Environmental exposures and asthma morbidity in children living in urban neighborhoods

Robust identification of environmental exposures and community characteristics predictive of rapid lung disease progression

Environmental exposures and community characteristics have been linked to accelerated lung function decline in people with cystic fibrosis (CF), but geomarkers, the measurements of these exposures, have not been comprehensively evaluated in a single study. To determine which geomarkers have the greatest predictive potential for lung function decline and pulmonary exacerbation (PEx), a retrospective longitudinal cohort study was performed using novel Bayesian joint covariate selection methods, which were compared with respect to PEx predictive accuracy. Non-stationary Gaussian linear mixed effects models were fitted to data from 151 CF patients aged 6-20 receiving care at a CF Center in the midwestern US (2007-2017). The outcome was forced expiratory volume in 1 s of percent predicted (FEV1pp). Target functions were used to predict PEx from established criteria. Covariates included 11 routinely collected clinical/demographic characteristics and 45 geomarkers comprising 8 categories. Unique covariate selections via four Bayesian penalized regression models (elastic-net, adaptive lasso, ridge, and lasso) were evaluated at both 95 % and 90 % credible intervals (CIs). Resultant models included one to 6 geomarkers (air temperature, percentage of tertiary roads outside urban areas, percentage of impervious nonroad outside urban areas, fine atmospheric particulate matter, fraction achieving high school graduation, and motor vehicle theft) representing weather, impervious descriptor, air pollution, socioeconomic status, and crime categories. Adaptive lasso had the lowest information criteria. For PEx predictive accuracy, covariate selection from the 95 % CI elastic-net had the highest area under the receiver-operating characteristic curve (mean ± standard deviation; 0.780 ± 0.026) along with the 95 % CI ridge and lasso methods (0.780 ± 0.027). The 95 % CI elastic-net had the highest sensitivity (0.773 ± 0.083) while the 95 % CI adaptive lasso had the highest specificity (0.691 ± 0.087), suggesting the need for different geomarker sets depending on monitoring goals. Surveillance of certain geomarkers embedded in prediction algorithms can be used in real-time warning systems for PEx onset.

Evaluating the relationship between health-related social needs, patient demographics, and access to biologics in patients with moderate-to-severe asthma in Bronx, NY

OBJECTIVES

This study assesses the relationship between patient age, gender, race, socioeconomic status, social determinants of health (SDoH), and access to biologics (products isolated from natural sources that target specific molecules, proteins, and cells) in patients with moderate-to-severe asthma in Bronx, NY.

METHODS

Cohort of 289 patients with moderate-to-severe asthma treated at Montefiore Medical Center (MMC) from 2018 to 2020 was used. Patient demographics, self-reported social needs, and neighborhood socioeconomic characteristics were analyzed. Neighborhood socioeconomic status was estimated by determining median income in patients' residential zip codes using 2020 Census data and grouping patients based on whether neighborhood median income was above or below New York State (NYS) median ($71,117/year). Area Deprivation Index tool (ADI) was used as an additional measure of neighborhood socioeconomic status.

RESULTS

Patients living in regions with incomes below NYS median found to have longer wait times between biologic approval to administration than patients living in regions above median income (p = 0.012). Mean time from insurance approval to biologic administration was significantly different between Black and Latinx patients (p = 0.009). No significant difference found for patient regional income status and time from biologic prescription to approval. No significant differences in access to biologics were found for age, gender, number of health-related social needs, or patient ADI quartile.

CONCLUSIONS

Patients who live in areas of NYC where median income is below NYS median are more likely to experience delays in access to biologics, specifically due to time between approval and administration of medication.

Bronchiolitis recovery and the use of High Efficiency Particulate Air (HEPA) Filters (The BREATHE Study): study protocol for a multi-center, parallel, double-blind, randomized controlled clinical trial

BACKGROUND

Acute viral bronchiolitis is the most common reason for hospitalization of infants in the USA. Infants hospitalized for bronchiolitis are at high risk for recurrent respiratory symptoms and wheeze in the subsequent year, and longer-term adverse respiratory outcomes such as persistent childhood asthma. There are no effective secondary prevention strategies. Multiple factors, including air pollutant exposure, contribute to risk of adverse respiratory outcomes in these infants. Improvement in indoor air quality following hospitalization for bronchiolitis may be a prevention opportunity to reduce symptom burden. Use of stand-alone high efficiency particulate air (HEPA) filtration units is a simple method to reduce particulate matter ≤ 2.5 µm in diameter (PM2.5), a common component of household air pollution that is strongly linked to health effects.

METHODS

BREATHE is a multi-center, parallel, double-blind, randomized controlled clinical trial. Two hundred twenty-eight children < 12 months of age hospitalized for the first time with bronchiolitis will participate. Children will be randomized 1:1 to receive a 24-week home intervention with filtration units containing HEPA and carbon filters (in the child's sleep space and a common room) or to a control group with units that do not contain HEPA and carbon filters. The primary objective is to determine if use of HEPA filtration units reduces respiratory symptom burden for 24 weeks compared to use of control units. Secondary objectives are to assess the efficacy of the HEPA intervention relative to control on (1) number of unscheduled healthcare visits for respiratory complaints, (2) child quality of life, and (3) average PM2.5 levels in the home.

DISCUSSION

We propose to test the use of HEPA filtration to improve indoor air quality as a strategy to reduce post-bronchiolitis respiratory symptom burden in at-risk infants with severe bronchiolitis. If the intervention proves successful, this trial will support use of HEPA filtration for children with bronchiolitis to reduce respiratory symptom burden following hospitalization.

TRIAL REGISTRATION

NCT05615870. Registered on November 14, 2022.

Asthma exacerbations in New Zealand 2010-2019: A national population-based study

INTRODUCTION

Asthma is one of the most common long-term conditions in the world, with New Zealand (NZ) having one of the highest rates of asthma symptoms. Despite the significant burden of asthma in NZ, there is a lack of data on asthma exacerbation rates in NZ and how these have varied over time. This study is a national population-based study of asthma exacerbation rates in NZ between 2010 and 2019, and explores how these rates vary amongst different demographic groups.

METHODS

A retrospective population-based observational cohort study covering the ten years 2010-2019 to determine asthma prevalence, and asthma exacerbation and hospitalisation rates, using de-identified data from five national healthcare datasets. Exacerbations were defined based on hospital discharge diagnoses or oral corticosteroid dispensing.

RESULTS

Total number of patients with asthma was 447,797 in 2010 to 512,627 in 2019, equating to approximately 10% of the population. Of these 19.4% experienced an exacerbation in 2010 (a population rate of 376.2 per 1000 patient-years); this exacerbation rate increased to 25.1% in 2019 (438.3 per 1000 patient-years). Exacerbations rates were consistently higher for females than males, and among Pacific peoples and Māori. In contrast, hospital admissions 25% lower in 2019 than 2010, decreasing from 1.4% to 0.9%, however over 50% of these admissions were in Māori and Pacific peoples.

CONCLUSION

Asthma exacerbation rates in NZ have increased over 2010-2019, however hospitalisation rates have decreased. This potentially suggests a move away from secondary to primary care management of exacerbations and provides important information for asthma care planning.

Proinflammatory polarization of monocytes by particulate air pollutants is mediated by induction of trained immunity in pediatric asthma

BACKGROUND

The impact of exposure to air pollutants, such as fine particulate matter (PM), on the immune system and its consequences on pediatric asthma, are not well understood. We investigated whether ambient levels of fine PM with aerodynamic diameter ≤2.5 microns (PM_2.5 ) are associated with alterations in circulating monocytes in children with or without asthma.

