British adults, child maltreatment was associated with current asthma in men and women, whereas adulthood adverse events were associated with current asthma in women only. This was independent of cigarette smoking or eosinophil count.

Association between e-cigarette use and asthma among US adolescents: Youth Risk Behavior Surveillance System 2015-2019

BACKGROUND

Previous studies have suggested that e-cigarette use, which has increased rapidly among US adolescents, may cause respiratory distress. This cross-sectional study aimed to investigate the factors associated with e-cigarette use and the relationship between e-cigarette use and asthma among US adolescents.

METHODS

Data from the Youth Risk Behavior Surveillance System between 2015 and 2019 were analyzed, and multivariable logistic regression was used to identify demographic and behavioral factors associated with e-cigarette use. Stratified analyses were conducted to assess the relationship between e-cigarette use and asthma among adolescents by previous combustible product use.

RESULTS

This study found that Hispanic adolescents had lower odds of e-cigarette use than White adolescents in Texas, with factors such as age, substance use, and depression being associated with use. In the US, male gender, previous combustible and substance use, and depression were associated with higher odds of ever using e-cigarettes, while current use was associated with several factors including age and White race. E-cigarette use was significantly associated with asthma among adolescents who have never used combustible products in both Texas and the entire US after adjusting for covariates (OR 1.32, 95% CI 1.06-1.66 and OR 1.18, 95% CI 1.02-1.37, respectively).

CONCLUSION

The findings from this study can be used to inform public health strategies and policies aimed at reducing e-cigarette use and its associated health risks among adolescents.

Bidirectional crosstalk between the peripheral nervous system and lymphoid tissues/organs

The central nervous system (CNS) influences the immune system generally by regulating the systemic concentration of humoral substances (e.g., cortisol and epinephrine), whereas the peripheral nervous system (PNS) communicates specifically with the immune system according to local interactions/connections. An imbalance between the components of the PNS might contribute to pathogenesis and the further development of certain diseases. In this review, we have explored the "thread" (hardwiring) of the connections between the immune system (e.g., primary/secondary/tertiary lymphoid tissues/organs) and PNS (e.g., sensory, sympathetic, parasympathetic, and enteric nervous systems (ENS)) in health and disease in vitro and in vivo. Neuroimmune cell units provide an anatomical and physiological basis for bidirectional crosstalk between the PNS and the immune system in peripheral tissues, including lymphoid tissues and organs. These neuroimmune interactions/modulation studies might greatly contribute to a better understanding of the mechanisms through which the PNS possibly affects cellular and humoral-mediated immune responses or vice versa in health and diseases. Physical, chemical, pharmacological, and other manipulations of these neuroimmune interactions should bring about the development of practical therapeutic applications for certain neurological, neuroimmunological, infectious, inflammatory, and immunological disorders/diseases.

Current Approaches in the Multimodal Management of Asthma in Adolescents-From Pharmacology to Personalized Therapy

Asthma and adolescence are two sensitive points and are difficult to manage when they coexist. The first is a chronic respiratory condition, with frequent onset in early childhood (between 3 and 5 years), which can improve or worsen with age. Adolescence is the period between childhood and adulthood (12-19 years), marked by various internal and external conflicts and a limited capacity to understand and accept any aspect that is delimited by the pattern of the social circle (of the entourage) frequented by the individual. Therefore, the clinician is faced with multiple attempts regarding the management of asthma encountered during the adolescent period, starting from the individualization of the therapy to the control of compliance (which depends equally on the adverse reactions, quality of life offered and support of the close circle) and the social integration of the subject, communication probably having a more important role in the monitoring and evolution of the condition than the preference for a certain therapeutic scheme. Current statistics draw attention to the increase in morbidity and mortality among children with bronchial asthma, an aspect demonstrated by the numerous hospitalizations recorded, due either to an escalation in the severity of this pathology or to faulty management. The purpose of this article is to review the delicate aspects in terms of controlling symptoms and maintaining a high quality of life among teenagers.

