Violence, abuse, and asthma in Puerto Rican children

Community violence and asthma: A review

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

Social determinants of health and asthma

PURPOSE OF REVIEW

Social determinants of health play a major role in healthcare utilization and outcomes in patients with asthma. Continuing to understand how these complex and interwoven relationships interact to impact patient care will be crucial to creating innovative programmes that address these disparities.

RECENT FINDINGS

The current literature continues to support the association of substandard housing, urban and rural neighbourhoods, and race/ethnicity with poor asthma outcomes. Targeted interventions with community health workers (CHWs), telemedicine and local environmental rectifications can help improve outcomes.

SUMMARY

The link between social determinants and poor asthma outcomes continues to be supported by recent literature. These factors are both nonmodifiable and consequences of institutionalized racist policies that require innovative ideas, technologic equity and funding for groups most at risk for poorer outcomes.

Environmental justice and allergic disease: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee and the Diversity, Equity and Inclusion Committee

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

Social vulnerability, medical care access and asthma related emergency department visits and hospitalization: An observational study

BACKGROUND

The Social Vulnerability Index (SVI) is a publicly available dataset to identify communities in greatest need of resources.

OBJECTIVE

To examine the utility of using the county-level SVI as predictors of asthma-related outcomes.

METHODS

We used the American Community Survey-derived SVI and the National Environmental Public Health Tracking Network - Query Tool to retrieve data for all counties with available SVI data and at least one matched outcome of interest. Then, we tested SVI as a predictor for emergency department visits (EDV) and hospitalizations, with investigating disparities in primary care physician (PCP) density and emergency department physicians (EDP) density. Linear and logistic regression models were used.

RESULTS

Compared to counties of the lowest SVI quartile, counties of mid-low, mid-high, and highest SVI quartiles had 1%, 4%, and 5% higher odds of asthma-related EDV per 10,000 population, respectively, and 4%, 21%, and 24% higher odds of asthma-related hospitalization per 10,000 population, respectively. Moreover, the data showed an apparent resources mismatch between the EDP densities per 10,000 populations and the SVI quartiles, and the effect of the county level SVI on the asthma-related EDV and hospitalization is not strongly affected by PCP or EDP densities.

CONCLUSION

The counties with the highest SVI -and the most vulnerable to asthma hazards- have a lower coverage of PCP and EDP. Interventions directed to address persistent social vulnerability would offer the opportunity of primary prevention with less exhaustion for the medical resources.

Child maltreatment and asthma

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

Intimate partner violence and asthma in pediatric and adult populations

OBJECTIVE

To evaluate the relationship between intimate partner violence (IPV) and adult and childhood asthma outcomes.

DATA SOURCES

We conducted a systematic literature review using 4 databases (PubMed, Ovid MEDLINE, Ovid Embase, and Ovid PsycINFO) with asthma and IPV-associated terms.

STUDY SELECTIONS

We included published studies, available in English, to October 2021, which included IPV as an exposure and asthma as an outcome. Both adult and pediatric populations were included in the following settings: community, health care, and home.

RESULTS

There were 37 articles identified. There was evidence among multiple studies to support increased prevalence of asthma in adults exposed to IPV and prevalence and incidence in children with parental IPV exposure. There were fewer studies evaluating IPV exposure and adult asthma morbidity, but they found statistically significant associations between IPV and increased rate of asthma exacerbations and worsened asthma control. There was sparse evidence evaluating a relationship between IPV and adult asthma mortality. There were no studies identified evaluating IPV and childhood asthma morbidity or mortality.

CONCLUSION

The association between IPV and increased asthma prevalence, incidence, and worsened morbidity merits recognition and further investigation into potential mechanisms. Health care providers can implement practical strategies to help mitigate the negative effects of IPV on health and asthma. These include addressing potential impactful biopsychosocial factors and comorbidities, implementing routine screening and referrals, and partnering with community advocacy organizations. Given their positions of respect and power in society, health care providers can have lasting impacts on the lives of pediatric and adult patients affected by IPV.

Multi-Dimensional Assessment and Interdisciplinary Care to Reduce Asthma Readmissions in Safety Net Hospitals

Asthma is a prevalent disease that disproportionately affects socioeconomically underprivileged minorities. In fact, racial and ethnic minorities such as Blacks and Latinos have higher rates of severe asthma, asthma-associated emergency department visits, hospitalizations, and readmissions compared with whites. Such disparities exist due to genetic predispositions and to socioeconomic determinants of health such as environmental factors and limited health-care access. A value-based purchasing program encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans, and, in turn, reduce avoidable readmissions. The program supports the national goal of improving health care by linking payment to the quality of hospital care. Efforts have been made to address asthma-related complications in these populations, which have been addressed at various levels of the care system, including the patient and family, community, organization, provider/microsystem, and policy. Many of these programs promote patient education and health-care accessibility through interdisciplinary and multi-dimensional approaches, and have been shown to be effective in reducing asthma-associated readmissions and hospitalizations, but these localized approaches have not been largely adopted. The wide-spread implementation of asthma programs is necessary to address factors related to the increased incidence of asthma and associated rates of hospitalizations and readmissions in impoverished, minority populations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adverse childhood experiences and risk factors associated with asthma among children in the United States: the intersection of sex and race/ethnicity

OBJECTIVE

The objectives of this cross-sectional study were to examine: 1) the association between adverse childhood experiences (ACEs) and asthma among children, and 2) the interaction between sex and race/ethnicity on asthma.

METHODS

Data for this study were obtained from the 2017-2018 National Survey of Children's Health. Binary logistic regression was conducted on an analytic sample of 49,000 children ages 0-17 years with asthma as the outcome variable and ACEs as the main explanatory variable.

RESULTS

Based on parent reports, we found that 11.5% of children had asthma and about 42% had at least one ACE, with 9.7% having ≥3 ACEs. Controlling for other factors, children with ≥3 ACEs had 1.45 times higher odds of having asthma when compared to children with no ACEs. Non-Hispanic Black males and females were more likely to have asthma when compared to non-Hispanic White males.

CONCLUSIONS

The findings of this study demonstrate an association between ACEs and asthma with children exposed to ≥3 ACEs more likely to have asthma underscoring the importance of cumulative effect of ACEs on asthma. Our study also revealed an interaction between sex and race/ethnicity on asthma among children. Additional studies are needed to understand the mechanisms through which ACEs is associated with asthma among children.