METHODS

Monocyte phenotyping was performed by cytometry time-of-flight (CyTOF). Cytokines were measured using cytometric bead array and Luminex assay. ChIP-Seq was utilized to address histone modifications in monocytes.

RESULTS

Increased exposure to ambient PM_2.5 was linked to specific monocyte subtypes, particularly in children with asthma. Mechanistically, we hypothesized that innate trained immunity is evoked by a primary exposure to fine PM and accounts for an enhanced inflammatory response after secondary stimulation in vitro. We determined that the trained immunity was induced in circulating monocytes by fine particulate pollutants, and it was characterized by the upregulation of proinflammatory mediators, such as TNF, IL-6, and IL-8, upon stimulation with house dust mite or lipopolysaccharide. This phenotype was epigenetically controlled by enhanced H3K27ac marks in circulating monocytes.

CONCLUSION

The specific alterations of monocytes after ambient pollution exposure suggest a possible prognostic immune signature for pediatric asthma, and pollution-induced trained immunity may provide a potential therapeutic target for asthmatic children living in areas with increased air pollution.

Structural Racism and the Social Determinants of Health in Asthma

Asthma prevalence and morbidity are disproportionately higher among minoritized communities in the United States. Racial and ethnic disparities in asthma result from complex interactions across biological, environmental, and social factors. Asthma is considered a complex heterogeneous disease consisting of different phenotypes, some of which may be more common in individuals impacted by the downstream effects of structural racism and lack of access to the social determinants of health. Structural racism across generations has created and reinforced inequitable systems through policies and practices which are embedded in the economic, educational, health care, and justice systems (Bailey et al., N Engl J Med 384(8):768-773, 2021; Bailey et al., Lancet 389:1453-1463, 2017; Williams et al., Annu Rev Public Health 40:105-125, 2019). This manifests in an inequitable distribution of resources and the social determinants of health affecting an individual's physical and social environment (Bailey et al., Lancet 389:1453-1463, 2017; Thakur et al., Am J Respir Crit Care Med 202:943-949, 2020; Martinez et al., J Allergy Clin Immunol 148(5):1112-1120, 2021). In this chapter, we outline how inequity in housing, zoning laws, urban planning, education, employment, healthcare access, and healthcare delivery is linked to higher asthma prevalence and morbidity. We also describe the role that chronic physiologic stress has on asthma by enhancing neuroimmune and immunologic responses to environmental exposures. Interventions aimed at addressing the physical or social environment of an individual or community have been shown to improve asthma outcomes in patients at higher risk of severe disease.

In-home environmental exposures predicted from geospatial characteristics of the built environment and electronic health records of children with asthma

PURPOSE

Children may be exposed to numerous in-home environmental exposures (IHEE) that trigger asthma exacerbations. Spatially linking social and environmental exposures to electronic health records (EHR) can aid exposure assessment, epidemiology, and clinical treatment, but EHR data on exposures are missing for many children with asthma. To address the issue, we predicted presence of indoor asthma trigger allergens, and estimated effects of their key geospatial predictors.

METHODS

Our study samples were comprised of children with asthma who provided self-reported IHEE data in EHR at a safety-net hospital in New England during 2004-2015. We used an ensemble machine learning algorithm and 86 multilevel features (e.g., individual, housing, neighborhood) to predict presence of cockroaches, rodents (mice or rats), mold, and bedroom carpeting/rugs in homes. We reduced dimensionality via elastic net regression and estimated effects by the G-computation causal inference method.

RESULTS

Our models reasonably predicted presence of cockroaches (area under receiver operating curves [AUC] = 0.65), rodents (AUC = 0.64), and bedroom carpeting/rugs (AUC = 0.64), but not mold (AUC = 0.54). In models adjusted for confounders, higher average household sizes in census tracts were associated with more reports of pests (cockroaches and rodents). Tax-exempt parcels were associated with more reports of cockroaches in homes. Living in a White-segregated neighborhood was linked with lower reported rodent presence, and mixed residential/commercial housing and newer buildings were associated with more reports of bedroom carpeting/rugs in bedrooms.

CONCLUSIONS

We innovatively applied a machine learning and causal inference mixture methodology to detail IHEE among children with asthma using EHR and geospatial data, which could have wide applicability and utility.

Environmental Interventions for Asthma

Exposure and sensitization to environmental factors play a fundamental role in asthma development and is strongly associated with asthma morbidity. While hereditary factors are critical determinants of asthma, exposures to environmental factors are implicated in the phenotypic expression of asthma and have been strongly associated in the risk of its development. Significant interest has thus been geared toward potentially modifiable environmental exposures which may lead to the development of asthma. Allergen exposure, in particular indoor allergens, plays a significant role in the pathogenesis of asthma, and remediation is a primary component of asthma management. In the home, multifaceted and multitargeted environmental control strategies have been shown to reduce home exposures and improve asthma outcomes. In addition to the home environment, assessment of the school, daycare, and workplace environments of patients with asthma is necessary to ensure appropriate environmental control measures in conjunction with medical care. This article will discuss the role of the environment on asthma, review targeted environmental therapy, and examine environmental control measures to suppress environmental exposures in the home and school setting.

Prioritizing homelessness in emergency medicine education: A concept paper

Patients experiencing homelessness visit the emergency department (ED) often and have worse clinical outcomes. Caring for this patient population is complex, challenging, and resource-intensive. Emergency medicine (EM) education is lacking in formal curricula on the topic of homelessness, despite benefits for resident morale and patient care. Our goals were to identify a gap in EM education and training of the intersection of housing and health and propose educational topics and teaching methods to be included in residency curricula. Methodology was based on the development of a didactic session at the 2021 SAEM Annual Meeting. A needs assessment was performed through a review of medical education literature, a national survey of EM residency curricula, the individual curricula utilized by respective team members, and perspective from the team's own individual experiences with teaching about homelessness. Topics presented were chosen through discussion between the authors and determined to be common and relevant and cover a broad spectrum of content. The four presented topics included the intersection of COVID-19 and housing, the impact of LGBTQIA+ status on homelessness, housing status related to health system utilization and health outcomes, and housing inequity as a means of perpetuating structural racism. Suggestions for education of these topics included case-based learning, journal clubs, simulation, collaboration with social work, quality improvement projects, and engagement with community leaders. The ED is uniquely positioned to encounter the impacts of homelessness on health. Emergency physicians should be prepared to effectively care for these patients with complex social needs. Structured learning on this topic would benefit EM resident growth and lead to better patient care through improved screening, recognition of risk factors, and use of social resources.

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.

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.

Housing and asthma disparities

The burden of asthma disproportionately affects minority and low-income communities, resulting in racial and socioeconomic disparities in asthma prevalence, asthma exacerbations, and asthma-related death. Social determinants of health are increasingly implicated as root causes of disparities, and healthy housing is perhaps the most critical social determinant in asthma health disparities. In many minority communities, poor housing conditions and value are a legacy of historical policies and practices imbued with structural racism, including redlining, displacement, and exclusionary zoning. As a result, poor-quality, substandard housing is a characteristic feature of many underrepresented minority communities. Consequently, structurally deficient housing stock cultivates home environments rife with indoor asthma triggers. In this review we consider the historical context of urban housing policies and practices and how these policies and practices have contributed to the substandard housing conditions for many minoritized children in the present day. We describe the impact of poor housing quality on asthma and interventions that have attempted to mitigate its influence on asthma symptoms and health care utilization. We discuss the need to promote asthma health equity by reinvesting in these neighborhoods and communities to provide healthy housing.