Exposure to violence and asthma in Puerto Rican youth with high Th2 immunity

BACKGROUND

Little is known about the determinants of asthma among youth with high T helper 2 (Th2) immunity. We hypothesized that exposure to violence (ETV) and violence-related distress are associated with asthma in children and adolescents with high Th2 immunity.

METHODS

We analyzed data from Puerto Ricans with high Th2 immunity aged 9-20 years in the Puerto Rico Genetics of Asthma and Lifestyle (PR-GOAL) and the Epigenetic Variation of Childhood Asthma in Puerto Ricans (EVA-PR) studies, and in a prospective study (PROPRA). High Th2-immunity was defined as ≥1 positive allergen-specific IgE and/or a total IgE ≥ 100 IU/mL and/or an eosinophil count ≥ 150 cells/μL. Asthma was defined as physician-diagnosed asthma and current wheeze. ETV and violence-related distress were assessed with the validated ETV Scale and Checklist of Children's Distress Symptoms (CCDS) questionnaires, respectively.

RESULTS

In multivariable analyses, each 1-point increment in ETV score was significantly associated with 1.13-1.17 times increased odds of asthma in PR-GOAL and in EVA-PR (both at p ≤ 0.01), and each 1-point increment in CCDS score was significantly associated with 1.53-1.54 increased odds of asthma in PR-GOAL and in EVA-PR (both at p ≤ 0.03). Further, a persistently high ETV score was significantly associated with asthma in PROPRA (odds ratio [OR] = 2.83, 95% confidence interval [CI] = 1.10-7.29). Similar results were obtained in a sensitivity analysis using an eosinophil count ≥ 300 cells/μL instead of ≥150 cells/μL to define high Th2 immunity.

CONCLUSIONS

ETV during childhood is associated with increased risk of persistent or new-onset asthma in youth with high Th2 immunity.

Asthma is associated with bullying victimization in rural adolescents

OBJECTIVE

We characterized bullying among rural adolescents and examined the association between asthma and bullying victimization.

METHODS

Participants (N = 1905; 44.5% Black) were students attending rural high schools who were screened for a randomized trial to address uncontrolled asthma. Screening questions asked students about asthma diagnosis and symptoms, bullying victimization, and demographic characteristics. Logistic regression analyses with school as a fixed effect were employed to examine the extent to which demographic factors, asthma diagnosis, asthma status (i.e. current asthma, no asthma, possible undiagnosed asthma), and among those with current asthma, asthma severity, were associated with bullying victimization. Sensitivity analyses using bullying frequency as the outcome were also conducted.

RESULTS

26.0% reported being bullied. Younger age and self-identifying as White were associated with increased risk of bullying victimization. Compared to those with no asthma, those with current asthma or possible undiagnosed asthma were at increased risk for bullying victimization (adjusted odds ratio [AOR] = 2.46; 95% confidence interval (CI) = 1.76-3.46 and AOR = 2.42; 95% CI = 1.87-3.14, respectively). Among those with current asthma, persistent symptoms increased the risk for bullying victimization (AOR = 2.59; 95% CI = 1.45-4.71). Similar results were obtained with sensitivity analyses.

CONCLUSIONS

In a large rural community cohort, asthma was associated with bullying victimization. Findings suggest that rural students with asthma, with or without diagnosis, could benefit from schools creating inclusive environments that reduce victimization based on this medical condition. School administrators should foster environments that are accepting of all students' abilities and statuses, and healthcare providers can provide proper asthma management education to these adolescents.

Prediction of Chronic Stress and Protective Factors in Adults: Development of an Interpretable Prediction Model Based on XGBoost and SHAP Using National Cross-sectional DEGS1 Data

BACKGROUND

Chronic stress is highly prevalent in the German population. It has known adverse effects on mental health, such as burnout and depression. Known long-term effects of chronic stress are cardiovascular disease, diabetes, and cancer.

OBJECTIVE

This study aims to derive an interpretable multiclass machine learning model for predicting chronic stress levels and factors protecting against chronic stress based on representative nationwide data from the German Health Interview and Examination Survey for Adults, which is part of the national health monitoring program.

