The relationship of psychologic stress with childhood asthma

Work-related stress and incident asthma and rhinitis: results from the SOLAR study

OBJECTIVES

This study analyzes the association of work-related stress with incident asthma and rhinitis in young adults with a special focus on gender-specific differences.

METHODS

Incident asthma, wheezing and rhinitis were measured in a cohort of 2051 young German adults (aged 16-18 years at baseline) recruited by the prospective population-based SOLAR study (Study of Occupational Allergy Risks). Work-related stress was measured by the Trier Inventory for the Assessment of Chronic Stress (TICS). Two TICS scales, work overload and work discontent, were analysed. Logistic regression was conducted to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

In females, the odds for incident asthma were found to be 17% higher for each increase of the work discontent score by one point (OR 1.17, 95% CI 1.04-1.31). In males, no association was statistically significant. Incident rhinitis showed no association with any exposure variable.

CONCLUSION

This study shows a link between work-related stress and incident asthma which seems to be confined to women. This study adds evidence about the association of work-related stress and asthma in young adults and can contribute to prevention for that particular age group.

Parental Depressive Symptoms Potentiate the Effect of Youth Negative Mood Symptoms on Gene Expression in Children with Asthma

Depressive symptoms in parents and in youths have been found to relate to disease comorbidity processes in children, including greater disease-related impairment and poorer clinical outcomes. The current study sought to assess whether coming from a family characterized by more depressive symptoms on average would potentiate the effects of changes in youths' own negative mood on the expression of two receptor genes relevant to asthma that are the primary targets of asthma medication, such that the combination of low child negative mood in the context of greater parental depressive symptoms would relate to the lowest levels of gene expression. One-hundred-twenty youths with diagnosed asthma and their parents participated every 6 months for 2 years. Parents reported on their depressive symptoms, children reported negative mood symptoms, and youths completed blood draws from which expression of Glucocorticoid Receptor (GR) and Beta2 Adrenergic Receptor (β2-AR) genes was extracted. Multilevel linear modeling revealed significant interactions between average levels of parental depressive symptoms and changes in youths' negative mood symptoms predicting gene expression, such that youths expressed significantly less GR and β2-AR during times when they experienced more negative mood symptoms, but this was only true if they came from families with higher levels of average parental depressive symptoms. The current study identifies novel and biologically-proximal molecular signaling patterns that connect depressive symptoms to pediatric asthma while also highlighting the important role of family environment for biological processes that may operate within depression comorbidity.

Prenatal maternal depression related to allergic rhinoconjunctivitis in the first 5 years of life in children of the EDEN mother-child cohort study

Backgroud: Evidence about the relationship between prenatal maternal depression and the development of childhood asthma and allergies in early life is scarce. We aimed to examine this relationship by using data set of EDEN mother-child cohort study. A total of 1139 children were followed-up until the age of 5 years.

METHODS

Prenatal maternal depression was self-reported by using the Centre for Epidemiological Studies-Depression scale (CES-D) questionnaire and was classified into binary variable (maternal depression [CES-D score of ≥16] and no maternal depression [CES-D score of <16]). Asthma and allergies in the first 5 years were assessed by using the questionnaire of the International Study of Asthma and Allergies in Childhood (ISAAC). Adjusted odds ratio (aOR) was estimated for the relationship between prenatal maternal depression and early life asthma and allergies by marginal models through the method of generalized estimating equation (GEE) when adjusting for the confounders.

RESULTS

In our study population, 13.67 % of the mothers had clinical significant depression (the total scores for CES-D ≥16) during pregnancy. For children ages 5 years, the prevalence of wheezing, physician-diagnosed asthma, physician-diagnosed eczema and allergic rhinoconjunctivitis were 46.78, 20.99, 29.17, and 22.54%, respectively. Prenatal maternal depression was associated with ever allergic rhinoconjunctivitis (aOR 1.87 [95% confidence interval {CI}, 1.33-2.62]). No significant relationships were found between prenatal maternal depression and wheezing, physician-diagnosed asthma and physician-diagnosed eczema (aOR 1.12 [95% CI, 0.91-1.39], aOR 1.23 [95% CI, 0.81-1.85] and aOR 1.17 [95% CI, 0.86-1.61], respecitvely).

CONCLUSION

Prenatal maternal depression was related to ever allergic rhinoconjunctivitis in the first 5 years of life in children of EDEN mother-child cohort study.