Using the Moving To Opportunity Experiment to Investigate the Long-Term Impact of Neighborhoods on Healthcare Use by Specific Clinical Conditions and Type of Service

We performed a secondary analysis of the Moving To Opportunity (MTO) social experiment to investigate the impact of different types of housing assistance and neighborhood environments on long-term patterns of health care use for specific conditions and across different types of health care services. MTO participants, who were randomized at baseline, were linked to up to 21 years of all-payer hospital discharge and Medicaid data. Among the 9,170 children at the time of randomization, those who received a voucher had subsequent hospital admissions rates that were 36% lower for asthma and 30% lower for mental health disorders compared to the control group; rates of psychiatric services, outpatient hospital services, clinic services and durable medical equipment were also lower among the voucher groups. Findings for adults were not statistically significant. The results suggest that housing policies that reduce neighborhood poverty exposure as a child are associated with lower subsequent healthcare use for specific clinical conditions and types of services.

Allergic rhinitis aggravated by air pollutants in Latin America: A systematic review

The aim of this systematic review (SR) was to evaluate the most frequent pollutants and their effect on allergic rhinitis in Latin American countries. Observational studies up to December 2020 and comparing different indoor and outdoor pollutants that had allergic rhinitis (AR) as an outcome were included in the systematic review. Random-effect meta-analyses were conducted for the presence of allergic rhinitis. Estimates were presented as pooled odds ratios (ORs) and their respective 95% confidence intervals (CIs). Twenty-two publications comprised this review according to the inclusion and exclusion criteria and 12 had data that could be analyzed statistically. The most frequent pollutant was PM10, followed by NO2 /O3 and PM2.5 in studies conducted in Argentina, Brazil, Bolivia, Chile, Colombia, Costa Rica, and Peru. The OR of an exposed subject experiencing allergic rhinitis was 1.43 (95% CI 1.026; 1.980). The OR of children and adolescents experiencing of allergic rhinitis was 1.359 (95% CI 1.051; 1.759). Asymmetry and great variability in the effect estimated from the selected studies were observed. The publication bias was quantified by Kendall's correlation and Egger's test resulted in 0.152 (p-value = 0.493). Egger's test provided an intercept equal to 2.511 and a p-value = 0.398. The I2 statistic was 89.3% and reinforces the hypothesis of heterogeneity. This first systematic review conducted in Latin America confirmed the chance of a person exposed to pollutants and experiencing allergic rhinitis is 43% greater than that of a non-exposed person, reinforcing the importance of policies to reduce pollutant exposure and the use of protection systems for workforces exposed to occupational pollutants in work environments.

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.

Material Hardship and Indoor Allergen Exposure among Low-Income, Urban, Minority Children with Persistent Asthma

Traditional measures of socioeconomic status (SES) are associated with asthma morbidity, but their specific contributions are unclear. Increased exposure to indoor allergens among low SES children is an important consideration. Material hardship, a concept describing poor access to basic goods and services, may explain the relationship between low SES and indoor allergen exposure, and thereby, the increased risk of asthma morbidity. We sought to (i) describe the specific hardships experienced by low-Income, urban, minority children with asthma and indoor allergen sensitization and (ii) determine if material hardship is associated with indoor allergen exposure in this population. We conducted a cross-sectional analysis of children undergoing the baseline assessment for a clinical trial of home environmental modification. Participants were scored in five domains of material hardship. Domain scores were assigned based on caregiver responses to a questionnaire and were summed to generate a total material hardship score. Linear regression was used to examine the relationship between material hardship scores and bedroom floor concentrations of five common indoor allergens. Participants experienced high levels of material hardship in each of the five domains, with 33% not having access to a car, 35% not being able to pay utility bills, and 28% not being able to pay rent in the past year. Each one-point increase in material hardship was associated with an increase in cockroach allergen of 16.2% (95% CI 9.4%, 24.6%) and an increase in mouse allergen of 9.4% (95% CI 1.0%, 18.5%). After adjusting for traditional measures of SES, including household income, health insurance type, caregiver education, and caregiver employment status, the association between material hardship and cockroach allergen, but not mouse allergen, remained. These data suggest that a significant proportion of families of low-income, minority children with asthma may experience material hardship, and that they may be at greater risk of cockroach allergen exposure than their peers with similar income, but without material hardship.

Does Public Housing Increase the Risk of Child Health Problems? Evidence from Linked Survey-Administrative Data

Research on the effects of major federal housing assistance programs on children's outcomes has produced mixed results. Although housing assistance programs provide one of the few sources of affordable and stable housing for low-income families, there remains concern that living in public housing developments increases the risk of poor health for children. This paper uses a unique survey-administrative linked dataset to examine the effect of living in public housing on children's risk of health problems, including frequent diarrhea, frequent headaches, skin allergies, asthma, and fair/poor health status. Children living in public housing have substantially more health problems than children who do not live in public housing. However, the analysis develops several additional comparison groups to demonstrate that the excess health problems reflect unobserved selection into public housing. The main selection adjustment compares children living in public housing to children who enter public housing in the near future. Results indicate that public housing does not increase the risk of child health problems, and it is important to consider the substantial selection into public housing on factors that are likely to be correlated with children's outcomes. The broad effects of public housing may be mixed, but policymakers should not confuse the economic and health challenges of public housing residents for the effects of the program itself.

Exploring low-income African American and Latinx caregiver perspectives on asthma control in their children and reactions to messaging materials

BACKGROUND

African-American and Latinx children suffer from higher rates of uncontrolled asthma and poorer outcomes compared to white children. Sociocultural factors play a prominent role in how caregivers navigate asthma control for their children.

OBJECTIVES

(1) Explore the knowledge, perceptions and behaviors of Latinx and African-American caregivers related to their children's asthma and identify barriers to achieving asthma control; and (2) Elicit caregiver responses to messaging materials intended to help them better recognize uncontrolled asthma and seek timely medical treatment.

METHODS

Study participants were recruited and screened to meet the following inclusion criteria: African-American or Latinx race/ethnicity, household income at or below 185% of the federal poverty line, and at least one child diagnosed with asthma with symptom frequency consistent with uncontrolled asthma according to national guidelines. Participants attended one of three moderator-led focus groups. The transcripts were qualitatively analyzed using a thematic analysis approach.

RESULTS

Themes emerged among the nineteen participants related to asthma assessment, management, emotion, support, and trust. Caregivers exhibited gaps in their asthma knowledge, especially pertaining to the term "asthma control." Caregivers generally worried about asthma emergencies more than the daily impairments caused by uncontrolled asthma. Many were uncomfortable using daily controller medications, citing issues of provider trust and side effect concerns. Caregivers did not recognize uncontrolled asthma in their own child, even after viewing messaging materials informing them of symptom frequency criteria.

CONCLUSION

Culturally tailored interventions, including public asthma messaging, should address low trust in provider recommendations and caregiver concerns about controller medications.

Sociocultural Influences on Disparities in United States Children with Atopic Dermatitis: A Narrative Review of the Literature

Approximately 13% of United States (US) children have atopic dermatitis (AD), also known as eczema. AD is a chronic skin condition associated with significant burdens on quality of life and both individual and overall health-care system costs. The pathogenesis of AD is considered to be multifactorial, with biologic factors such as family history and genetics often reported as influencing risk. Some lesser discussed determinants of AD prevalence and severity are sociocultural, such as race/ethnicity, neighborhood, housing type, income level, and family structure. While several factors appear to contribute to disparities in childhood AD, black or African American race/ethnicity most significantly predicts AD prevalence, severity, disease control, access to care, and family impact. There is a shortage of research related to disparities in AD, an important topic considering the large percentage of families that are affected by the disease. This article is a narrative literature review of sociocultural influences on AD disparities in US children. The purpose of this review is to increase awareness of these important risk factors and to suggest related, future areas of research that may positively impact overall outcomes in children with AD. Much work remains to be done in order to ensure equitable care and outcomes among all children with AD.