METHODS

A data set from the German Health Interview and Examination Survey for Adults study including demographic, clinical, and laboratory data from 5801 participants was analyzed. A multiclass eXtreme Gradient Boosting (XGBoost) model was constructed to classify participants into 3 categories including low, middle, and high chronic stress levels. The model's performance was evaluated using the area under the receiver operating characteristic curve, precision, recall, specificity, and the F1-score. Additionally, SHapley Additive exPlanations was used to interpret the prediction XGBoost model and to identify factors protecting against chronic stress.

RESULTS

The multiclass XGBoost model exhibited the macroaverage scores, with an area under the receiver operating characteristic curve of 81%, precision of 63%, recall of 52%, specificity of 78%, and F1-score of 54%. The most important features for low-level chronic stress were male gender, very good general health, high satisfaction with living space, and strong social support.

CONCLUSIONS

This study presents a multiclass interpretable prediction model for chronic stress in adults in Germany. The explainable artificial intelligence technique SHapley Additive exPlanations identified relevant protective factors for chronic stress, which need to be considered when developing interventions to reduce chronic stress.

Socioeconomic status associates with worse asthma morbidity among Black and Latinx adults

BACKGROUND

Asthma disproportionately affects African American/Black (AA/B) and Hispanic/Latinx (H/L) patients and individuals with low socioeconomic status (SES), but the relationship between SES and asthma morbidity within these racial/ethnic groups is inadequately understood.

OBJECTIVE

To determine the relationship between SES and asthma morbidity among AA/B and H/L adults with moderate to severe asthma using multidomain SES frameworks and mediation analyses.

METHODS

We analyzed enrollment data from the PeRson EmPowered Asthma RElief randomized trial, evaluating inhaled corticosteroid supplementation to rescue therapy. We tested for direct and indirect relationships between SES and asthma morbidity using structural equation models. For SES, we used a latent variable defined by poverty, education, and unemployment. For asthma morbidity, we used self-reported asthma exacerbations in the year before enrollment (corticosteroid bursts, emergency room/urgent care visits, or hospitalizations), and Asthma Control Test scores. We tested for mediation via health literacy, perceived stress, and self-reported discrimination. All models adjusted for age, sex, body mass index, ethnicity, and comorbidities.

RESULTS

Among 990 AA/B and H/L adults, low SES (latent variable) was directly associated with hospitalizations (β = 0.24) and worse Asthma Control Test scores (β = 0.20). Stress partially mediated the relationship between SES and increased emergency room/urgent care visits and worse asthma control (β = 0.03 and = 0.05, respectively). Individual SES domains were directly associated with asthma morbidity. Stress mediated indirect associations between low educational attainment and unemployment with worse asthma control (β = 0.05 and = 0.06, respectively).

CONCLUSIONS

Lower SES is directly, and indirectly through stress, associated with asthma morbidity among AA/B and H/L adults. Identification of stressors and relevant management strategies may lessen asthma-related morbidity among these populations.

Child maltreatment and asthma

A growing body of evidence suggests a potential link between child maltreatment and asthma. Determining whether and how child maltreatment causes or worsens asthma would have major implications for disease prevention and treatment, as well as public health policy. In this article, we examine epidemiologic studies of child maltreatment and asthma and asthma-related outcomes, review the evidence for potential mechanisms underlying the child maltreatment-asthma association, and discuss future directions. To date, a child maltreatment-asthma link has been reported in most studies of children and adults, though the type of maltreatment associated with asthma has differed across studies. Such discrepant findings are likely explained by differences in study design and quality. All studies have been limited by potential under-reporting of child maltreatment and selection bias, and nonthorough assessment of asthma. Despite these limitations, the aggregate evidence from epidemiologic studies suggests a possible causal link between child maltreatment and asthma, though the relative contributions of various types of maltreatment (physical, sexual, emotional, or neglect) are unclear. To date, there is insufficient evidence of an association between child maltreatment and lung function in children or adults. Limited evidence further suggests that child maltreatment could influence the development or severity of asthma through direct effects on stress responses and anxiety- or depressive-related disorders, immunity, and airway inflammation, as well as indirect effects such as increased obesity risk. Future prospective studies should aim to adequately characterize both child maltreatment and asthma, while also assessing relevant covariates and biomarkers of stress, immune, and therapeutic responses.