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

Background

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

Methods

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

Results

In the EWAS of stress/violence in EVA-PR, gun violence was associated with methylation of cg18961589 in LINC01164 (β=0.03, P =1.28×10 ^-7 ), and maternal stress was associated with methylation of cg03402351 in SNN (β=0.04, P =1.69×10 ^-7 ) and cg19064846 in PTPRN2 (β=0.03, P =3.36×10 ^-7 ). In a meta-analysis of three cohorts, which included the top CpGs associated with stress/violence in EVA-PR, CpGs in STARD3NL, SLC35F4, TSR3, CDC42SE2, KLHL25, PLCB1, BUD13, OR2B3, GALR1, TMEM196, TEAD4 and ANAPC13 were associated with atopic asthma at FDR- P < 0.05.

Conclusions

ETV and chronic stress may increase the risk of atopic asthma through DNA methylation in airway epithelium, though this needs confirmation in future longitudinal studies.

Medical Neglect as a Contributor to Poorly Controlled Asthma in Childhood

Child maltreatment, including medical neglect, is a frequent contributor to the development of asthma as well as a barrier to its proper management. This article aims to review the role of medical neglect as a contributor to poor asthma control. Medical neglect can present as failure of the caretaker to recognize severe asthma symptoms in a child, non-adherence to medical management, failure to prevent chronic exposure to allergens or tobacco smoke, poor child nutrition leading to obesity, and allowing a young child to manage his/her illness without supervision. This article will explore the different factors leading to medical neglect (as illustrated by two cases) and suggest possible interventions aiming to prevent emergency department visits, hospitalizations, and asthma-related deaths.

Chronic stress and asthma in adolescents

OBJECTIVE

First, to review and critically discuss published evidence on psychosocial stressors, stress, and asthma in adolescents and, then, discuss potential future directions in this field.

DATA SOURCES

The data source is the National Library of Medicine (PubMed database).

STUDY SELECTIONS

A literature search was conducted for human studies on stressors or stress and asthma between 2000 and 2020. Studies that were published in English, contained a full text, and included adolescents were considered for inclusion in this review.

RESULTS

Compared with the available body of evidence in children and adults, relatively few studies have been published in adolescents. Current evidence suggests that exposure to stressors (at the individual, family, and community levels) or stress (acute and chronic) is associated with asthma and worse asthma outcomes, but such evidence must be cautiously interpreted owing to limitations in the design or the analytical approach of the published studies.

CONCLUSION

Future large studies with a prospective design should determine whether and how stressors or stress causes or worsens asthma in adolescents. At present, clinicians should assess exposure to stressors (eg, violence or abuse) and screen for anxiety and depressive disorders when caring for adolescents with asthma in addition to providing referrals to social workers or mental health professionals when appropriate. Public health policies are needed to reduce psychosocial stressors, such as gun violence and racism, in adolescents.

Latent factors of adverse childhood experiences and adult-onset asthma

Asthma is a chronic respiratory disease with complex etiology. Adverse childhood experiences (ACEs) have been linked to asthma in adulthood. Underlying potential mechanisms for the ACE-asthma relationship include stress-induced inflammatory pathways and immune dysregulation. We conducted a cross-sectional secondary data analysis of the 2013 Alberta ACE Survey to explore the relationship between latent ACE factors and self-reported adult asthma. We evaluated the underlying correlation structure among eight different ACEs using exploratory factor analysis. We conducted a logistic regression model to evaluate whether ACE factors retained from the factor analysis predicted self-reported asthma in adulthood. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). We analyzed ACE survey results from 1207 participants. Factor analysis yielded four ACE latent factors: factor 1/relational violence, factor 2/negative home environment, factor 3/illness at home, and factor 4/sexual abuse. Results of the logistic regression showed that experiencing sexual abuse (OR: 3.23; 95% CI: 1.89, 5.23), relational violence (OR: 1.99; 95% CI: 1.17, 3.38), and being exposed to a negative home environment (OR: 1.86; 95% CI: 1.03, 3.35) were predictive of a diagnosis of asthma in adulthood, whereas living in a household with someone experiencing illness did not show an effect (OR: 1.38; 95% CI: 0.75, 2.56). Factor analysis provides an effectual approach to understand the long-term impact of ACEs on respiratory health. Our findings have important implications to understand the developmental origins of asthma in adulthood and inform interventions aimed at reducing the lasting negative impact of childhood adversities on future respiratory health.

The "envirome" and what the practitioner needs to know about it

OBJECTIVE

This review on the "envirome" focuses on pollution, microbial, and social stressor elements of the environment that may impact development or expression of allergic diseases.

DATA SOURCES

Peer-reviewed publications on the impact of environmental factors indexed in PubMed were the primary data source for this review.

STUDY SELECTIONS

The primary search strategy for this review employed cross-referencing asthma, atopic dermatitis, and immunoglobulin E (IgE) against pollution (ozone, particulate matter, nitrogen oxides, tobacco smoke), microbial exposures (farm exposure, microbiome, infection, antibiotic use) and psychosocial stressors, with emphasis on results in the past 5 years, with inclusion of key seminal articles or comprehensive reviews.

RESULTS

Air pollution is a clear cause of allergic disease exacerbation, with increasing recognition that pollutant exposure increases risk of allergic disease. Microbial exposures and maternal and child stress also modulate development and expression of allergic disease. Early life exposures are especially critical periods during which all of these factors have notable impacts on allergic disease.

CONCLUSION

Nonallergenic environmental factors are important modulators and adjuvants for development of allergic disease, with early life exposures being especially important. Development and validation of interventions directed toward these factors during early life is a significant opportunity for primary prevention of allergic disease.

Use of Health Services by Maltreated Children in Two Different Sociocultural Contexts: Where Can Doors for Interventions Be Opened?

Among maltreated children, elevated use of non-routine (for illness or injury) services may coexist with underutilization of preventive services. Besides physical health problems, lack of contact with primary care may preclude the identification and delivery of appropriate interventions. We examined health service utilization in the longitudinal Boricua Youth Study of Puerto Rican children residing in the South Bronx (SBx), New York City ( n = 901), and San Juan metropolitan area, Puerto Rico ( n = 1,163). Parents and children ( M_age = 9 years) reported on child physical abuse, sexual abuse, and neglect. Parents reported if their child had been to illness, injury, and well-child visits in the past year. In the SBx site, caretakers were more likely to report the children seeing a doctor for a well-child visit (90%) compared with children in Puerto Rico (71%). Children in Puerto Rico were more likely to visit a doctor for an injury in the past year compared with children in the SBx (39% vs. 24%). Twenty-one percent of children in the SBx reported maltreatment versus 16% in Puerto Rico. Adjusting for sociodemographic factors, compared with non-maltreated children, those who experienced two or more types of maltreatment were more likely to have an illness visit in Puerto Rico (prevalence ratio [PR] = 1.5, 95% confidence interval [CI] = [1.1, 2.2]) and the SBx (PR = 1.8, 95% CI = [1.1, 3.0]), or an injury visit (PR = 4.1, 95% CI = [1.9, 8.9]) in Puerto Rico only. Children in the SBx who reported only one type of maltreatment were less likely to use services for injuries than non-maltreated children (PR = 0.42, 95% CI = [0.2, 0.9]). No relation between maltreatment and well-child visits was noted. Children who experience maltreatment may frequently come in contact with health care providers, presenting opportunities for intervention and the prevention of further maltreatment.