The Indoor Environment and Childhood Asthma

PURPOSE OF REVIEW

Sensitization and exposure to triggers in the indoor environment, including aeroallergens, indoor air pollution, and environmental tobacco smoke, have a significant role in asthma development and morbidity. This review discusses indoor environmental exposures and their effect on children with asthma as well as environmental interventions and their role in improving asthma morbidity.

RECENT FINDINGS

Recent research has emphasized the role of aeroallergen sensitization and exposure in asthma morbidity and the importance of the school indoor environment. There is an established association between indoor exposures and asthma development and morbidity. Recent evidence has highlighted the importance of the indoor environment in childhood asthma, particularly the role of the school indoor environment. While home environmental interventions have had mixed results, interventions in the school environment have the potential to significantly impact the health of children, and ongoing research is needed to determine their effectiveness.

Influences of environmental exposures on individuals living with cystic fibrosis

INTRODUCTION

Natural, social, and constructed environments play a critical role in the development and exacerbation of respiratory diseases. However, less is known regarding the influence of these environmental/community risk factors on the health of individuals living with cystic fibrosis (CF), compared to other pulmonary disorders.

AREAS COVERED

Here, we review current knowledge of environmental exposures related to CF, which suggests that environmental/community risk factors do interact with the respiratory tract to affect outcomes. Studies discussed in this review were identified in PubMed between March 2019 and March 2020. Although the limited data available do not suggest that avoiding potentially detrimental exposures other than secondhand smoke could improve outcomes, additional research incorporating novel markers of environmental exposures and community characteristics obtained at localized levels is needed.

EXPERT OPINION

As we outline, some environmental exposures and community characteristics are modifiable; if not by the individual, then by policy. We recommend a variety of strategies to advance understanding of environmental influences on CF disease progression.

Obesity may enhance the adverse effects of NO2 exposure in urban schools on asthma symptoms in children

BACKGROUND

Sparse data address the effects of nitrogen dioxide (NO₂) exposure in inner-city schools on obese students with asthma.

OBJECTIVE

We sought to evaluate relationships between classroom NO₂ exposure and asthma symptoms and morbidity by body mass index (BMI) category.

METHODS

The School Inner-City Asthma Study enrolled students aged 4 to 13 years with asthma from 37 inner-city schools. Students had baseline determination of BMI percentile. Asthma symptoms, morbidity, pulmonary inflammation, and lung function were monitored throughout the subsequent academic year. Classroom NO₂ data, linked to enrolled students, were collected twice per year. We determined the relationship between classroom NO₂ levels and asthma outcomes by BMI stratification.

RESULTS

A total of 271 predominantly black (35%) or Hispanic students (35%) were included in analyses. Fifty percent were normal weight (5-84th BMI percentile), 15% overweight (≥85-94th BMI percentile), and 35% obese (≥95th BMI percentile). For each 10-parts per billion increase in NO₂, obese students had a significant increase in the odds of having an asthma symptom day (odds ratio [OR], 1.86; 95% CI, 1.15-3.02) and in days caregiver changed plans (OR, 4.24; 95% CI, 2.33-7.70), which was significantly different than normal weight students who exhibited no relationship between NO₂ exposure and symptom days (OR, 0.90; 95% CI, 0.57-1.42; pairwise interaction P = .03) and change in caregiver plans (OR, 1.37; 95% CI, 0.67-2.82; pairwise interaction P = .02). Relationships between NO₂ levels and lung function and fractional exhaled nitric oxide did not differ by BMI category. If we applied a conservative Holm-Bonferroni correction for 16 comparisons (obese vs normal weight and overweight vs normal weight for 8 outcomes), these findings would not meet statistical significance (all P > .003).

CONCLUSIONS

Obese BMI status appears to increase susceptibility to classroom NO₂ exposure effects on asthma symptoms in inner-city children. Environmental interventions targeting indoor school NO₂ levels may improve asthma health for obese children. Although our findings would not remain statistically significant after adjustment for multiple comparisons, the large effect sizes warrant future study of the interaction of obesity and pollution in pediatric asthma.

Variability in Diagnosed Asthma in Young Children in a Large Pediatric Primary Care Network

OBJECTIVE

Our objectives were to 1) quantify the frequency of wheezing episodes and asthma diagnosis in young children in a large pediatric primary care network and 2) assess the variability in practice-level asthma diagnosis, accounting for common asthma risk factors and comorbidities. We hypothesized that significant variability in practice-level asthma diagnosis rates would remain after adjusting for associated predictors.

METHODS

We generated a retrospective longitudinal birth cohort of children who visited 1 of 31 pediatric primary care practices within the first 6 months of life from 1/2005 to 12/2016. Children were observed for up to 8 years or until the end of the observation window. We used multivariable discrete time survival models to evaluate predictors of asthma diagnosis by 3-month age intervals. We compared unadjusted and adjusted proportions of children diagnosed with asthma by practice.

RESULTS

Of the 161,502 children in the cohort, 34,578 children (21%) received at least 1 asthma diagnosis. In multivariable modeling, male gender, minority race/ethnicity, gestational age <34 weeks, allergic rhinitis, food allergy, and prior wheezing episodes were associated with asthma diagnosis. After adjusting for variation in these predictors across practices, the cumulative incidence of asthma diagnosis by practice by age 6 years ranged from 11% to 47% (interquartile range: 24%-29%).

CONCLUSIONS

Across pediatric primary care practices, adjusted incidence of asthma diagnosis by age 6 years ranged widely, though variation gauged by the interquartile range was more modest. Potential sources of practice-level variation, such as differing diagnosis thresholds and labeling of different wheezing phenotypes as "asthma," should be further investigated.

Acute Severe Asthma in Adolescent and Adult Patients: Current Perspectives on Assessment and Management

Asthma is a chronic airway inflammatory disease that is associated with variable expiratory flow, variable respiratory symptoms, and exacerbations which sometimes require hospitalization or may be fatal. It is not only patients with severe and poorly controlled asthma that are at risk for an acute severe exacerbation, but this has also been observed in patients with otherwise mild or moderate asthma. This review discusses current aspects on the pathogenesis and pathophysiology of acute severe asthma exacerbations and provides the current perspectives on the management of acute severe asthma attacks in the emergency department and the intensive care unit.

Children with poorly controlled asthma: Randomized controlled trial of a home-based environmental control intervention

BACKGROUND

Few trials have tested targeted environmental control (EC) interventions based on biomarkers of second hand smoke (SHS) exposure and allergen sensitization in reducing asthma emergency department (ED) visits in children with poorly controlled asthma.

METHODS

Overall, 222 children with poorly controlled asthma were randomized into a home-based EC intervention (INT) or control (CON) group and followed for ED visits over 12 months. All children received allergen-specific IgE serologic testing and SHS exposure biomarker testing to inform the EC intervention. Pharmacy data was examined for asthma medication fills. Cox proportional hazards and multivariate regression models were performed to examine factors associated with repeat ED visits.

RESULTS

There was no difference in increased risk of >1 ED visit at 12 months between INT and CON groups. Most children (75%) had moderate/severe persistent asthma. Over half (56%) had SHS exposure and 83% tested positive for >1 allergen sensitization. Among children without SHS exposure, the median time to first recurrent ED visit differed by group (CON: 195; INT: >365 days) after adjusting for child age, allergic sensitization, medication fills prior to baseline, controller medication use, and the interaction between group status and SHS exposure. Children who had positive allergic sensitizations, younger, had increased controller medication use and randomized to the CON group and had no SHS exposure had increased risk for a repeat ED visit over 12 months.