Associations of asthma self-management and mental health in adolescents: A scoping review

BACKGROUND

Adolescent asthma is highly prevalent and frequently uncontrolled despite control being achievable with good self-management. Anxiety, depression, and stress are associated with worse asthma outcomes, and may impact self-management; no previous review has examined this relationship.

AIM

This scoping review assessed the nature of the current literature on mental health and asthma self-management among adolescents ages 11 to 24 and synthesized their relationships.

METHODS

Guided by the PRISMA-ScR guidelines, we systematically searched the literature using MEDLINE, Embase, CINAHL, PsycInfo, and Scopus in September 2020 and updated it in June 2021. Included studies examined associations between anxiety, depression, and/or stress and asthma self-management in adolescents ages 11-24. We did not restrict study design, location, or date.

RESULTS

Out of 1559 records identified, 14 met inclusion criteria. Types of self-management included trigger control, healthcare adherence, and overall symptom prevention and management. Anxiety symptoms were associated with poorer asthma self-management in four studies, but better in three. Depressive symptoms were associated with poorer asthma self-management in five studies, but better in two. Stress was associated with poorer self-management in one study. Mental health symptoms were nearly universally associated with poorer trigger control, but associations with healthcare adherence and overall symptom prevention and management varied.

CONCLUSION

Mental health symptoms may facilitate or hinder asthma self-management depending on the types of mental health and self-management. Further research is needed to better understand this relationship and inform future interventions. Providers might assess mental health as a potential barrier to adolescent asthma self-management.

Child and adolescent mental health multiaxial classification: A useful biopsychosocial framework for paediatrics?

In child and adolescent psychiatry, the multiaxial classification approach has been developed over some decades and remains very relevant as it encapsulates the biopsychosocial approach, an approach which is also central to paediatric practice. There is considerable overlap between developmental-behavioural paediatrics and child and adolescent mental health, including presenting clinical problems, diagnoses, multidisciplinary and holistic approach to assessment and management, and similar use of pharmacological agents and psychosocial interventions. Multiaxial classification can be of use to paediatricians in a variety of ways, both in clinical practice and for teaching purposes. It can improve communication between the two disciplines and promotes a more holistic diagnostic representation in a structured and consistent format. Presented here are a number of practical ways in which the multiaxial biopsychosocial framework can be used, including case description, formulation, timeline and interventions, training and teaching.

The influence of urban exposures and residence on childhood asthma

Children with asthma who live in urban neighborhoods experience a disproportionately high asthma burden, with increased incident asthma and increased asthma symptoms, exacerbations, and acute visits and hospitalizations for asthma. There are multiple urban exposures that contribute to pediatric asthma morbidity, including exposure to pest allergens, mold, endotoxin, and indoor and outdoor air pollution. Children living in urban neighborhoods also experience inequities in social determinants of health, such as increased poverty, substandard housing quality, increased rates of obesity, and increased chronic stress. These disparities then in turn can increase the risk of urban exposures and compound asthma morbidity as poor housing repair is a risk factor for pest infestation and mold exposure and poverty is a risk factor for exposure to air pollution. Environmental interventions to reduce in-home allergen concentrations have yielded inconsistent results. Population-level interventions including smoking bans in public places and legislation to decrease traffic-related air pollution have been successful at reducing asthma morbidity and improving lung function growth. Given the interface and synergy between urban exposures and social determinants of health, it is likely population and community-level changes will be needed to decrease the excess asthma burden in children living in urban neighborhoods.

A study on depression among adolescents with asthma in South Korea using the 15th Korea Youth Risk Behaviour Web-Based Survey

Purpose

This study investigated the factors that influence depression in adolescents diagnosed with asthma in South Korea, providing basic data supporting efforts to improve adolescents' mental health.