Maltreatment history, trauma symptoms and research reactivity among adolescents in child protection services

OBJECTIVE

There is a well-documented link between child maltreatment and poor health across the lifespan. This provides a strong case for ongoing research with youth involved in the child welfare system to reduce negative outcomes and support resilience while being inclusive of youth voices. However, detailed inquiries about maltreatment history and health consequences may cause re-experiencing of events and psychological distress for study participants. Data that accounts for different contexts, such as severity of maltreatment history and current trauma symptomatology, have been limited in considering the question of potential harms to youth who participate in research-especially longitudinal studies.

METHODS

This study compared self-reported impact of research participation against maltreatment history and current post-traumatic stress symptomatology among a randomly selected group of adolescents (< 18 years old) in the child protection service (CPS) system.

RESULTS

Adolescents who report more serious child maltreatment and current trauma symptom severity reported higher scores on distress questions from pre- to post-assessment participation. Critically, participants who were more negatively impacted by study involvement also reported greater benefit from study involvement.

CONCLUSION

The increase in both negative and positive impact does not shift the risk/reward ratio for participation, as risks alone do not increase for this vulnerable group of CPS involved youth. These results are consistent with previous findings from studies involving non-CPS populations and underlies the importance of empirical data to address the question of change in the risk/reward ratio and what factors might play a role in any change. This information can inform inclusion/exclusion criteria for future research with these vulnerable populations, thereby reducing the risk of distress among study participants.

Health risk behaviors, violence exposure, and current asthma among adolescents in the United States

BACKGROUND

Asthma may worsen during adolescence, due to both health risk behaviors and psychosocial stressors commonly encountered during this life stage.

METHODS

Cross-sectional study of 24 612 high school students who participated in the 2009 and 2011 National Youth Risk Behavior Survey. Multivariable logistic regression was used to examine the relation between self-reported health risk behaviors or psychosocial stressors and current asthma. Mediation analysis was performed to assess whether depressive symptoms or suicidal behavior contribute to the link between psychosocial stressors and asthma.

RESULTS

Current asthma was reported by 13.1% of the study participants. In a multivariable analysis, female sex, obesity, shorter sleep duration, frequent soda/pop consumption, and marijuana use were each significantly associated with 14-36% increased odds of asthma. Any violent behavior (adjusted odds ratio [OR] = 1.12, 95% confidence interval [CI] = 1.02-1.24), any victimization (OR = 1.43, 95%CI = 1.29-1.58), any suicidal behavior (OR = 1.41, 95%CI = 1.22-1.64) and having felt sad or hopeless in the past year (OR = 1.57, 95%CI = 1.40-1.75) were each associated with current asthma. In a mediation analyses, having felt sad/hopeless and suicidal behaviors accounted for 21% and 14%, respectively, of the victimization-asthma association.

CONCLUSION

Potentially modifiable risk factors, including obesity, short sleep duration, frequent soda/pop consumption, and psychosocial stressors are associated with asthma in US adolescents. Promoting healthier lifestyles, as well as screening for violence exposure and treating depressive symptoms, could help reduce asthma burden in this population.

Functional connectivity in central executive network protects youth against cardiometabolic risks linked with neighborhood violence

Although violent crime has declined in recent decades, it remains a recurring feature of daily life in some neighborhoods. Mounting evidence indicates that such violence has a long reach, which goes beyond family and friends of the victim and undermines the health of people in the surrounding community. However, like all forms of adversity, community violence elicits a heterogeneous response: Some remain healthy, but others deteriorate. Despite much scientific attention, the neural circuitries that contribute to differential adaptation remain poorly understood. Drawing on knowledge of the brain's intrinsic functional architecture, we predicted that individual differences in resting-state connectivity would explain variability in the strength of the association between neighborhood violence and cardiometabolic health. We enrolled 218 urban youth (age 12-14 years, 66% female; 65% black or Latino) and used geocoding to characterize their exposure to neighborhood murder over the past five years. Multiple aspects of cardiometabolic health were assessed, including obesity, insulin resistance, and metabolic syndrome. Functional MRI was used to quantify the connectivity of major intrinsic networks. Consistent with predictions, resting-state connectivity within the central executive network (CEN) emerged as a moderator of adaptation. Across six distinct outcomes, a higher neighborhood murder rate was associated with greater cardiometabolic risk, but this relationship was apparent only among youth who displayed lower CEN resting-state connectivity. By contrast, there was little evidence of moderation by the anterior salience and default mode networks. These findings advance basic and applied knowledge about adaptation by highlighting intrinsic CEN connectivity as a potential neurobiological contributor to resilience.

Systematic Review: Exposure to Community Violence and Physical Health Outcomes in Youth

Objective

To systematically review the evidence for associations between exposure to community violence and physical health outcomes in children and adolescents.

Methods

A thorough search of multiple online databases and careful consideration of inclusion and exclusion criteria yielded a final 28 studies for detailed review. In addition to review of findings, studies were rated on overall quality based on study design.

Results

Seven categories of physical health outcomes emerged, including asthma/respiratory health, cardiovascular health, immune functioning, hypothalamic-pituitary-adrenal axis functioning, sleep problems, weight, and a general health category. There were mixed findings across these categories. Evidence for a positive association between community violence exposure and health problems was strongest in the cardiovascular health and sleep categories.

Conclusion

There is reason to believe that community violence exposure has an effect on some areas of physical health. Additional well-designed research that focuses on mechanisms as well as outcomes is warranted.

The association between substantiated childhood maltreatment, asthma and lung function: A prospective investigation

BACKGROUND

Asthma reflects multiple and likely complex causal pathways. We investigate the possibility that childhood maltreatment is one such causal pathway. Childhood maltreatment can be interpreted as a form of early life adversity and like other life adversities may predict a range of negative health outcomes, including asthma.

METHODS

A total of 3762 young adults (52.63% female) from the Mater Hospital-University of Queensland Study of Pregnancy (MUSP) participated in this study. MUSP is a prospective Australian birth cohort study of mothers consecutively recruited during their first antenatal clinic visit at Brisbane's Mater Hospital from 1981 to 1983. The study followed both mother-child dyads to the age of 21years after birth. Participants reported whether they had been diagnosed by a physician with asthma by the 21-year follow-up. Trained research assistants also performed gender- and height-standardized lung function tests using a Spirobank G spirometer system attached to a laptop computer. We linked this dataset with data obtained from the child protection services and which comprised all substantiated cases of childhood maltreatment in the MUSP cohort. Substantiations of childhood maltreatment included children in an age range of 0-14years.