CONCLUSIONS

In this study, a home-based EC intervention was not successful in reducing asthma ED revisits in children with poorly controlled asthma with SHS exposure. Allergic sensitization, young age, and increased controller medication use were important predictors of asthma ED visits.

Vitamin D Status Modifies the Response to Indoor Particulate Matter in Obese Urban Children with Asthma

BACKGROUND

Indoor fine particulate air pollution (PM_2.5) is linked to asthma morbidity; however, whether vitamin D status influences individual susceptibility to airborne exposures is unclear.

OBJECTIVE

We aimed to determine if vitamin D modifies the effects of indoor PM_2.5 on asthma symptoms in urban children.

METHODS

A total of 120 children aged 5 to 12 years with physician-diagnosed asthma were evaluated at baseline and every 3 months for 9 months. Indoor PM_2.5, serum 25-hydroxy vitamin D (25-OH D) levels, and asthma symptoms were simultaneously assessed at each time point. Adjusting for confounders, generalized estimating equations assessed the 3-way interaction effects of 25-OH D, obesity, and PM on asthma symptoms.

RESULTS

Children were of mean (standard deviation [SD]) age 9.7 (2.2) years, 36% were obese, and 95% self-reported black race. Mean (SD) PM_2.5 indoor exposure was 38.2 (42.9) μg/m³ and 25-OH D was 19.1 (7.5) ng/mL. Three-way interaction models demonstrated significantly greater PM_2.5-associated effects on daytime asthma symptoms only among obese children with low 25-OH D levels (odds ratio [OR]_PM2.5 = 1.26, P = .049 at vitamin D = 15.5 ng/mL, increasingly stronger PM effects at levels <15.5 ng/mL). In homes with increased PM_2.5, higher 25-OH D was associated with decreased symptom odds (eg, OR_{Vitamin D} = 0.87; P = .049 at PM_2.5 = 52.5 μg/m³, increasingly protective effects >52.5 μg/m³) among obese children.

CONCLUSIONS

Among obese urban children with asthma, low individual 25-OH D enhanced adverse respiratory effects associated with indoor PM_2.5. In high PM_2.5 environments, 25-OH D was protective against asthma symptoms. Optimizing vitamin D status in children may help reduce asthma morbidity driven by indoor air pollution.

Air pollution and resistance to inhaled glucocorticoids: Evidence, mechanisms and gaps to fill

Substantial evidence indicates that cigarette smoke exposure induces resistance to glucocorticoids, the primary maintenance medication in asthma treatment. Modest evidence also suggests that air pollution may reduce the effectiveness of these critical medications. Cigarette smoke, which has clear parallels with air pollution, has been shown to induce glucocorticoid resistance in asthma and it has been speculated that air pollution may have similar effects. However, the literature on an association of air pollution with glucocorticoid resistance is modest to date. In this review, we detail the evidence for, and against, the effects of air pollution on glucocorticoid effectiveness, focusing on results from epidemiology and controlled human exposure studies. Epidemiological studies indicate a correlation between increased air pollution exposure and worse asthma symptoms. But these studies also show a mix of beneficial and harmful effects of glucocorticoids on spirometry and asthma symptoms, perhaps due to confounding influences, or the induction of glucocorticoid resistance. We describe mechanisms that may contribute to reductions in glucocorticoid responsiveness following air pollution exposure, including changes to phosphorylation or oxidation of the glucocorticoid receptor, repression by cytokines, or inflammatory pathways, and epigenetic effects. Possible interactions between air pollution and respiratory infections are also briefly discussed. Finally, we detail a number of therapies that may boost glucocorticoid effectiveness or reverse resistance in the presence of air pollution, and comment on the beneficial effects of engineering controls, such as air filtration and asthma action plans. We also call attention to the benefits of improved clean air policy on asthma. This review highlights numerous gaps in our knowledge of the interactions between air pollution and glucocorticoids to encourage further research in this area with a view to reducing the harm caused to those with airways disease.

The effects of particulate matter on atopic dermatitis symptoms are influenced by weather type: Application of spatial synoptic classification (SSC)

The effects of weather and air pollution on atopic dermatitis (AD) flares have not been well investigated. To investigate the effects of particulate matter (PM) on AD symptoms by weather type, a total of 125 young children (76 boys and 49 girls) under 6 years of age with AD living in Seoul, Korea, were enrolled as a panel and followed for 17 months between August 2013 and December 2014. AD symptoms were recorded on a daily basis, including itching, sleep disturbance, erythema, dry skin, oozing, and edema. Daily weather was classified into 7 categories according to spatial synoptic classification (SSC). Personal exposure to PM with an aerodynamic diameter less than 2.5 and 10 μm (PM_2.5 and PM₁₀, respectively) in each individual was estimated with time-weighted average concentrations considering outdoor and indoor levels of PMs and time to spend outdoors or indoors in a day. Generalized linear mixed models were used to analyze the effects of PM_2.5 and PM₁₀ on AD symptoms, controlling for ambient temperature, humidity, age, sex, SCORAD (SCORing of AD) at enrollment, fever, day of week, and topical corticosteroid use. A total of 20,168 person-days of symptom records were collected. The presence of AD symptoms was higher on dry polar (DP) days (45.4%, P < .0001) than on moist tropical (MT) days (37.7%, P < .0001). Overall, the risk of AD symptoms significantly increased with increased exposure to PM_2.5 and PM₁₀. Among the 7 weather types, the risks of AD symptoms caused by PM_2.5 and PM₁₀ exposure were significantly increased on dry moderate (DM) days, while not significant on the other weather types. In addition, lagged effect of PM_2.5 up to 4 days was found on DM days. In conclusion, dry moderate weather type, particulate matters, and their modifying effects should be simultaneously considered for proper management of AD.

Thirdhand smoke component can exacerbate a mouse asthma model through mast cells

BACKGROUND

Thirdhand smoke (THS) represents the accumulation of secondhand smoke on indoor surfaces and in dust, which, over time, can become more toxic than secondhand smoke. Although it is well known that children of smokers are at increased risk for asthma or asthma exacerbation if the disease is already present, how exposure to THS can influence the development or exacerbation of asthma remains unknown.

OBJECTIVE

We investigated whether epicutaneous exposure to an important component of THS, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), can influence asthma pathology in a mouse model elicited by means of repeated intranasal challenge with cockroach antigen (CRA).

METHODS

Wild-type mice, α7 nicotinic acetylcholine receptor (nAChR)- or mast cell (MC)-deficient mice, and mice with MCs that lacked α7 nAChRs or were the host's sole source of α7 nAChRs were subjected to epicutaneous NNK exposure, intranasal CRA challenge, or both, and the severity of features of asthma pathology, including airway hyperreactivity, airway inflammation, and airway remodeling, was assessed.

RESULTS

We found that α7 nAChRs were required to observe adverse effects of epicutaneous NNK exposure on multiple features of CRA-induced asthma pathology. Moreover, MC expression of α7 nAChRs contributed significantly to the ability of epicutaneous NNK exposure to exacerbate airway hyperreactivity to methacholine, airway inflammation, and airway remodeling in this model.

CONCLUSION

Our results show that skin exposure to NNK, a component of THS, can exacerbate multiple features of a CRA-induced model of asthma in mice and define MCs as key contributors to these adverse effects of NNK.