Evaluation of quality of life according to asthma control and asthma severity in children and adolescents

OBJECTIVE:

To evaluate quality of life according to the level of asthma control and degree of asthma severity in children and adolescents.

METHODS:

We selected children and adolescents with asthma (7-17 years of age) from the Pediatric Pulmonology Outpatient Clinic of the State University of Campinas Hospital de Clínicas, located in the city of Campinas, Brazil. Asthma control and asthma severity were assessed by the Asthma Control Test and by the questionnaire based on the Global Initiative for Asthma, respectively. The patients also completed the Paediatric Asthma Quality of Life Questionnaire (PAQLQ), validated for use in Brazil, in order to evaluate their quality of life.

RESULTS:

The mean age of the patients was 11.22 ± 2.91 years, with a median of 11.20 (7.00-17.60) years. We selected 100 patients, of whom 27, 33, and 40 were classified as having controlled asthma (CA), partially controlled asthma (PCA), and uncontrolled asthma (UA), respectively. As for asthma severity, 34, 19, and 47 were classified as having mild asthma (MiA), moderate asthma (MoA), and severe asthma (SA), respectively. The CA and the PCA groups, when compared with the NCA group, showed higher values for the overall PAQLQ score and all PAQLQ domains (activity limitation, symptoms, and emotional function; p < 0.001 for all). The MiA group showed higher scores for all of the PAQLQ components than did the MoA and SA groups.

CONCLUSIONS:

Quality of life appears to be directly related to asthma control and asthma severity in children and adolescents, being better when asthma is well controlled and asthma severity is lower.

The role of caregiver social support, depressed mood, and perceived stress in changes in pediatric secondhand smoke exposure and asthma functional morbidity following an asthma exacerbation

OBJECTIVE

Caregiver depressed mood and stress are associated with increased child asthma functional morbidity (AFM) and secondhand smoke exposure (SHSe), whereas social support (SS) reduces risk. This study extends previous literature by examining (1) longitudinal patterns of pediatric AFM and SHSe and (2) how caregiver stress, depressed mood, and SS are related to child SHSe and AFM changes.

METHOD

Participants were 334 caregivers who smoked, had a child with asthma, and were enrolled in a smoking cessation induction/asthma intervention. SHSe and AFM were measured at baseline and 4, 6, and 12 months. All measures were caregiver self-report. We used an autoregressive latent trajectory model to examine the intercept, linear, and quadratic growth factors and autoregressive and cross-lagged effects of SHSe and AFM.

RESULTS

After an asthma exacerbation, decreases in child AFM and SHSe were followed by respective increases over time. Child SHSe at 4 months and 6 months predicted subsequent child AFM. Autoregressive paths were significant for only AFM. Higher baseline caregiver depressed mood and stress predicted higher baseline child AFM but not other growth factors. Higher baseline caregiver self-esteem SS was associated with only lower baseline child AFM and fewer increases in AFM across time. Exploratory analyses indicated higher baseline caregiver depressed mood and stress were associated with less-favorable changes in child SHSe and AFM.

CONCLUSIONS

Caregiver depressed mood, stress, and SS should be considered when addressing pediatric SHSe and AFM. Caregiver support may be needed to maintain intervention gains. (PsycINFO Database Record

Indicators of violence and asthma: An ecological study

BACKGROUND

Global studies on asthma point to socioeconomic status as one of the main variables in terms of prevalence and disease severity in various parts of the world. Social factors related to community violence have been linked to higher incidence of asthma in the current studies. This study investigates the relationship between indicators of both community violence and development and hospital admissions due to asthma.

METHODS

This was an analytical ecological study of multiple groups, using public databases with information up until 2006. All Brazilian municipalities with more than 100,000 inhabitants were considered as units of analysis. The main index used as socioeconomic indicator was the FIRJAN Index of Municipal Development (FIMD). The Index of Youth Vulnerability to Violence (IYVV) was used as indicators of community violence. The rate of admissions due to asthma was used as the outcome. Pearson's correlation was used for multivariate analyses. The coefficient of determination (R(2)) was calculated and the simple linear regression model adjusted for significant correlations.

RESULTS

There was an inverse correlation between asthma admissions and FIMD (r = -0.354, p < 0.001), with statistical significance for all dimensions of the index. Admissions due to asthma were associated with the IYVV (r = 0.240, p < 0.001) and its component related to school attendance and employment (r = 0.315, p < 0.001), homicides (r = 0.112, p = 0.034), and poverty (r = 0.303, p < 0.001).