Methods

Multiple regression analysis was conducted on 4,020 subjects who had been diagnosed with lifelong asthma among the 57,303 respondents to the 15th Korea Youth Risk Behaviour Web-Based Survey from 2019.

Results

The participants were more likely to have depression if they were female, in middle school, their academic achievement was poor, they were drinkers or smokers, if they felt a very high amount of stress, and if they experienced very inadequate recovery from fatigue. Adolescents with asthma were 9.00 times more likely to experience depression when they felt a very high amount of stress (95% confidence interval [CI]=5.51-14.69, p<.001) than when they felt no stress.

Conclusion

Given these factors, measures to improve the mental health of adolescents should be developed and expanded, especially to decrease their stress levels. A separate program that is different from the school's regular health curriculum should be developed to manage the stress levels of adolescents with asthma, such as an after-school program or a program conducted at a local community centre.

Asthma and the social determinants of health

OBJECTIVE

To synthesize the growing body of literature on the role of social determinants of health (SDoH) in asthma and asthma disparities.

DATA SOURCES

A pubmed.gov search was performed to identify published literature on SDoH, asthma, asthma disparities, and race and ethnicity. Current asthma statistics of the Centers for Disease Control and Prevention were reviewed.

STUDY SELECTIONS

Relevant articles on SDoH, asthma, asthma disparities, and race and ethnicity were reviewed in detail.

RESULTS

Black and Latinx Americans have a higher asthma prevalence and greater asthma morbidity than White Americans and also bear a disproportionate burden of SDoH. Inequities in SDoH are rooted in structural racism and population-level injustices that affect the socioeconomic status, physical environment, and health care access/quality of Black and Latinx Americans. There is evidence that racial/ethnic inequities in SDoH, such as socioeconomic status, neighborhood environment, housing, environmental exposures, and health care access/quality, contribute to excess burden of asthma prevalence/incidence, morbidity, exacerbations, and abnormal lung function among certain racial/ethnic populations. In addition, Black and Latinx communities experience high levels of long-term stress, which may increase asthma risk through direct effects on the immune system and hypothalamic-pituitary-adrenocortical activation. Long-term stress may also mediate the effects of SDoH on asthma.

CONCLUSION

Although there is clear evidence linking SDoH to excess asthma risk and implicating SDoH in asthma disparities, the extent to which asthma disparities are explained by inequities in SDoH and the relative contributions of each of these SDoH to asthma disparities remain unclear. This knowledge is needed to effectively develop and test systems-level interventions targeting SDoH, with the ultimate goal of meaningfully reducing racial/ethnic asthma disparities.

Frontiers Review: Severe Asthma in Adolescents

Asthma remains the most prevalent chronic respiratory disease of childhood. Severe asthma accounts for a minority group of patients but with substantial morbidity burden. It may reflect disease which is resistant to treatment or that which is difficult to treat, or a combination of both. The adolescent patient cohort denote a unique group and are the focus of this review. This group of patients embody transitioning priorities and evolving health beliefs, all of which may influence the management and burden of disease. Factors of importance include the influence of physiological parameters such as sex and race, which have confer implications for medical management and non-physiological factors, such as adherence, risk-taking behavior, and vaping. The holistic approach to management of severe asthma within this group of patients must acknowledge the evolving patient independence and desire for autonomy and strive for a collaborative, patient tailored approach. This review will focus on the factors that may pose a challenge to the management of severe adolescent asthma whilst offering suggestions for changes in practice that might harness patient priorities and shared clinical decision-making.