School Environmental Intervention Programs

Exposure to indoor allergens and pollutants plays a significant part in the development of asthma and its associated morbidity. Inner-city children with asthma are disproportionately affected by these exposures with increased asthma morbidity. Although years of previous research have linked exposures in the urban home environment with significant childhood asthma disease, many of these allergens are also present in inner-city school environments. Therefore, evaluation of the school environment of patients with asthma is also essential. School-based environmental interventions may offer benefit for this problem and has the potential to help many children with asthma at once in a cost-effective manner. It is important that environmental health researchers continue to assess which interventions are most practical and result in the greatest measurable improvements.

NIAID, NIEHS, NHLBI, and MCAN Workshop Report: The indoor environment and childhood asthma-implications for home environmental intervention in asthma prevention and management

Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases; National Institute of Environmental Health Sciences; National Heart, Lung, and Blood Institute; and Merck Childhood Asthma Network sponsored a joint workshop to discuss the current state of science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included US and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment, and exposure reduction techniques. This informed a primary focus of the workshop: to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in scientific methodologies and knowledge and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

Association between exercise-induced asthma and parental socio-economic status among school-aged adolescents in a semiurban community in Nigeria

This study investigated the prevalence and association between exercise-induced asthma (EIA) and parental socio-economic status (PSES) among school-aged adolescents in a semiurban community in Nigeria. Three hundred and eighty-five adolescents (185 male and 200 female adolescents) whose ages ranged between 10 and 19 years participated in this cross-sectional study. Participants were recruited from four government approved secondary schools in Ido-Ekiti using a multistage sampling technique. Peak expiratory flow rate (PEFR) was assessed at baseline and after 6-min run test (6-MRT) on a level playing ground using a standard peak flow meter. PEFR measurements were repeated at 5th, 10th, 15th, and 20th min post 6-MRT. Participants who had >15.0% PEFR fall were considered to have EIA. PSES was assessed using a validated socio-economic status questionnaire. Descriptive and inferential statistics were used to analyze data. Alpha level was set at P<0.05. The mean ages of males and females were 13.9±2.0 and 13.8±1.6 years, respectively. More than half of the participants, 58.2% had EIA (>15.0% PEFR scores) while 53.5% belonged to middle PSES class. There was no significant difference between PEFR scores of male and female participants at baseline and 5th min post 6-MRT. However, male participants had significant higher PEFR than the female counterparts at 10th (t=2.090, P=0.037), 15th (t=2.162, P=0.031), and 20th min (t=2.978, P=0.003). There was significant association between EIA and PSES (χ²=152.4; P=0.001). The prevalence of EIA is very high among school-aged adolescents in Nigeria and was significantly associated with PSES.

The role of micronutrients in the response to ambient air pollutants: Potential mechanisms and suggestions for research design

People living in regions of low socioeconomic status are thought to be prone to higher exposures to environmental pollutants, poor nutrition, and numerous preventable diseases and infections. Poverty correlates with pollution and malnutrition; however, limited studies examined their interrelationship. The well-studied, deleterious health effects attributed to environmental pollutants and poor nutrition may act in combination with produce more severe adverse health outcomes than any one factor alone. Deficiencies in specific nutrients render the body more susceptible to injury which may influence the pathways that serve as the mechanistic responses to ambient air pollutants. This review (1) explores specific micronutrients that are of global concern, (2) explains how these nutrients may impact the body's response to ambient air pollution, and (3) provides guidance on designing animal models of nutritional deficiency. It is likely that those individuals who reside in regions of high ambient air pollution are similarly malnourished. Therefore, it is important that research identifies specific nutrients of concern and their impact in identified regions of high ambient air pollution.

DNA methylation levels associated with race and childhood asthma severity

OBJECTIVE

Asthma is a common chronic childhood disease worldwide. Socioeconomic status, genetic predisposition and environmental factors contribute to its incidence and severity. A disproportionate number of children with asthma are economically disadvantaged and live in substandard housing with potential indoor environmental exposures such as cockroaches, dust mites, rodents and molds. These exposures may manifest through epigenetic mechanisms that can lead to changes in relevant gene expression. We examined the association of global DNA methylation levels with socioeconomic status, asthma severity and race/ethnicity.

METHODS

We measured global DNA methylation in peripheral blood of children with asthma enrolled in the Kansas City Safe and Healthy Homes Program. Inclusion criteria included residing in the same home for a minimum of 4 days per week and total family income of less than 80% of the Kansas City median family income. DNA methylation levels were quantified by an immunoassay that assessed the percentage of 5-methylcytosine.

RESULTS

Our results indicate that overall, African American children had higher levels of global DNA methylation than children of other races/ethnicities (p = 0.029). This difference was more pronounced when socioeconomic status and asthma severity were coupled with race/ethnicity (p = 0.042) where low-income, African American children with persistent asthma had significantly elevated methylation levels relative to other races/ethnicities in the same context (p = 0.006, Hedges g = 1.14).

CONCLUSION

Our study demonstrates a significant interaction effect among global DNA methylation levels, asthma severity, race/ethnicity, and socioeconomic status.

The Proinflammatory Potential of Nitrogen Dioxide and Its Influence on the House Dust Mite Allergen Der p 1

Asthma and allergies are both major global health problems with an increasing prevalence, and environmental data implicate an influence of air pollutants on their development. The present study focuses on the influence of nitrogen dioxide (NO2) and the major allergen of the house dust mite Der p 1 on human nasal epithelial cells of nonallergic patients in vitro. Nasal epithelial mucosa samples of 11 donors were harvested during nasal air passage surgery and cultured as an air-liquid interface. Exposure to 0.1, 1 and 10 ppm NO2 or synthetic air as a control was performed for 1 h. Subsequently, the cells were exposed to Der p 1 for 24 h. The release of interleukin (IL)-6 and IL-8 was measured by ELISA, and the production of IL-6 mRNA and IL-8 mRNA was measured by RT-PCR. NO2 exposure resulted in a concentration-dependent release of IL-6, but not IL-8 release. The coexposure of 0.1 ppm NO2 and Der p 1, or 1 ppm NO2 and Der p 1 significantly increased both IL-6 and IL-8 release. Exposure to NO2, Der p 1, or their combination, did not significantly influence the production of IL-6 or IL-8 mRNA. In conclusion, NO2 increases the release of inflammatory cytokines in human nasal epithelial cells, especially in coexposure with Der p 1, as a mechanism of allergotoxicology.

Effectiveness of air purifier on health outcomes and indoor particles in homes of children with allergic diseases in Fresno, California: A pilot study

OBJECTIVE

Epidemiologic studies indicate that indoor air pollution is correlated with morbidity caused by allergic diseases. We evaluated the effectiveness of reducing the levels of indoor fine particulate matter <2.5 micrometer diameter (PM_2.5) in Fresno, California using air purifiers on health outcomes in children with asthma and/or allergic rhinitis.

METHODS

The active group (with air purifiers) and the control group consisted of eight houses each. Air purifiers were installed in the living rooms and bedrooms of the subjects in the active group during the entire 12-week study duration. Childhood asthma control test, peak flow rate monitoring, and nasal symptom scores were evaluated at weeks 0, 6, and 12.

RESULTS

At 12 weeks, the active group showed a trend toward an improvement of childhood asthma control test scores and mean evening peak flow rates, whereas the control group showed deterioration in the same measures. Total and daytime nasal symptoms scores significantly reduced in the active group (p = 0.001 and p = 0.011, respectively). The average indoor PM_2.5 concentrations reduced by 43% (7.42 to 4.28 μg/m³) in the active group (p = 0.001).

CONCLUSIONS

Intervention with air purifiers reduces indoor PM_2.5 levels with significant improvements in nasal symptoms in children with allergic rhinitis in Fresno.

Path to health asthma study: A survey of pediatric asthma in an urban community

OBJECTIVE

Minority children with asthma who live in low-income urban communities bear a disproportionate burden of the disease. This study explores the perceived health care needs related to asthma care, identifies asthma triggers, potential barriers to care, and assesses the need for additional community resources.