CONCLUSIONS

There was a direct correlation between indicators of violence and rates of admission due asthma, and an inverse correlation with indicators of development. These results suggest that social detriment can act as a risk factor for hospital admissions due to asthma.

Major affective disorders in chronic obstructive pulmonary disease compared with other chronic respiratory diseases

Background

Chronic obstructive pulmonary disease (COPD) and other chronic respiratory diseases (CRDs) have significant impacts on quality of life including psychomotor domain.

Purpose

To evaluate three major affective disorders in subjects with COPD compared with other CRDs and nonill population.

Materials and methods

The Thai version of Mini International Neuropsychiatric Interview (MINI) was used as a diagnostic instrument for three major affective disorders (generalized anxiety disorder, major depressive disorder, and panic disorder) by face-to-face interview in assessing patients with CRDs [COPD, asthma, rhinasthma, all asthma (asthma and rhinasthma), and chronic rhinitis], and nonill subjects. Logistic regression analyses were used to determine the relation between major affective disorders and CRDs adjusting for age, sex, and disease severity.

Results

Major affective disorders were more prevalent in CRDs than nonill groups (adjusted OR =2.6 [95% CI, 1.8−3.9], P<0.001). COPD patients had significantly more generalized anxiety and panic disorder (adjusted OR =4.0 [95% CI, 1.4−11.9], P=0.011, and 4.4 [95% CI, 1.1−18.1], P=0.038, respectively) but not major depressive disorder (adjusted OR =2.7 [95% CI, 0.8−9.0, P=0.105]) than nonill group. Comparing with all asthma, COPD patients had lower occurrence of major depressive and panic disorders (adjusted OR =0.1 [95% CI, 0.0−0.4], P=0.002, and 0.1 [95% CI, 0.0−0.9], P=0.043, respectively). There was no difference in major mood disorders in COPD, rhinasthma, and chronic rhinitis patients. Major affective disorders were not increased by disease severity in COPD.

Conclusion

Major affective disorders were significantly higher in CRDs than nonill population. Generalized anxiety and panic disorders were significantly high in COPD patients. Moreover, major depressive and panic disorders in COPD were significantly lower than all asthma. The prevalence of major affective disorders may not be related to severity of COPD.

Research on psychosocial aspects of asthma in the Arab world: a literature review

The importance of psychosocial factors in the management of bronchial asthma has long been recognized. This paper offers a review of research published in the English language related to psychosocial aspects of bronchial asthma in Arab countries. Several databases (PubMed, Science Direct, Springer Link, ERIC, and PsychInfo) were searched using the following keywords: bronchial asthma, Arab countries, Algiers, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine (West Bank, Gaza), Qatar, Saudi Arabia, Syria, Tunisia, Sudan, Somalia; United Arab Emirates, and Yemen. Thirty-two studies were conducted in 9 Arab countries. Almost all studies found were published in the last fourteen years with an apparent increasing rate in the last five years. In descending order, these studies addressed: knowledge of and attitudes toward asthma, quality of life, behavioral and emotional problems and factors related to academic achievement. The main results of the studies reviewed were: (a) physicians', school staff's, and parents' knowledge of and attitudes toward asthma were generally unsatisfactory, (b) in-service asthma education programs significantly impacted parent and staff knowledge and attitudes, and asthma management practices, (c) quality of life in children and adolescents was significantly adversely affected by asthma, (d) asthma was a common cause of school absenteeism, and had a significant negative impact on academic achievement of students, and (e) students with asthma had significantly higher rates of behavioral and emotional difficulties compared to students without asthma. The paper concludes with a discussion about the implications of these results and a call for further research in this area.