Keeping Pace with Adolescent Asthma: A Practical Approach to Optimizing Care

Known for their pre-occupation with body image, self-identity creation, peer acceptance, and risk-taking behaviors, adolescents with asthma face unique challenges. Asthma is a heterogeneous disease and accurate diagnosis requires assessment through detailed clinical history, examination, and objective tests. Diagnostic challenges exist as many adolescents can present with asthma-like symptoms but do not respond to asthma treatment and risk being mis-diagnosed. Under-recognition of asthma symptoms and denial of disease severity must also be addressed. The over-reliance on short-acting beta-agonists in the absence of anti-inflammatory therapy for asthma is now deemed unsafe. Adolescents with mild asthma benefit from symptom-driven treatment with combination inhaled corticosteroids (ICS) and long-acting beta-agonist (LABA) on an as-required basis. For those with moderate-to-persistent asthma requiring daily controller therapy, maintenance and reliever therapy using the same ICS-LABA controller simplifies treatment regimes, while serving to reduce exacerbation risk. A developmentally staged approach based on factors affecting asthma control in early, middle, and late adolescence enables better understanding of the individual's therapeutic needs. Biological, psychological, and social factors help formulate a risk assessment profile in adolescents with difficult-to-treat and severe asthma. Smoking increases risks of developing asthma symptoms, lung function deterioration, and asthma exacerbations. Morbidity associated with e-cigarettes or vaping calls for robust efforts towards smoking and vaping cessation and abstinence. As adolescents progress from child-centered to adult-oriented care, coordination and planning are required to improve their self-efficacy to ready them for transition. Frequent flare-ups of asthma can delay academic attainment and adversely affect social and physical development. In tandem with healthcare providers, community and schools can link up to help shoulder this burden, optimizing care for adolescents with asthma.

Violence-related distress and lung function in two longitudinal studies of youth

Increasing violence-related distress over time was associated with worse lung function and worse asthma-related quality of life in youth with asthma despite treatment with low-dose inhaled corticosteroids.Exposure to violence has been associated with lower lung function in cross-sectional studies. We examined whether increasing violence-related distress over time is associated with worse lung function and worse asthma control or quality of life in a secondary analysis of a 48-week randomized clinical trial in 98 youth with asthma (ages 9-16 years) treated with low-dose inhaled corticosteroids (the Vitamin D Kids Asthma Study [VDKA]). We then replicated our findings for lung function in a prospective study of 232 Puerto Rican youth followed for an average of 5·4 years. Violence-related distress was assessed using the Checklist of Children's Distress Symptoms (CCDS) scale. Our outcomes of interest were percent predicted (%pred) lung function measures and (in VDKA only) asthma control (assessed using the Asthma Control Test) and asthma-related quality of life (assessed using the Pediatric Asthma Quality of Life questionnaire). In a multivariable analysis in VDKA, each 1-point increment in the CCDS score was associated with decrements of 3.27% in %predFEV₁ (95% confidence interval [CI]=-6.44% to -0.22%, p=0.04) and a 2.65% decrement in percent predicted FVC (95% CI=-4.86% to -0.45%, p=0.02), and 0.30 points in the overall PAQLQ score (95% CI=-0.50 to -0.10, p<0.01). Similar findings for FEV₁ and FVC were obtained in the prospective study of Puerto Rican youth. Our findings suggest that violence-related distress may worsen lung function and quality of life in youth with asthma (even those treated with low-dose inhaled corticosteroids) and further support policies to reduce exposure to violence among children in the U.S. and Puerto Rico.

Socioeconomic status, financial stress, and glucocorticoid resistance among youth with asthma: Testing the moderation effects of maternal involvement and warmth

OBJECTIVES

Children who grow up in more socioeconomically disadvantaged homes experience greater levels of inflammation and worse asthma symptoms than children from more advantaged families. However, recent evidence suggests that certain family-level factors can mitigate health disparities associated with socioeconomic status (SES). In a sample of youth with asthma, we investigated the potential buffering effects of maternal involvement and warmth on SES disparities in asthma-related immune responses, assessed via glucocorticoid resistance (GR) of immune cells.

METHODS

One hundred and forty-three youth (10-16 years of age) with asthma completed measures of maternal involvement and warmth, and their primary caregivers reported their levels of education, income, and financial stress. Peripheral blood mononuclear cells from youth's blood were isolated, cultured, and assayed to determine mitogen-stimulated (PMA/INO + Etho) and mitogen/hydrocortisone-stimulated (PMA/INO + Cort) levels of two Th-2 cytokines (i.e., interleukin-5, interleukin-13) and one Th-1 cytokine (i.e., interferon-γ). GR was calculated by subtracting log-transformed cytokine concentration in the PMA/INO + Etho samples from log-transformed cytokine concentration in the PMA/INO + Cort samples.