METHODS

We conducted a cross-sectional survey of Hispanic and African American adults (n = 53) who take care of a child with asthma and live in an urban community of North Philadelphia. Input from community leaders was obtained in the development the survey tool resulting in a unique 'community-centric' questionnaire. The survey was also available in Spanish. All surveys were conducted in the community setting.

RESULTS

Variables were used to measure asthma severity and triggers. Children were categorized with intermittent (n = 24, 45.3%), mild persistent (n = 13, 24.5%), or moderate-to-severe persistent asthma (n = 16, 30.2%). Most children with persistent asthma were enrolled under Medicaid or CHIP (n = 24, p = 0.011) and reflected a low-income socioeconomic status. Persistent asthma was found to be associated with most triggers: pets, dust mites, mice, mold, and cockroaches. There was no significant association between environmental tobacco smoke and persistent asthma. Children with persistent asthma and 2 or more triggers were more likely to be hospitalized and go to the Emergency Department.

CONCLUSION

Urban minority children living in low-income communities face neighborhood-specific asthma triggers and challenges to care. Studies conducted in urban neighborhoods, with collaboration from community members, will highlight the need of comprehensive services to account for community-centric social determinants.

Difficult-to-control asthma: epidemiology and its link with environmental factors

PURPOSE OF REVIEW

The aim of the present review was to discuss the epidemiology of inadequate asthma control with an examination of contributing environmental factors.

RECENT FINDINGS

Despite advances in asthma therapies, a proportion of patients with asthma continue to have difficulty in gaining adequate asthma control. Asthma severity and control in childhood are of particular importance as they translate to asthma morbidity in adulthood. Children with comorbid severe allergic rhinitis were more likely to have uncontrolled asthma. Recent data suggest that mouse allergen, more so than cockroach allergen, may be the most relevant urban allergen exposure. Tobacco smoke exposure, even passive exposure, leads to increased asthma symptoms and decreased response to inhaled corticosteroids. Efforts to ban smoking in public places have resulted in promising asthma results for entire populations. Energy-saving efforts to tighten a home's air leaks can lead to increased indoor pollutant levels and, therefore, must be accompanied by efforts to reduce, filter, or exchange indoor pollutants. Obesity is independently associated with decreased asthma control. Furthermore, the detrimental effects of pollutant exposure are enhanced in an overweight individual with asthma.

SUMMARY

Lack of asthma control can be because of a complex web of factors including adherence, intrinsic factors, and environmental exposures. Further research into intervention strategies is needed to achieve improved rates of asthma control.

Inner-city asthma: special considerations for management

PURPOSE OF REVIEW

Asthma is prevalent in inner-city populations, exhibiting significant morbidity and mortality. This review focuses on the consequential findings of recent literature, providing insight into onset of asthma, complicating factors, prediction of exacerbations, and novel treatment strategies.

RECENT FINDINGS

Analyses of environmental influence on inner-city children demonstrated novel interactions, implicating potentially protective benefits from early life exposures to pests and pets and isolating detrimental effects of air pollution on asthma morbidity. Through detailed characterization of inner-city asthmatics, predictors of seasonal exacerbations surfaced. Focused, season-specific treatment of inner-city asthmatics with omalizumab identified those most likely to benefit from season-tailored therapy. Comparative studies of urban and rural populations revealed that race and household income, rather than location of residence, impose the greatest risk for increased asthma prevalence and morbidity.

SUMMARY

Challenging previously conceived exposure-disease relationships, recent literature has elucidated new avenues in the complex interplay between immunologically active exposures and their effects on inner-city asthma. These findings, and improved understanding of other relevant exposures, could steer the direction of primary (and secondary) disease prevention research. Moreover, careful identification of asthma characteristics has effectively established predictors of exacerbations, highlighting individuals for which additional therapies are warranted and for whom such treatments are most likely to be effective.

Two new types of allergens from the cockroach, Periplaneta americana

Periplaneta americana cockroach is an important source of inhalant indoor allergen resource, and there are more than twenty IgE-binding components identified in P. americana, but only nine allergens were characterized. Our knowledge about cockroach allergens remains poor. In this work, two novel allergen proteins Per a 11 (alpha-amylase) and Per a 12 (chitinase) with molecular weight around 55 and 45 kDa, respectively, were purified and characterized from the midgut of cockroaches. Their primary sequences were determined by Edman degradation, mass spectrometry, and cDNA cloning. Sera from 39 and 30 of 47 (83.0% and 63.8%) patients reacted to Per a 11 and Per a 12 on immunoblots, respectively. The allergenicity of Per a 11 and Per a 12 was further confirmed by competitive ELISA, basophil activation test (BAT), and skin prick test (SPT). They appear to be of importance for the allergic reactions induced by cockroach and have a potential for component-based diagnosis of allergy.

Stress and Quality of Life in Urban Caregivers of Children With Poorly Controlled Asthma: A Longitudinal Analysis

INTRODUCTION

The intent of this analysis was to examine the longitudinal effects of risk and protective factors on quality of life (QOL) in caregivers of minority children with asthma.

METHOD

Caregivers (n = 300) reported on demographics, child asthma characteristics, daily asthma caregiving stress, general life stress, social support, and QOL. Latent growth curve modeling examined changes in QOL across 12 months as a function of stress, asthma control, and social support.

RESULTS

Caregivers were primarily the biological mother (92%), single (71%), unemployed (55%), and living in poverty. Children were African American (96%), Medicaid eligible (92%), and had poorly controlled asthma (93%). Lower QOL was associated with higher life stress, greater asthma caregiving stress, and lower asthma control over time.

DISCUSSION

Findings underscore the importance of assessing objective and subjective measures of asthma burden and daily life stress in clinical encounters with urban, low-income caregivers of children with poorly controlled asthma.

Association of Roadway Proximity with Indoor Air Pollution in a Peri-Urban Community in Lima, Peru

The influence of traffic-related air pollution on indoor residential exposure is not well characterized in homes with high natural ventilation in low-income countries. Additionally, domestic allergen exposure is unknown in such populations. We conducted a pilot study of 25 homes in peri-urban Lima, Peru to estimate the effects of roadway proximity and season on residential concentrations. Indoor and outdoor concentrations of particulate matter (PM_2.5), nitrogen dioxide (NO₂), and black carbon (BC) were measured during two seasons, and allergens were measured in bedroom dust. Allergen levels were highest for dust mite and mouse allergens, with concentrations above clinically relevant thresholds in over a quarter and half of all homes, respectively. Mean indoor and outdoor pollutant concentrations were similar (PM_2.5: 20.0 vs. 16.9 μg/m³, BC: 7.6 vs. 8.1 μg/m³, NO₂: 7.3 vs. 7.5 ppb), and tended to be higher in the summer compared to the winter. Road proximity was significantly correlated with overall concentrations of outdoor PM_2.5 (r_s = −0.42, p = 0.01) and NO₂ (r_s = −0.36, p = 0.03), and outdoor BC concentrations in the winter (r_s = −0.51, p = 0.03). Our results suggest that outdoor-sourced pollutants significantly influence indoor air quality in peri-urban Peruvian communities, and homes closer to roadways are particularly vulnerable.

Mouse Sensitivity is an Independent Risk Factor for Rhinitis in Children with Asthma

BACKGROUND

Although mouse and cockroach allergy is known to be important in urban children with asthma, the independent association of mouse and cockroach sensitization with rhinitis in these children is unknown.

OBJECTIVE

To determine the association of mouse and cockroach sensitization with rhinitis in urban children with asthma.