RESULTS

The experience of any childhood maltreatment, particularly emotional abuse, was independently associated with self-reported physician-diagnosed asthma by the 21-year follow-up. The association was no longer significant after adjustment for a range of confounders and covariates in neglected children. Childhood maltreatment, including multiple events, was not associated with lung function in adjusted models.

CONCLUSIONS

Childhood maltreatment, including emotional abuse, was associated with lifetime ever asthma. This was in contrast to the absence of an association with objective measures of lung function. More research is indicated on the effect of childhood maltreatment on lung function using objective measures. In the meantime, there should be a greater awareness of the potential impact of childhood maltreatment on the potential to develop asthma, as well as of the possibility that asthma in adulthood may precede childhood maltreatment.

Childhood abuse and adult-onset asthma among Peruvian women

OBJECTIVE

Childhood abuse has been found to be associated with adult-onset asthma; however, this association has not been studied in low- and middle-income countries with a high burden of gender-based violence, including childhood abuse. We examined the odds of asthma diagnosed at age 18 or older in relation to history of physical and sexual abuse among Peruvian pregnant women.

METHODS

This cross-sectional study collected demographic characteristics, history of abuse and asthma diagnoses from 3081 pregnant women. Logistic regression procedures estimated adjusted odds ratios and 95% confidence intervals (aOR, [95% CI]) for asthma diagnoses in relation to abuse.

RESULTS

Overall, 71% of the women reported a history of abuse (<18 years), and asthma was diagnosed among 2.6% of the cohort participants. The prevalence of physical only, sexual only and both physical and sexual childhood abuse was 38, 8 and 25%, respectively. The history of physical only (1.16, [0.63-2.17]), sexual only (2.11, [0.92-4.84]) or both physical and sexual childhood abuse (1.75, [0.94-3.29]) was positively associated with increased odds of asthma, although the associations were not statistically significant in the multivariate analysis. However, the odds of asthma increased with increasing numbers of abuse events (p_trend = 0.01). Women who reported ≥3 abuse events had an increased odds of asthma (1.88, [1.06-3.34]).

CONCLUSION

Our results do not provide convincing evidence that childhood abuse is associated with asthma among pregnant Peruvian women; however, we were able to demonstrate that an increased number of abuse events are associated with asthma. Further research is required to better understand the effects of abuse on asthma.

Maternal History of Childhood Abuse and Risk of Asthma and Allergy in 2-Year-Old Children

OBJECTIVES

Exposure to child abuse (CA) is associated with an increased risk of developing asthma and allergies; it is unknown if that risk is present across generations. This study investigated if 2-year-old children born to mothers with a history of CA were at an increased risk of receiving a diagnosis of asthma or allergies.

METHODS

Data from 1,551 participants were collected as part of the All Our Babies (AOB) study, a prospective pregnancy cohort. During pregnancy, each woman provided information about her own history of CA, and at 24 months postpartum, she provided information about her child's medical diagnoses. Symptoms of maternal depression and anxiety were assessed during pregnancy and at 24 months postpartum.

RESULTS

Unadjusted models showed that compared to children born to mothers without a history of CA, 2-year-old children born to mothers with a history of CA were more likely to have had a diagnosis of asthma (7.4% vs 4.2%, p = .016) or allergy (15.6% vs 9.2%, p < .001). Maternal symptoms of depression assessed in late pregnancy and symptoms of depression and anxiety at 24 months postpartum were significant mediators of the relationship between maternal CA and 2-year-old asthma diagnosis. Maternal symptoms of depression and anxiety assessed in late pregnancy were also significant mediators of the relationship between maternal CA and 2-year-old allergy diagnosis.

CONCLUSIONS

The results indicate that maternal exposure to CA is associated with increased risk of asthma and allergy in their 2-year-old children; symptoms of maternal depression and anxiety were identified as pathways linking the variables.

The effects of early life adversity on the immune system

Early life adversity (ELA) is associated with a higher risk for diseases in adulthood. Although the pathophysiological effects of ELA are varied, there may be a unifying role for the immune system in all of the long-term pathologies such as chronic inflammatory disorders (autoimmune diseases, allergy, and asthma). Recently, significant efforts have been made to elucidate the long-term effects ELA has on immune function, as well as the mechanisms underlying these immune changes. In this review, we focus on data from human studies investigating immune parameters in relation to post-natal adverse experiences. We describe the current understanding of the 'ELA immune phenotype', characterized by inflammation, impairment of the cellular immune system, and immunosenescence. However, at present, data addressing specific immune functions are limited and there is a need for high-quality, well powered, longitudinal studies to unravel cause from effect. Besides the immune system, also the stress system and health behaviors are altered in ELA. We discuss probable underlying mechanisms based on epigenetic programming that could explain the ELA immune phenotype and whether this is a direct effect of immune programming or an indirect consequence of changes in behavior or stress reactivity. Understanding the underlying mechanisms will help define effective strategies to prevent or counteract negative ELA-associated outcomes.

Post-traumatic Stress Disorder, Bronchodilator Response, and Incident Asthma in World Trade Center Rescue and Recovery Workers

RATIONALE

Post-traumatic stress disorder (PTSD) has been associated with asthma in cross-sectional studies. Whether PTSD leads to clinically significant bronchodilator response (BDR) or new-onset asthma is unknown.

OBJECTIVES

We sought to determine the relationship between probable PTSD and both BDR and incident asthma in a high-risk cohort of World Trade Center workers in New York (NY).

METHODS

This study was conducted on data from a high-risk cohort of 11,481 World Trade Center workers in New York, including 6,133 never smokers without a previous diagnosis of asthma. Of the 6,133 never smokers without asthma, 3,757 (61.3%) completed a follow-up visit several years later (mean = 4.95 yr, interquartile range = 3.74-5.90 yr). At the baseline visit, probable PTSD was defined as a score 44 points or greater in the PTSD Checklist questionnaire, and BDR was defined as both a change of 12% or greater and an increment of 200 ml or greater in FEV₁ after bronchodilator administration. Incident asthma was defined as a self-report of new physician-diagnosed asthma after the baseline visit. Multivariable logistic regression was used for the analysis of probable PTSD and baseline BDR or incident asthma. Measurements and Main and Results: At baseline, probable PTSD was associated with BDR among all participants (adjusted odds ratio = 1.43; 95% confidence interval = 1.19-1.72), with similar results among never smokers without asthma. Among 3,757 never smokers, probable PTSD at baseline was associated with incident asthma, even after adjustment for baseline BDR (odds ratio = 2.41; 95% confidence interval = 1.85-3.13). This association remained significant in a confirmatory analysis after excluding 195 subjects with baseline BDR.