Psychosomatic treatment for allergic diseases

Many reports have been published concerning how psychosocial stress influences the occurrence and progression of allergic diseases such as bronchial asthma and atopic dermatitis. As for asthma, a typical allergic disease often accompanied by psychosomatic related problems, the Global Initiative for Asthma (GINA), international medical guidelines for asthma, describes psychosocial problems as causative factors of poor asthma control and as risk factors for asthma exacerbation, even if symptoms are well controlled. However, because there is little high quality evidence for effective treatments for asthma patients with psychosocial problems, concrete assessments and treatments for such problems is scarcely described in GINA. Therefore, psychosomatic intervention for asthma patients is not effectively conducted on a worldwide scale. In contrast, the “Japanese Guidelines for the Diagnosis and Treatment of Psychosomatic Diseases” describe the assessment and treatment of psychosomatic disorders in detail. In the guidelines, psychosocial factors are classified into five categories; 1) Relation between stress and asthma occurrence or progression, 2) Relation between emotion and asthma symptoms, 3) Problems related to a patient’s character and behaviors, 4) Problems of daily life and Quality of Life (QOL), and 5) Problems related to family relationships and life history. The employment of a self-administered questionnaire, the “Psychosomatic Questionnaire related to Asthmatic Occurrence and Progression”, is useful for clarifying psychosocial factors and for setting up treatment strategies according to the problems identified. The Japanese guidelines have been proven to be useful, but empirical evidence for their effectiveness is still relatively limited. It will be necessary in the future to accumulate high-quality evidence and to revise the psychosomatic approaches in the guidelines that are universally valid.

Psychological stress and hospitalization for childhood asthma-a nationwide cohort study in two Nordic countries

OBJECTIVE

Exposures to psychological stress in early life may contribute to the development or exacerbation of asthma. We undertook a cohort study based on data from several population-based registers in Denmark and Sweden to examine whether bereavement in childhood led to increased asthma hospitalization.

METHODS

All singleton children born in Denmark during 1977-2008 and in Sweden during 1973-2006 were included in the study (N=5,202,576). The children were followed from birth to the date of first asthma hospitalization, emigration, death, their 18(th) birthday, or the end of study (31 December 2007 in Sweden and 31 December 2008 in Denmark), whichever came first. All the children were assigned to the non-bereaved group until they lost a close relative (mother, father or a sibling), from when they were included in the bereaved group. We evaluated the hazard ratio (HR) of first hospitalization for asthma in bereaved children using Cox proportional hazards regression models, compared to those who were in the non-bereaved group. We also did a sub-analysis on the association between bereavement and first asthma medication.

RESULTS

A total of 147,829 children were hospitalized for asthma. The overall adjusted HR of asthma hospitalization in bereaved children was 1.10 (95% confidence interval (CI): 1.04-1.16), compared to non-bereaved children. The risk of asthma hospitalization was increased in those who lost a close relative at age of 14-17 years (HR=1.54, 95% CI: 1.23-1.92), but not in younger age groups. The association between bereavement and asthma hospitalization did not change over time since bereavement. In the sub-analysis in singleton live births during 1996-2008 recorded in the DMBR, bereavement was associated with a lower use of asthma medication (HR=0.87, 95% CI: 0.80-0.95).

CONCLUSIONS

Our data suggests that psychological stress following bereavement in late adolescence is associated with an increased risk of asthma hospitalization or lowers the threshold for asthma hospitalization.

Asthma, life events and psychiatric disorders: a population-based study

PURPOSE

Although asthma and other chronic physical conditions have been shown to be associated with psychiatric symptoms, the relative contributions of negative life events to this association and impaired quality of life (QOL) are not clear.

METHODS

This is a cross-sectional study of a nationally representative sample of Singaporean adults aged 20-59 (n = 2,847). Individuals were grouped by asthma, other chronic physical conditions, and no chronic physical conditions. Participants were assessed life events (list of threatening experiences questionnaire), psychiatric disorders [schedule for clinical assessment in neuropsychiatry diagnoses of psychiatric disorder including any psychiatric disorder, major depressive disorder (MDD) and generalized anxiety disorder (GAD)], and QOL (medical outcomes study 12-item short form).

RESULTS

In multivariate analyses controlling for confounding variables, asthma and other chronic physical conditions, compared to no chronic physical conditions, both showed similarly (two- to four-fold) elevated odds ratio (OR) of association with MDD and GAD. However, the asthma group reported more life events as compared to other chronic physical conditions (OR = 4.33, 95 % CI: 2.09-8.95) or no chronic physical conditions (OR = 7.64, 95 % CI: 3.87-15.06). Life events accounted significantly for excess coexistence of psychiatric disorders with asthma over participants without chronic physical conditions. It also contributed significantly to relatively worse QOL observed among individuals with asthma.

CONCLUSIONS

In this cross-sectional study, life events among adults in Singapore appeared to mediate the co-occurrence of psychiatric disorders and functional impairment with asthma, more than with other chronic physical conditions. This should be further investigated in longitudinal studies.