METHODS

As part of the Mouse Allergen and Asthma Intervention Trial, 499 urban children (5-17 years) with persistent asthma underwent spirometry, skin prick testing to 14 common environmental allergens, and serology for mouse-specific IgE. In 269 subjects, cockroach-specific IgE serology was also obtained. Patient/parent-reported rhinitis in the last 2 weeks and the last 1 year was the primary outcome measure. Mouse/cockroach exposure was measured by reported frequency of sightings. Mouse allergen-settled bedroom dust samples were also measured in mouse-sensitized children.

RESULTS

Rhinitis was reported in 49.9% and 70.2% of the participants within the last 2 weeks and the last 1 year, respectively. Serum mouse IgE level of 0.35 IU/mL or more was associated with rhinitis in the past 2 weeks (adjusted odds ratio, 2.15; 95% CI, 1.02-4.54; P = .04) and the past 1 year (adjusted odds ratio, 2.40; 95% CI, 1.12-5.1; P = .02) after controlling for age, race, sex, the presence of any smokers at home, primary caregiver education level, number of allergen sensitivities, cockroach IgE level of 0.35 IU/mL or more, and study site (Boston or Baltimore). Measures of home mouse exposure were not associated with rhinitis, regardless of mouse sensitivity. Cockroach sensitivity was not associated with rhinitis regardless of sensitization to other allergens.

CONCLUSIONS

In urban children with asthma, increased mouse IgE, but not cockroach IgE, in the sera (mouse IgE ≥ 0.35 IU/mL) may be associated independently with rhinitis.

Risk factors for chronic rhinosinusitis

PURPOSE OF REVIEW

To review the recent literature on risk factors for chronic rhinosinusitis (CRS) with an emphasis on genetic, comorbid diseases and environmental factors associated with CRS. Through identifying potential risk factors for CRS, we aim to glean insights into the underlying pathogenic mechanisms essential for developing effective therapeutic strategies.

RECENT FINDINGS

Recent findings demonstrate that genetics and comorbid medical conditions including airway diseases, gastroesophageal reflux disease, inflammatory and autoimmune diseases, and various demographic and environmental factors are associated with having a CRS diagnosis. Limitations of current studies include variable application of disease definitions, lack of prospective longitudinal studies and a disproportionate focus on tertiary care populations.

SUMMARY

CRS has a broad spectrum of associations ranging from genetics to comorbid diseases and environmental factors. These predisposing factors may provide valuable information for possible designing of therapeutic and preventive interventions. However, to better understand whether these associations cause CRS, further studies are needed to independently replicate findings, establish temporal relationships between exposure and disease onset, evaluate the influence of exposure dose on disease severity, and to understand the biological effects of these risk factors in the context of CRS.

Asthma risk factors

BACKGROUND

Bronchial asthma is one of the most common chronic diseases in childhood, with a current prevalence of 6% to 9%, but a prevalence that is increasing at an alarming rate. Asthma is a complex genetic disorder with strong environmental influence. It imposes a growing burden on our society in terms of morbidity, quality of life, and healthcare costs. Despite large-scale efforts, only a few asthma genes have been confirmed, suggesting that the genetic underpinning of asthma is highly complex.

METHODS

A review of the literature was performed regarding atopic and nonatopic asthma risk factors, including environmental risk factors and genetic studies in adults and children.

RESULTS

Several environmental risk factors have been identified to increase the risk of developing asthma such as exposure to air pollution and tobaccos smoke as well as occupational risk factors. In addition atopy, stress, and obesity all can increases the risk for asthma in genetically susceptible persons.

CONCLUSION

Asthma represents a dysfunctional interaction with our genes and the environment to which they are exposed, especially in fetal and early infant life. The increasing prevalence of asthma in all age groups indicate that our living environment and immunity are in imbalance with each other reacting with airway inflammation to the environmental exposures and often non-harmful proteins, such as allergens causing the current "asthma and allergy epidemic." Because of the close relationship between asthma and chronic rhinosinusitis, it is important that otolaryngologists have a good understanding of asthma, the etiologic factors associated with disease, and its evaluation and management.

The need to differentiate between adults and children when treating severe asthma

Severe asthma at all ages is heterogeneous incorporating several phenotypes that are distinct in children and adults, however, there are also numerous similar features including the limitation that they may not remain stable longitudinally. Severe asthma in both children and adults is characterized by eosinophilic airway inflammation and evidence of airway remodeling. In adults, targeting eosinophilia with anti-IL-5 antibody therapy is very successful, resulting in the recommendation that sputum eosinophils should be used to guide treatment. In contrast, data for the efficacy of blocking IL-5 remain unavailable in children. However, its effectiveness is uncertain since many children with severe asthma have normal blood eosinophils and the dominance of Th2-mediated inflammation is controversial. Approaches that have revealed gene signatures and biomarkers such as periostin that are specific to adult disease now need to be adopted in children to identify effective pediatric specific therapeutics and minimize the extrapolation of adult therapeutics to children.

Factors associated with high short-acting β2-agonist use in urban children with asthma

BACKGROUND

One goal of guideline-based asthma therapy is minimal use of short-acting β₂ agonist (SABA) medications. Inner-city children with asthma are known to have high SABA use.

OBJECTIVE

To examine factors associated with high SABA use in inner-city children with asthma.

METHODS

One hundred inner-city children with persistent asthma were enrolled into a randomized controlled trial of an emergency department (ED) and home intervention. All children underwent serologic allergen specific IgE and salivary cotinine testing at the ED enrollment visit. Pharmacy records for the past 12 months were obtained. Number of SABA fills during the past 12 months was categorized into low- to moderate- vs high-use groups. SABA groups were compared by the number of symptom days and nights, allergen sensitization, and exposures. Regression models were used to predict high SABA use.

RESULTS

Mean number of SABA fills over 12 months was 3.12. Unadjusted bivariate analysis showed that high SABA users were more than 5 times more likely to have an asthma hospitalization, almost 3 times more likely to have an asthma intensive care unit admission, and more than 3 times more likely to have prior specialty asthma care or positive cockroach sensitization than low to moderate SABA users. In the final regression model, for every additional inhaled corticosteroid fill, a child was 1.4 times more likely and a child with positive cockroach sensitization was almost 7 times more likely to have high SABA use when controlling for prior intensive care unit admission, receipt of specialty care, child age, and income.

CONCLUSION

Providers should closely monitor SABA and controller medication use, allergen sensitization, and exposures in children with persistent asthma.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT01981564.

The Microbiome and Sustainable Healthcare

Increasing prevalences, morbidity, premature mortality and medical needs associated with non-communicable diseases and conditions (NCDs) have reached epidemic proportions and placed a major drain on healthcare systems and global economies. Added to this are the challenges presented by overuse of antibiotics and increased antibiotic resistance. Solutions are needed that can address the challenges of NCDs and increasing antibiotic resistance, maximize preventative measures, and balance healthcare needs with available services and economic realities. Microbiome management including microbiota seeding, feeding, and rebiosis appears likely to be a core component of a path toward sustainable healthcare. Recent findings indicate that: (1) humans are mostly microbial (in terms of numbers of cells and genes); (2) immune dysfunction and misregulated inflammation are pivotal in the majority of NCDs; (3) microbiome status affects early immune education and risk of NCDs, and (4) microbiome status affects the risk of certain infections. Management of the microbiome to reduce later-life health risk and/or to treat emerging NCDs, to spare antibiotic use and to reduce the risk of recurrent infections may provide a more effective healthcare strategy across the life course particularly when a personalized medicine approach is considered. This review will examine the potential for microbiome management to contribute to sustainable healthcare.