CONCLUSIONS

In a cohort of adult workers exposed to a severe traumatic event, probable PTSD is significantly associated with BDR at baseline and predicts incident asthma.

Emotionally triggered asthma and its relationship to panic disorder, ataques de nervios, and asthma-related death of a loved one in Latino adults

OBJECTIVE

Research has demonstrated high comorbidity between asthma and panic disorder (PD). Less is known about the relationship between asthma and the Latino cultural idiom of distress of ataques de nervios, as well as the role that psychosocial stressors play. The current study tested the hypotheses that Latino asthma patients who experience PD, ataques de nervios, and/or asthma-related death of a loved one endorse greater psychological triggers of asthma, greater perceived impact of asthma triggers, and greater difficulty controlling such triggers than do those without these conditions.

METHODS

Data originated from an interview conducted prior to a randomized controlled trial in which 292 Latino adults with self-reported asthma were recruited from outpatient clinics in the Bronx, NY. The PRIME-MD Patient Health Questionnaire (PHQ) was used to screen for PD symptoms, while the Structured Clinical Interview for DSM-IV (SCID-I) was used to confirm diagnosis of PD. Lifetime history of ataques de nervios and asthma-related death of a loved one were based upon self-report. Asthma triggers were examined using the Asthma Trigger Inventory (ATI).

RESULTS

PD, ataques de nervios, and asthma-related death of a loved one each predicted a higher frequency of psychological asthma triggers, controlling for gender and comorbid medical conditions. Participants with PD also reported greater impact of asthma triggers than those without PD, while no significant differences in perceived control were observed.

CONCLUSION

Providers should screen for PD, ataques de nervios, and asthma-related death of a loved one in Latino asthma patients, given their observed association with emotionally triggered asthma.

Asthma in childhood

Several topics on childhood asthma were addressed in the Paediatric Clinical Year in Review session at the 2015 European Respiratory Society International Congress. With regard to the relationship between lower respiratory tract infections and asthma, it emerges that is the number of respiratory episodes in the first years of life, but not the particular viral trigger, to be associated with later asthma development. Understanding which characteristics of individual patients are associated with an increased risk for asthma exacerbation is a critical step to implement strategies preventing these seasonal events. Recent data suggest the possibility that exhaled volatile organic compounds may qualify as biomarkers in detecting early signs of asthma. Adding information of exhaled volatile organic compounds and expression of inflammation genes to a clinical tool significantly improves asthma prediction in preschool wheezy children. Personal communication with children and adolescents is likely more important than the tools actually used for monitoring asthma. Systemic corticosteroids do not affect the long-term prognosis in children with first viral-induced wheezing episode and should be used cautiously during acute episodes. Finally, stress and a polymorphism upstream of a specific gene are both associated with reduced bronchodilator response in children with asthma.

Mind-body interactions in the regulation of airway inflammation in asthma: A PET study of acute and chronic stress

BACKGROUND

Psychological stress has long been recognized as a contributing factor to asthma symptom expression and disease progression. Yet, the neural mechanisms that underlie this relationship have been largely unexplored in research addressing the pathophysiology and management of asthma. Studies that have examined the mechanisms of this relationship in the periphery suggest that it is the superimposition of acute stress on top of chronic stress that is of greatest concern for airway inflammation.

METHODS

We compared asthmatic individuals with high and low levels of chronic life stress in their neural and peripheral physiological responses to the Trier Social Stress Test and a matched control task. We used FDG-PET to measure neural activity during performance of the two tasks. We used both circulating and airway-specific markers of asthma-related inflammation to assess the impact of acute stress in these two groups.

RESULTS

Asthmatics under chronic stress had a larger HPA-axis response to an acute stressor, which failed to show the suppressive effects on inflammatory markers observed in those with low chronic stress. Moreover, our PET data suggest that greater activity in the anterior insula during acute stress may reflect regulation of the effect of stress on inflammation. In contrast, greater activity in the mid-insula and perigenual anterior cingulate seems to reflect greater reactivity and was associated with greater airway inflammation, a more robust alpha amylase response, and a greater stress-induced increase in proinflammatory cytokine mRNA expression in airway cells.

CONCLUSIONS

Acute stress is associated with increases in markers of airway inflammation in asthmatics under chronic stress. This relationship may be mediated by interactions between the insula and anterior cingulate cortex, that determine the salience of environmental cues, as well as descending regulatory influence of inflammatory pathways in the periphery.

Prenatal Stress, Prematurity, and Asthma

Asthma is the most common chronic disease of childhood, affecting millions of children in the United States and worldwide. Prematurity is a risk factor for asthma, and certain ethnic or racial minorities such as Puerto Ricans and non-Hispanic blacks are disproportionately affected by both prematurity and asthma. In this review, we examine current evidence to support maternal psychosocial stress as a putative link between prematurity and asthma, while also focusing on disruption of the hypothalamic-pituitary-adrenal (HPA) axis and immune responses as potential underlying mechanisms for stress-induced "premature asthma." Prenatal stress may cause not only abnormalities in the HPA axis but also epigenetic changes in the fetal glucocorticoid receptor gene (NR3C1), leading to impaired glucocorticoid metabolism. Moreover, maternal stress can alter fetal cytokine balance, favoring TH2 (allergic) immune responses characteristic of atopic asthma: interleukin 6 (IL-6), which has been associated with premature labor, can promote TH2 responses by stimulating production of IL-4 and IL-13. Given a link among stress, prematurity, and asthma, future research should include birth cohorts aimed at confirming and better characterizing "premature asthma." If confirmed, clinical trials of prenatal maternal stress reduction would be warranted to reduce the burden of these common comorbidities. While awaiting the results of such studies, sound policies to prevent domestic and community violence (eg, from firearms) are justified, not only by public safety but also by growing evidence of detrimental effects of violence-induced stress on psychiatric and somatic health.

Asthma as a disruption in iron homeostasis

Over several decades, asthma has evolved from being recognized as a single disease to include a diverse group of phenotypes with dissimilar natural histories, pathophysiologies, responses to treatment, and distinctive molecular pathways. With the application of Occam's razor to asthma, it is proposed that there is one cause underlying the numerous phenotypes of this disease and that the responsible molecular pathway is a deficiency of iron in the lung tissues. This deficiency can be either absolute (e.g. asthma in the neonate and during both pregnancy and menstruation) or functional (e.g. asthma associated with infections, smoking, and obesity). Comparable associations between asthma co-morbidity (e.g. eczema, urticaria, restless leg syndrome, and pulmonary hypertension) with iron deficiency support such a shared mechanistic pathway. Therapies directed at asthma demonstrate a capacity to impact iron homeostasis, further strengthening the relationship. Finally, pathophysiologic events producing asthma, including inflammation, increases in Th2 cells, and muscle contraction, can correlate with iron availability. Recognition of a potential association between asthma and an absolute and/or functional iron deficiency suggests specific therapeutic interventions including inhaled iron.