Intra-ethnic disparities in respiratory health problems among Hispanic residents impacted by a flood

OBJECTIVES

The primary objective of this article is to assess the respiratory health impacts of a flood disaster on Hispanic people residing in the United States, with a focus on intra-ethnic disparities related to age, sex, socioeconomic status, mold exposure, family conflict, English-language proficiency, and a lack of US citizenship.

METHODS

Data were collected in 2010 after a flood disaster (2006) in El Paso County (Texas), which has a Hispanic majority population. A mail-out population-based survey was used retrospectively to assess respiratory health impacts for 363 people residing in 176 self-identified Hispanic households impacted by the flood; logistic regression was utilized to assess intra-ethnic health disparities in flood impacts.

RESULTS

About 41% of individuals experienced one or more post-flood respiratory health problem. Lower income (OR = 0.532,p = .002), mold exposure (OR = 2.267, p < .001), increased family conflict (OR = 1.452, p = .025), English-language proficiency (OR = 4.023, p < .001) and a lack of US citizenship (OR = 13.111, p = .013) were significantly associated with higher odds of respiratory health problems in the regression model.

CONCLUSION

Statistical findings provide evidence of intra-ethnic disparities in post-flood respiratory health status. Specifically within this Hispanic sample, individuals with lower household incomes, whose homes were covered by larger surface areas of mold, and whose families were characterized by increased tension experienced higher odds of post-flood respiratory health problems. Interestingly, greater English-language proficiency and lacking US citizenship were also risk factors. Given that this is one of the first studies of intra-Hispanic disparities in health following a US-based disaster, the findings underscore the importance of considering diversity within the US Hispanic population when studying environmental and post-disaster respiratory health.

A life course perspective on stress and health among caregivers of children with asthma in Detroit

Low-income caregivers raising children with asthma experience many obstacles to their own health, including stress. To understand and describe their daily experiences, researchers conducted 40 qualitative interviews supplemented with descriptive quantitative surveys in Detroit, Michigan, as part of a community-based participatory research partnership of Community Action Against Asthma. Prevalence of chronic illness is noticeably higher among participants than the general US population. Caregivers identified stress processes that may influence disproportionate health outcomes and risk-related behaviors over their lifetime. Applying a life course perspective, findings suggest that public health interventions should address family-level comorbidities, increase instrumental social support, and acknowledge practical coping mechanisms.

Socioeconomic status and the health of youth: a multilevel, multidomain approach to conceptualizing pathways

Previous research has clearly established associations between low socioeconomic status (SES) and poor youth physical health outcomes. This article provides an overview of the main pathways through which low SES environments come to influence youth health. We focus on 2 prevalent chronic health problems in youth today, asthma and obesity. We review and propose a model that encompasses (a) multiple levels of influence, including the neighborhood, family and person level; (b) both social and physical domains in the environment; and finally (c) dynamic relationships between these factors. A synthesis of existing research and our proposed model draw attention to the notion of adverse physical and social exposures in youth's neighborhood environments altering family characteristics and youth psychosocial and behavioral profiles, thereby increasing youth's risk for health problems. We also note the importance of acknowledging reciprocal influences across levels and domains (e.g., between family and child) that create self-perpetuating patterns of influence that further accentuate the impact of these factors on youth health. Finally, we document that factors across levels can interact (e.g., environmental pollution levels with child stress) to create unique, synergistic effects on youth health. Our model stresses the importance of evaluating influences on youth's physical health not in isolation but in the context of the broader social and physical environments in which youth live. Understanding the complex relationships between the factors that link low SES to youth's long-term health trajectories is necessary for the creation and implementation of successful interventions and policies to ultimately reduce health disparities.

Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity a community guide systematic review

CONTEXT

A recent systematic review of home-based, multi-trigger, multicomponent interventions with an environmental focus showed their effectiveness in reducing asthma morbidity among children and adolescents. These interventions included home visits by trained personnel to assess the level of and reduce adverse effects of indoor environmental pollutants, and educate households with an asthma client to reduce exposure to asthma triggers. The purpose of the present review is to identify economic values of these interventions and present ranges for the main economic outcomes (e.g., program costs, benefit-cost ratios, and incremental cost-effectiveness ratios).