RESULTS

Both maternal involvement and warmth moderated the indirect pathway from family SES to GR of Th-2 cytokines via financial stress. Specifically, we found that low family SES was associated with elevated GR of Th-2 cytokines via increased financial stress among youth reporting low levels of maternal involvement and warmth, but not among those reporting high levels of maternal involvement or warmth.

CONCLUSIONS

These results highlight the protective role of maternal involvement and warmth in health-related biological processes modulated by family SES among youth with asthma.

Knowledge, attitudes, and practices concerning cockroach exposure among caregivers of children with asthma

Background

Cockroach allergen is one of the most important asthma triggers for children. There is an extensive body of research on interventions to reduce exposure. However, adherence to these interventions is low. Insight into the knowledge, attitudes, and practices (KAP) associated with cockroach remediation is needed. We assessed KAP using the Health Beliefs Model (HBM) as a framework for predicting behavior. This study aimed to assess the socio-demographic and psycho-social characteristics associated with cockroach KAP and to quantify the relationship between KAP and number of cockroaches in the home.

Methods

To identify factors associated with cockroach KAP a cross-sectional study was conducted using a structured questionnaire administered to caregivers of children with asthma in New Orleans, Louisiana. Positive scores in each metric of the KAP signified better cockroach knowledge, increased concern about cockroaches’ impact on health (attitudes), and participation in recommended cockroach remediation practices (practices). To evaluate cockroach KAP scores as a predictor of cockroach exposure in the home, a cohort study was conducted among a sub-sample of participants.

Results

Fifty-six caregivers participated in the study. Participants had positive scores on all subscales of KAP with knowledge having a lower score compared to attitudes and practices. Cockroach knowledge was inversely correlated with age at asthma diagnosis (ρ = − 0.36, p = 0.01). Caregivers identifying as black/African American had higher cockroach knowledge scores compared to other races (Median: 6.0 v 3.0; p = 0.05). Caregivers other than mothers had higher cockroach attitude scores (Median 6.5 v 4.0; p = 0.003) and total KAP scores (Median 18.0 v 14.0; p = 0.05). Twenty-six participants completed the cohort study. Cockroach exposure was not significantly associated with higher cockroach knowledge, cockroach practice, or total KAP score. For attitude scores, participants in the highest quartile had significantly lower exposure (β: -1.96, 95% CI: − 3.50 - 0.42) compared to those in the lowest quartile (p = 0.01).

Conclusions

Different socio-demographic and psycho-social factors were associated with the components of cockroach KAP. Greater concern about cockroaches (attitude) was significantly associated with reduced cockroach exposure. This highlights the importance of identifying the key elements of caregiver KAP to improve cockroach remediation among caregivers of children with asthma.

Exposure to violence, chronic stress, nasal DNA methylation, and atopic asthma in children

BACKGROUND

Exposure to violence (ETV) or chronic stress may influence asthma through unclear mechanisms.

METHODS

Epigenome-wide association study (EWAS) of ETV or chronic stress measures and DNA methylation in nasal epithelium from 487 Puerto Ricans aged 9-20 years who participated in the Epigenetic Variation and Childhood Asthma in Puerto Ricans study [EVA-PR]). We assessed four measures of ETV and chronic stress in children (ETV scale, gun violence, and perceived stress) and their mothers (perceived stress). Each EWAS was conducted using linear regression, with CpGs as dependent variables and the stress/violence measure as a predictor, adjusting for age, sex, the top five principal components, and SVA latent factors. We then selected the top 100 CpGs (by p value) associated with each stress/violence measure in EVA-PR and conducted a meta-analysis of the selected CpGs and atopic asthma using data from EVA-PR and two additional cohorts (Project Viva and PIAMA).