Gun Violence, African Ancestry, and Asthma: A Case-Control Study in Puerto Rican Children

BACKGROUND

Exposure to gun violence and African ancestry have been separately associated with increased risk of asthma in Puerto Rican children.

OBJECTIVE

The objective of this study was to examine whether African ancestry and gun violence interact on asthma and total IgE in school-aged Puerto Rican children.

METHODS

This is a case-control study of 747 Puerto Rican children aged 9 to 14 years living in San Juan, Puerto Rico (n = 472), and Hartford, Connecticut (n = 275). Exposure to gun violence was defined as the child's report of hearing gunshots more than once, and the percentage of African ancestry was estimated using genome-wide genotypic data. Asthma was defined as parental report of physician-diagnosed asthma and wheeze in the previous year. Serum total IgE (IU/mL) was measured in study participants. Multivariate logistic and linear regressions were used for the analysis of asthma and total IgE, respectively.

RESULTS

In multivariate analyses, there was a significant interaction between exposure to gun violence and African ancestry on asthma (P = .001) and serum total IgE (P = .04). Among children exposed to gun violence, each quartile increase in the percentage of African ancestry was associated with approximately 45% higher odds of asthma (95% CI, 1.15-1.84; P = .002) and an approximately 19% increment in total IgE (95% , 0.60-40.65, P = .04). In contrast, there was no significant association between African ancestry and asthma or total IgE in children not exposed to gun violence.

CONCLUSIONS

Our results suggest that exposure to gun violence modifies the estimated effect of African ancestry on asthma and atopy in Puerto Rican children.

Child maltreatment and pediatric asthma: a review of the literature

BACKGROUND

Child maltreatment is a common problem with known adverse consequences, yet its contributions to the development and course of pediatric asthma are only poorly understood.

MAIN

This review first describes possible pathways connecting child maltreatment to pediatric asthma, including aspects of the physical home environment, health behaviors and disease management, and psychological consequences of child maltreatment. We subsequently review existing studies, which generally report an association between maltreatment experiences and asthma outcomes in childhood. However, this literature is in its early stages; there are only a handful studies, most of them rely on self-reports of both child maltreatment and asthma history, and none have investigated the physiological underpinnings of this association. Taken together, however, the studies are suggestive of child maltreatment playing a role in pediatric asthma incidence and expression that should be explored further.

CONCLUSION

Existing data are sparse and do not allow for specific conclusions. However, the data are suggestive of child maltreatment influencing asthma risk and morbidity long before the adult years. Future research should focus on understanding how child maltreatment contributes to asthma disease risk and progression in this highly vulnerable population.

Review of Environmental Impact on the Epigenetic Regulation of Atopic Diseases

There has been significant increase in the prevalence of atopy over the past decade that cannot be explained by genetic predisposition. Environmental factors including nutrition, the uterine environment, and lifestyle factors are known to play a role in gene expression through epigenetic modifications. In this article, we review the literature on the environmental impact on epigenetic modulation of atopic diseases including asthma, food allergy, eczema, and allergic rhinitis. Recent public release of epigenomic data for hundreds of human tissues provides a powerful resource for further investigation of the molecular basis of atopic diseases.

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.

Stress and Bronchodilator Response in Children with Asthma

RATIONALE

Stress is associated with asthma morbidity in Puerto Ricans (PRs), who have reduced bronchodilator response (BDR).

OBJECTIVES

To examine whether stress and/or a gene regulating anxiety (ADCYAP1R1) is associated with BDR in PR and non-PR children with asthma.

METHODS

This was a cross-sectional study of stress and BDR (percent change in FEV1 after BD) in 234 PRs ages 9-14 years with asthma. We assessed child stress using the Checklist of Children's Distress Symptoms, and maternal stress using the Perceived Stress Scale. Replication analyses were conducted in two cohorts. Polymorphisms in ADCYAP1R1 were genotyped in our study and six replication studies. Multivariable models of stress and BDR were adjusted for age, sex, income, environmental tobacco smoke, and use of inhaled corticosteroids.

MEASUREMENTS AND MAIN RESULTS

High child stress was associated with reduced BDR in three cohorts. PR children who were highly stressed (upper quartile, Checklist of Children's Distress Symptoms) and whose mothers had high stress (upper quartile, Perceived Stress Scale) had a BDR that was 10.2% (95% confidence interval, 6.1-14.2%) lower than children who had neither high stress nor a highly stressed mother. A polymorphism in ADCYAP1R1 (rs34548976) was associated with reduced BDR. This single-nucleotide polymorphism is associated with reduced expression of the gene for the β2-adrenergic receptor (ADRB2) in CD4(+) lymphocytes of subjects with asthma, and it affects brain connectivity of the amygdala and the insula (a biomarker of anxiety).

CONCLUSIONS

High child stress and an ADCYAP1R1 single-nucleotide polymorphism are associated with reduced BDR in children with asthma. This is likely caused by down-regulation of ADRB2 in highly stressed children.

Adverse Childhood Events are Related to the Prevalence of Asthma and Chronic Obstructive Pulmonary Disorder Among Adult Women in Hawaii

PURPOSE

In the US, women surpass men in the prevalence of lung diseases. Limited studies exist on the association of adverse childhood events (ACEs) to asthma and chronic obstructive pulmonary disorder (COPD) particularly among women and cohorts of understudied populations (e.g., Pacific Islanders). This study evaluated the ACEs-asthma and ACEs-COPD relationships among women in Hawaii and the contribution of poor health factors (smoking, binge drinking, and obesity) in these associations.

METHODS

Using data from 3363 women in the Behavioral Risk Factor Surveillance System-Hawaii, we assessed how self-reported ACEs [count and type (household dysfunction, and physical, verbal and sexual abuse)] relate to asthma and COPD. Multivariable log-binomial regression, accounting for the sampling design, and model adjustments for socio-demographics, healthcare access, emotional support, current smoking, binge drinking, and BMI status were used to generate prevalence ratios.

RESULTS

For every increase in ACE count, the likelihood for asthma increased by 7 % (CI = 1.02-1.13), and for COPD, by 21 % (CI = 1.12-1.31) accounting for socio-demographics, healthcare access, and emotional support. Verbal abuse was also associated with greater likelihood for asthma independent of these covariates (PR = 1.43, CI = 1.14-1.79). Household dysfunction (PR = 1.82, CI = 1.15-2.82) and physical (PR = 2.01, CI = 1.20-3.37), verbal (PR = 2.24, CI = 1.38-3.65) and sexual (PR = 1.81, CI = 1.10-2.97) abuse were all associated with COPD using similar adjustments. Additional adjustment for smoking, binge drinking, and BMI status did not impact the ACE-asthma associations and only modestly attenuated the ACE-COPD relationships.