EVIDENCE ACQUISITION

Using methods previously developed for Guide to Community Preventive Services economic reviews, a systematic review was conducted to evaluate the economic efficiency of home-based, multi-trigger, multicomponent interventions with an environmental focus to improve asthma-related morbidity outcomes. A total of 1551 studies were identified in the search period (1950 to June 2008), and 13 studies were included in this review. Program costs are reported for all included studies; cost-benefit results for three; and cost-effectiveness results for another three. Information on program cost was provided with varying degrees of completeness: six of the studies did not provide a list of components included in their program cost description (limited cost information), three studies provided a list of program cost components but not a cost per component (partial cost information), and four studies provided both a list of program cost components and costs per component (satisfactory cost information).

EVIDENCE SYNTHESIS

Program costs per participant per year ranged from $231-$14,858 (in 2007 U.S.$). The major factors affecting program cost, in addition to completeness, were the level of intensity of environmental remediation (minor, moderate, or major), type of educational component (environmental education or self-management), the professional status of the home visitor, and the frequency of visits by the home visitor. Benefit-cost ratios ranged from 5.3-14.0, implying that for every dollar spent on the intervention, the monetary value of the resulting benefits, such as averted medical costs or averted productivity losses, was $5.30-$14.00 (in 2007 U.S.$). The range in incremental cost-effectiveness ratios was $12-$57 (in 2007 U.S.$) per asthma symptom-free day, which means that these interventions achieved each additional symptom-free day for net costs varying from $12-$57.

CONCLUSIONS

The benefits from home-based, multi-trigger, multicomponent interventions with an environmental focus can match or even exceed their program costs. Based on cost-benefit and cost-effectiveness studies, the results of this review show that these programs provide a good value for dollars spent on the interventions.

Treatment of psychological factors in a child with difficult asthma: a case report

Difficult asthma is defined as the persistence of asthma symptoms, abnormal pulmonary function showing airway obstruction, and continued requirement for short-acting bronchodilator therapy, despite adequate treatment with inhaled corticosteroids. It calls for a thorough evaluation of the patient to look into alternate and complicating diagnoses. The authors report a case of a 9-year-old patient with difficult asthma who failed to respond to conventional therapy. Although it was recognized that he had a number of potential medical complicating factors including allergies, chronic sinusitis, and gastroesophageal reflux, a psychological intervention using hypnosis ultimately appeared to help alleviate his symptoms completely. Thus, psychological evaluation and intervention should be considered early in the course of management of a patient with difficult asthma, because it may help avoid time-consuming and expensive investigations of potential complicating factors, and it may yield rapid improvement in the patient's clinical condition.

Clinical potentials for measuring stress in youth with asthma

It is well established that the course of asthma can be affected by the psychological stress an individual experiences. This article reviews literature assessing the effects of psychological stress on asthma outcomes and discusses the benefits and disadvantages of different measures for assessing stress, including subjective questionnaires, event checklists, and interview-based approaches. We discuss the importance of taking into account the timing and chronicity of stress, as well as individuals' subjective appraisals of stress. We suggest that, although questionnaire and checklist approaches are easier to administer, interview-based stress assessments are preferable, where feasible, because they generate richer and more in-depth information regarding the stressors that people experience. In addition, this kind of information seems to be more robustly linked to pediatric asthma outcomes of interest.

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.

Is elevated noradrenaline an aetiological factor in a number of diseases?

1 Here I put forth the hypothesis that noradrenaline (NA), which is a signalling molecule in the brain and sympathetic nervous system (SNS), is an aetiological factor in a number of diseases. 2 In a previous paper (Fitzgerald, Int. J. Cancer, 124, 2009, 257), I examined evidence that elevated NA is a factor in various types of cancer. Here I extend the argument to several other diseases, including diabetes mellitus, open-angle glaucoma, osteoarthritis and rheumatoid arthritis and asthma. 3 The principal hypothesis is that, largely as a result of genetics, elevated noradrenergic tone in the SNS predisposes a large number of individuals to a broad range of diseases. 4 For each of the above five diseases, I briefly examine the following four lines of evidence to assess the hypothesis: i) whether pharmacological studies in rodents that manipulate NA levels or receptors affect these diseases; ii) whether pharmacological manipulation of NA in humans affects these diseases; iii) whether bipolar disorder, excessive body weight, and hypertension, which may all three involve elevated NA, tend to be comorbid with these diseases and iv) whether psychological stressors tend to cause or exacerbate these conditions, since psychological stress is associated with increased release of NA. 5 The four lines of evidence tend to support the hypothesis.