RESULTS

Three CpGs (in SNN, PTPRN2, and LINC01164) were associated with maternal perceived stress or gun violence (p = 1.28-3.36 × 10^-7 ), but not with atopic asthma, in EVA-PR. In a meta-analysis of three cohorts, which included the top CpGs associated with stress/violence measures in EVA-PR, 12 CpGs (in STARD3NL, SLC35F4, TSR3, CDC42SE2, KLHL25, PLCB1, BUD13, OR2B3, GALR1, TMEM196, TEAD4, and ANAPC13) were associated with atopic asthma at FDR-p < .05.

CONCLUSIONS

Pending confirmation in longitudinal studies, our findings suggest that nasal epithelial methylation markers associated with measures of ETV and chronic stress may be linked to atopic asthma in children and adolescents.

Association of stress management skills and stressful life events with allergy risk: a case-control study in southern China

BACKGROUND

Psychosocial stress and stressful life events are known to aggravate allergic diseases. Less is known about the impact of stress management skills on allergies. Here we sought to determine whether stress management skills are associated with the allergies and to assess the combined effects of stress management skills and stressful events on allergy risk.

METHODS

A survey on risk factors for self-reported allergic diseases was carried out among 28,144 southern Chinese people; 14 stressful life events and 8 stress management skills were retrospectively recorded in a case-control setting with multivariate logistic regression analysis. Multiplicative and additive interactions between stressful events and stress management skills were evaluated.

RESULTS

Stressful events significantly increased allergy risk. The odds ratio (OR) for allergies was 1.65 (95% confidence interval CI, 1.41-1.93) for those reporting one or two stressful events and 3.10 (95% CI, 2.55-3.79) for those reporting more than three stressful events compared to participants without stressful events. Stress management skills were adversely associated with allergic risk for people experiencing stressful events (OR, 0.71; 95% CI, 0.53-0.97) when adjusted demographically, particularly "concentrate on pleasant thoughts at bedtime" (OR, 0.67; 95% CI, 0.51-0.89), "pace myself to prevent tiredness" (OR, 0.67; 95% CI, 0.54-0.83), "get enough sleep" (OR, 0.48; 95% CI, 0.32-0.72) and "take some time for relaxation each day" (OR, 0.55; 95% CI, 0.37-0.80). But in people without stressful events, no association was observed. There was a significant linear trend for allergy risk from good stress management skills with no stressful events to poor stress management skills with stressful events (P < 0.001), with significant interaction in additive models (P = 0.006).

CONCLUSIONS

There are independent and antagonistic combined associations of stressful life events and stress management skills with allergy risk. The data supports the use of stress management skills in managing allergic disease among people with stressful life events.

The Association between Vigorous Physical Activity and Stress in Adolescents with Asthma

Asthma is a very common condition that affects 5-10% of the global population, and its prevalence is increasing. Vigorous physical activity (PA) is effective in improving cardiorespiratory fitness and managing stress. This study aimed to investigate the association between vigorous PA and stress among Korean adolescents with asthma using large-scale survey data. The questionnaire data of 57,303 adolescents were analyzed using raw data from the 2019 Korea Youth Risk Behavior Web-Based Survey. We performed logistic regression analysis to calculate the stress odds ratios (ORs) and 95% confidence intervals (CIs) for asthma and non-asthma groups using models 1 and 2. We also performed logistic regression analysis to calculate the stress OR for the asthma group with vigorous PA and non-vigorous PA using models 1, 2, and 3. Model 1 was adjusted for age, sex, obesity, smoking, and alcohol status; model 2 was further adjusted for household income, academic achievement, and comorbidities. Model 3 was further adjusted for moderate activity and resistance exercise. The OR of stress was 20% higher in the asthma group than in the non-asthma group (p < 0.05). In the fully adjusted models, the OR for the non-asthma group with vigorous PA versus non-vigorous PA was 0.89 (95% CI: 0.84-0.94). However, the OR for the asthma group with vigorous PA versus non-vigorous PA was 0.70 (95% CI: 0.57-0.86), indicating that adolescents who engage in vigorous PA had lower stress in the asthma group (p < 0.05). This study demonstrated that adolescents with asthma had higher stress levels than those without asthma; however, vigorous PA was associated with lower stress. These effects were more pronounced in adolescents with asthma.