CONCLUSIONS

Primary and secondary prevention of ACEs may optimize the health of young girls in Hawaii, and reduce the burden of asthma and COPD among women in the state.

Asthma in Latin America

Consistent with the diversity of Latin America, there is profound variability in asthma burden among and within countries in this region. Regional variation in asthma prevalence is likely multifactorial and due to genetics, perinatal exposures, diet, obesity, tobacco use, indoor and outdoor pollutants, psychosocial stress and microbial or parasitic infections. Similarly, non-uniform progress in asthma management leads to regional variability in disease morbidity. Future studies of distinct asthma phenotypes should follow-up well-characterised Latin American subgroups and examine risk factors that are unique or common in Latin America (eg, stress and violence, parasitic infections and use of biomass fuels for cooking). Because most Latin American countries share the same barriers to asthma management, concerted and multifaceted public health and research efforts are needed, including approaches to curtail tobacco use, campaigns to improve asthma treatment, broadening access to care and clinical trials of non-pharmacological interventions (eg, replacing biomass fuels with gas or electric stoves).

Exposure to gun violence and asthma among children in Puerto Rico

BACKGROUND AND OBJECTIVES

Although community violence may influence asthma morbidity by increasing stress, no study has assessed exposure to gun violence and childhood asthma. We examined whether exposure to gun violence is associated with asthma in children, particularly in those reporting fear of leaving their home.

METHODS

Case-control study of 466 children aged 9-14 years with (n = 234) and without (n = 232) asthma in San Juan, Puerto Rico. Lifetime exposure to gun violence was defined as hearing a gunshot more than once. We also assessed whether the child was afraid to leave his/her home because of violence. Asthma was defined as physician-diagnosed asthma and wheeze in the prior year. We used logistic regression for the statistical analysis. All multivariate models were adjusted for age, gender, household income, parental asthma, environmental tobacco smoke, prematurity and residential distance from a major road.

RESULTS

Cases were more likely to have heard a gunshot more than once than control subjects (n = 156 or 67.2% vs. n = 122 or 52.1%, P < 0.01). In a multivariate analysis, hearing a gunshot more than once was associated with asthma (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.1-1.7, P = 0.01). Compared with children who had heard a gunshot not more than once and were not afraid to leave their home because of violence, those who had heard a gunshot more than once and were afraid to leave their home due to violence had 3.2 times greater odds of asthma (95% CI for OR = 2.2-4.4, P < 0.01).

CONCLUSIONS

Exposure to gun violence is associated with asthma in Puerto Rican children, particularly in those afraid to leave their home. Stress from such violence may contribute to the high burden of asthma in Puerto Ricans.

Association between adverse childhood experiences in the home and pediatric asthma

BACKGROUND

Numerous studies suggest that psychosocial factors could contribute to pediatric asthma.

OBJECTIVE

To examine the relation between single and cumulative adverse childhood experiences (ACEs), a measurement of household dysfunction, on parent report of lifetime asthma in children.

METHODS

This cross-sectional study used data from the 2011 to 2012 National Survey of Children's Health, a nationally representative sample of children 0 to 17 years old (n = 92,472). The main exposure was parent or guardian report of 6 ACE exposures (eg, witnessing domestic violence). The relation between ACE exposures and parent-reported diagnosis of childhood asthma was examined using multivariable logistic regression after controlling for demographic, socioeconomic, and behavioral covariates.

RESULTS

Overall asthma prevalence was 14.6%. Exposure prevalence to any ACE was 29.2%. Increased number of ACE exposures was associated with increased odds of asthma. In the adjusted model, the odds of reporting asthma were 1.28 (95% confidence interval [CI] 1.14-1.43) for those reporting 1 ACE, 1.73 (95% CI 1.27-2.36) for those with 4 ACEs, and 1.61 (95% CI 1.15-2.26) for those with 5 or 6 ACEs compared with those with no ACE exposures. Effects were moderated by Hispanic ethnicity. Hispanic children exposed to 4 ACEs had a 4.46 times increase in lifetime asthma (95% CI 2.46-8.08); white children had a 1.19 times increase (95% CI 0.80-1.79) compared with those exposed to 0 ACE.

CONCLUSION

This study supports the growing evidence for the biopsychosocial model of asthma onset. Future studies should examine the association between ACEs and specific asthma-related health outcomes.

Results from a community-based trial testing a community health worker asthma intervention in Puerto Rican youth in Chicago

Abstract Objective: Puerto Rican children suffer disproportionately from asthma. Project CURA tested the efficacy of a community health worker (CHW) intervention to improve use of inhaled corticosteroids (ICS) and reduce home asthma triggers in Puerto Rican youth in Chicago.

METHODS

This study employed a behavioral randomized controlled trial design with a community-based participatory research approach. Medications and technique were visually assessed; adherence was determined using dose counters. Home triggers were assessed via self-report, visual inspection and salivary cotinine. All participants received education on core asthma topics and self-management skills. Participants in the CHW arm were offered home education by the CHW in four visits over four months. The attention control arm received four newsletters covering the same topics.

RESULTS

While most of the participants had uncontrolled persistent asthma, <50% had ICS at baseline. In the CHW arms, 67% of participants received the full four-visit intervention. In the Elementary school cohort (n=51), the CHW arm had lower odds of having an ICS (OR=0.2; p=0.02) at 12-months; no differences were seen in other outcomes between arms at any time point. The only significant treatment arm difference in the high school cohort (n=50) was in inhaler technique where the CHW arm performed 18.0% more steps correct at five months (p<0.01) and 14.2% more steps correct at 12 months (p<0.01).

CONCLUSIONS

While this CHW intervention did not increase the number of participants with ICS or reduce home asthma triggers, important lessons were learned including challenges to CHW intervention fidelity and the need for CHWs to partner with clinical providers.

Genetic ancestry influences asthma susceptibility and lung function among Latinos

BACKGROUND

Childhood asthma prevalence and morbidity varies among Latinos in the United States, with Puerto Ricans having the highest and Mexicans the lowest.

OBJECTIVE

To determine whether genetic ancestry is associated with the odds of asthma among Latinos, and secondarily whether genetic ancestry is associated with lung function among Latino children.