Asthma and lower respiratory symptoms in New York State employees who responded to the World Trade Center disaster

PURPOSE

To investigate whether New York State employees who responded to the World Trade Center disaster were more likely to report asthma or lower respiratory symptoms (LRS; cough, wheeze, chest tightness, shortness of breath) than non-exposed employees, 2 years post-September 11.

METHODS

Participants (578 exposed, 702 non-exposed) completed mailed questionnaires in 2003. A unique exposure assessment method was used; exposure scores were divided at the mean (at/below, above). Poisson regression was used.

RESULTS

Exposure was associated with LRS, but not asthma. Participants with exposure scores at/below the mean had a twofold increased risk of most LRS. Those with scores above the mean had a three to fourfold increased risk. For scores above the mean, the magnitude of effect was consistently higher for smoke exposure.

CONCLUSIONS

Moderately exposed responders may experience health impacts from exposures in later stages of a disaster. Exposure to smoke may have had a greater lower respiratory impact than resuspended dust.

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.

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.

Translating theory into practice: using Action Research to introduce a coordinated approach to emotional care

OBJECTIVE

This paper describes a translational project that explored the feasibility and effect of introducing a coordinated approach to emotional care.

METHODS

The project was undertaken using Action Research on one ward at St John of God Hospital Subiaco, Western Australia. A senior Registered Nurse was appointed to provide the leadership and direction to staff regarding emotional care and an education program for staff was provided. The project was evaluated using both quantitative and qualitative data.

RESULTS

Data demonstrated an increase in the patient's evaluation of emotional care, although levels were found to fluctuate throughout the project. Factors such as the emotional distress of the staff were hypothesised as impacting on the delivery of emotional care.

CONCLUSION

The approach used in this project was found to be a useful method of improving emotional care. However, the data collected in this study revealed the complexity of emotional care delivery and the possible impact of a number of factors within the environment.

PRACTICE IMPLICATIONS

Emotional care delivery can be improved by using a coordinated research-based educational approach led by a clinical champion. However, the impact of other factors within the hospital environment needs to be considered and more research is required.

Family psychological factors in relation to children's asthma status and behavioral adjustment at age 4

The objectives of this study were to determine whether family psychosocial factors influenced asthma development by age 4, and whether family factors and early wheezing illness were associated with behavioral adjustment at age 4. Participants were 98 children enrolled in an intervention study at 9-24 months and followed to age 4. Baseline evaluations assessed infants' respiratory illness severity, family psychosocial characteristics, and parental risk factors for asthma development. Active asthma categorization at age 4 utilized both parent report and objective data. Parents completed the Child Behavior Checklist (CBCL). Caregiver single-parent status, a composite of baseline family stresses, and early wheezing illness severity were associated with active asthma at age 4. The contribution of prenatal smoke exposure and early hospitalization to active asthma varied with racial/ethnic group membership. Maternal mental health and family stresses predicted CBCL scores at age 4, whereas early illness severity and hospitalization were unrelated to CBCL scores. CBCL scores were not elevated for children with active asthma at age 4. Family factors consistent with a negative emotional environment were associated with both active asthma and adjustment problems at age 4, suggesting that both outcomes may be influenced by a common factor.

The role of the social environment in children and adolescents with asthma

RATIONALE

Biopsychosocial models of asthma have been proposed in the literature, but few empirical tests of social factors at various levels of influence have been conducted.

OBJECTIVES

To test associations of neighborhood, peer, and family factors with asthma outcomes in youth, and to determine the pathways through which these social factors operate.

METHODS

Observational study of youths with asthma (n = 78).

MEASUREMENTS AND MAIN RESULTS

Youths completed questionnaires about neighborhood problems, peer support, and family support. Biological (IgE, eosinophil count, production of IL-4) and behavioral (youth smoking, exposure to smoke, adherence to medications) pathways were measured. Asthma symptoms and pulmonary function were assessed in the laboratory and at home for 2 weeks. Lower levels of family support were associated with greater symptoms (beta coefficients: -0.26 to -0.33, P < 0.05) and poorer pulmonary function (beta: 0.30, P < 0.05) via biological pathways (Z statistics from 1.19 to 1.51, P < 0.05). Higher levels of neighborhood problems were associated with greater symptoms (beta coefficients: 0.27-0.33, P < 0.05) via behavioral pathways related to smoking (Z statistics = 1.40, P < 0.05). Peer support was not associated with symptoms or pulmonary function.

CONCLUSIONS

This study indicates that family factors may affect youths' asthma via physiologic changes, whereas community factors may help shape the health behaviors of youths with asthma.

Prioritizing environmental issues around the world: opinions from an international Central and Eastern European environmental health conference

BACKGROUND

As the next generation of scientists enters the field of environmental health, it is imperative that they view their contributions in the context of global environmental stewardship. In this commentary, a group of international graduate students facilitated by three experienced environmental health scientists present their views on what they consider to be the global environmental health concerns of today. This group convened initially in October 2004 at an international health conference in Prague, Czech Republic.

OBJECTIVES

In this report we identify perceived environmental health concerns that exist around the world, with a focus on Central and Eastern Europe. Additionally, we address these perceived problems and offers some potential solutions.

DISCUSSION

At the meeting, students were invited to participate in two panel discussions. One group of young international scientists identified several significant global environmental health concerns, including air pollution, occupational hazards, and risk factors that may exacerbate current environmental health issues. The second panel determined that communication, education, and regulation were the mechanisms for addressing current environmental challenges.

CONCLUSIONS

In this commentary we expand on the views presented at the meeting and represent the concerns of young investigators from nine different countries. We provide ideas about and support the exchange of information between developed and developing countries on how to handle the environmental health challenges that face the world today.

Socioeconomic status and inflammatory processes in childhood asthma: The role of psychological stress

BACKGROUND

Although social environment variables such as socioeconomic status (SES) have been linked to childhood asthma, little is known about the psychobiological mechanisms underlying this relationship.

OBJECTIVES

The goal of this study was to investigate relationships among SES, psychological stress, and immune processes implicated in asthma.

METHODS

Thirty-seven children ages 9 to 18 years, physician-diagnosed with asthma, and 39 healthy children participated. Families were interviewed about chronic life stress, perceptions of threat, and SES. Blood samples were drawn from children to assess stimulated production of cytokines implicated in asthma (IL-4, IL-5, IL-13) and eosinophil counts.

RESULTS

In children with asthma, lower SES was associated with heightened production of IL-5 and IL-13 and higher eosinophil counts (P values < .05). Lower SES also was associated with higher chronic stress and perceived threat (both groups: P values < .05). Higher levels of stress and threat perception were associated with heightened production of IL-5 and IL-13, and higher eosinophil counts in children with asthma (P values < .05). Statistical mediation tests revealed that chronic stress and threat perception represented statistically significant pathways between SES and immune processes in children with asthma (P values < .05). In healthy children, associations were in the opposite direction from the asthma group, though generally not significant.

CONCLUSION

This is one of the first studies to document empirically a psychobiological explanation for the epidemiologic relationship between low SES and poor asthma outcomes.

CLINICAL IMPLICATIONS

Associations among SES, psychological stress, and immune pathways suggest that the experience of stress, particularly among lower SES children, has implications for childhood asthma morbidity.

Life stress and diminished expression of genes encoding glucocorticoid receptor and beta2-adrenergic receptor in children with asthma

Despite evidence that stressful experience can exacerbate the symptoms of asthma, little is known about the biological mechanisms through which this occurs. This study examined whether life stress reduces expression of the genes coding for the glucocorticoid receptor and the beta(2)-adrenergic receptor. A total of 77 children were enrolled in the study (59% male; mean age, 13.5 years). Thirty-nine of them were physician-diagnosed with asthma, and 38 were healthy. After an in-depth interview regarding stressful experiences, leukocytes were collected through antecubital venipuncture, and real-time RT-PCR was used to quantify mRNA. Chronic stress was associated with reduced expression of mRNA for the beta(2)-adrenergic receptor among children with asthma. In the sample of healthy children, however, the direction of this effect was reversed. The occurrence of a major life event in the 6 months before the study was not sufficient to influence patterns of gene expression. When such events occurred in the context of a chronic stressor, however, their association with patterns of gene expression was accentuated. Children with asthma who simultaneously experienced acute and chronic stress exhibited a 5.5-fold reduction in glucocorticoid receptor mRNA and a 9.5-fold reduction in beta(2)-adrenergic receptor mRNA relative to children with asthma without comparable stressor exposure. These findings suggest that stressful experience diminishes expression of the glucocorticoid and beta(2)-adrenergic receptor genes in children with asthma. To the extent that it diminishes sensitivity to the antiinflammatory properties of glucocorticoids or the bronchodilatory properties of beta-agonists, this process could explain the increased asthma morbidity associated with stress.