METHODS

We analyzed 5493 Latinos with and without asthma from 3 independent studies. For each participant, we estimated the proportion of African, European, and Native American ancestry using genome-wide data. We tested whether genetic ancestry was associated with the presence of asthma and lung function among subjects with and without asthma. Odds ratios (OR) and effect sizes were assessed for every 20% increase in each ancestry.

RESULTS

Native American ancestry was associated with lower odds of asthma (OR = 0.72, 95% CI: 0.66-0.78, P = 8.0 × 10(-15)), while African ancestry was associated with higher odds of asthma (OR = 1.40, 95% CI: 1.14-1.72, P = .001). These associations were robust to adjustment for covariates related to early life exposures, air pollution, and socioeconomic status. Among children with asthma, African ancestry was associated with lower lung function, including both pre- and post-bronchodilator measures of FEV1 (-77 ± 19 mL; P = 5.8 × 10(-5) and -83 ± 19 mL; P = 1.1 x 10(-5), respectively) and forced vital capacity (-100 ± 21 mL; P = 2.7 × 10(-6) and -107 ± 22 mL; P = 1.0 x 10(-6), respectively).

CONCLUSION

Differences in the proportions of genetic ancestry can partially explain disparities in asthma susceptibility and lung function among Latinos.

Stress and asthma: novel insights on genetic, epigenetic, and immunologic mechanisms

In the United States the economically disadvantaged and some ethnic minorities are often exposed to chronic psychosocial stressors and disproportionately affected by asthma. Current evidence suggests a causal association between chronic psychosocial stress and asthma or asthma morbidity. Recent findings suggest potential mechanisms underlying this association, including changes in the methylation and expression of genes that regulate behavioral, autonomic, neuroendocrine, and immunologic responses to stress. There is also evidence suggesting the existence of susceptibility genes that predispose chronically stressed youth to both post-traumatic stress disorder and asthma. In this review we critically examine published evidence and suggest future directions for research in this field.

Social disadvantage and asthma control in children

This review discusses various aspects of social disadvantage and their association with poor asthma control, including socioeconomic status, exposure to psychosocial stress and violence, minority affiliation, environmental concerns such as allergens and pollution, and poverty in rural settings. Each of these elements has been linked with worsened asthma outcomes in children. Known and hypothesized mechanisms behind these associations are described in an effort to further understand the complex entity of poorly controlled asthma among socially deprived children. Intervention studies to improve asthma outcomes in these vulnerable populations are also described.

Asthma in Hispanics. An 8-year update

This review provides an update on asthma in Hispanics, a diverse group tracing their ancestry to countries previously under Spanish rule. A marked variability in the prevalence and morbidity from asthma remains among Hispanic subgroups in the United States and Hispanic America. In the United States, Puerto Ricans and Mexican Americans have high and low burdens of asthma, respectively (the "Hispanic Paradox"). This wide divergence in asthma morbidity among Hispanic subgroups is multifactorial, likely reflecting the effects of known (secondhand tobacco smoke, air pollution, psychosocial stress, obesity, inadequate treatment) and potential (genetic variants, urbanization, vitamin D insufficiency, and eradication of parasitic infections) risk factors. Barriers to adequate asthma management in Hispanics include economic and educational disadvantages, lack of health insurance, and no access to or poor adherence with controller medications such as inhaled corticosteroids. Although considerable progress has been made in our understanding of asthma in Hispanic subgroups, many questions remain. Studies of asthma in Hispanic America should focus on environmental or lifestyle factors that are more relevant to asthma in this region (e.g., urbanization, air pollution, parasitism, and stress). In the United States, research studies should focus on risk factors that are known to or may diverge among Hispanic subgroups, including but not limited to epigenetic variation, prematurity, vitamin D level, diet, and stress. Clinical trials of culturally appropriate interventions that address multiple aspects of asthma management in Hispanic subgroups should be prioritized for funding. Ensuring high-quality healthcare for all remains a pillar of eliminating asthma disparities.

Home asthma triggers: barriers to asthma control in Chicago Puerto Rican children

We sought objectively to measure, summarize, and contextualize the asthma triggers found in the homes of urban high-risk Puerto Rican children and adolescents with asthma in Chicago. Data were from the baseline home assessments of Project CURA. Research assistants interviewed caregivers, conducted a home visual inspection, and collected saliva samples for cotinine analysis. A trigger behavior summary score was created. The housing inspected was old with multiple units and obvious structural deficiencies. Many allergic and irritant triggers were observed. Having a controller medicine or private insurance was associated with lower trigger behavior summary scores; caregiver depression, caregiver perceived stress, and child negative life events were associated with high trigger scores. The final multivariate model retained had a controller medicine, private insurance, and caregiver perceived stress. The data from this high-risk cohort identified modifiable areas where environmental interventions could reduce morbidity in Puerto Rican children and adolescents.

ADCYAP1R1 and asthma in Puerto Rican children

RATIONALE

Epigenetic and/or genetic variation in the gene encoding the receptor for adenylate-cyclase activating polypeptide 1 (ADCYAP1R1) has been linked to post-traumatic stress disorder in adults and anxiety in children. Psychosocial stress has been linked to asthma morbidity in Puerto Rican children.

OBJECTIVES

To examine whether epigenetic or genetic variation in ADCYAP1R1 is associated with childhood asthma in Puerto Ricans.

METHODS

We conducted a case-control study of 516 children ages 6-14 years living in San Juan, Puerto Rico. We assessed methylation at a CpG site in the promoter of ADCYAP1R1 (cg11218385) using a pyrosequencing assay in DNA from white blood cells. We tested whether cg11218385 methylation (range, 0.4-6.1%) is associated with asthma using logistic regression. We also examined whether exposure to violence (assessed by the Exposure to Violence [ETV] Scale in children 9 yr and older) is associated with cg11218385 methylation (using linear regression) or asthma (using logistic regression). Logistic regression was used to test for association between a single nucleotide polymorphism in ADCYAP1R1 (rs2267735) and asthma under an additive model. All multivariate models were adjusted for age, sex, household income, and principal components.

MEASUREMENTS AND MAIN RESULTS

EACH 1% increment in cg11218385 methylation was associated with increased odds of asthma (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.6; P = 0.03). Among children 9 years and older, exposure to violence was associated with cg11218385 methylation. The C allele of single nucleotide polymorphism rs2267735 was significantly associated with increased odds of asthma (adjusted odds ratio, 1.3; 95% confidence interval, 1.02-1.67; P = 0.03).

CONCLUSIONS

Epigenetic and genetic variants in ADCYAP1R1 are associated with asthma in Puerto Rican children.

The challenge of asthma in minority populations

The burden and disparity of asthma in race/ethnic minorities present a significant challenge. In this review, we will evaluate data on asthma epidemiology in minorities, examine potential reasons for asthma disparities, and discuss strategies of intervention and culturally sensitive care.