Exposure to Violence, Psychosocial Stress, and Asthma

The effects of violence and related stress on asthma

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

Recommendations for Clinicians to Combat Environmental Disparities in Pediatric Asthma: A Review

TOPIC IMPORTANCE

Asthma is a common and complex lung disease in children, with disproportionally higher prevalence and related adverse outcomes among children in racial and ethnic minority groups and of lower socioeconomic position. Environmental factors, including unhealthy housing and school-based exposures, can contribute to increased asthma morbidity and widening disparities. This underscores a significant environmental justice issue and suggests the need for clinical interventions to reduce sources of environmental exposures and ultimately diminish the observed disparities in childhood asthma.

REVIEW FINDINGS

Unhealthy housing conditions, including secondhand tobacco smoke, allergen exposure, and indoor air pollution, can exacerbate asthma symptoms in children. Although unhealthy housing can occur anywhere, such situations most frequently occur in urban, low-income environments where renting is common. To reduce environmental triggers, clinicians can recommend smoking cessation, cleaning techniques to mitigate exposure, and even directly contacting landlords to address poor housing conditions. Children spend much of their time in schools, where this built environment is also a source of asthma triggers (eg, poor ventilation) and allergens (eg, mold and pests, chemicals). As such, a multidisciplinary approach is needed to adequately address the burden of childhood asthma to equitably reduce disparities to both harmful exposures and negative health outcomes.

SUMMARY

Racial, ethnic, and socioeconomic disparities exist in asthma morbidity in children, and such disparities are driven in part by environmental factors at the housing and school level. Clinicians can make evidence-based recommendations to drive effective exposure reduction strategies to mitigate asthma morbidity and reduce observed disparities.

Disparities in prevalence and outcomes of respiratory disease in low- and middle-income countries

OBJECTIVES

To provide a comprehensive overview of disparities in prevalence and outcomes of respiratory diseases and notable challenges for providing optimal treatment to pediatric patients with respiratory diseases living in low- and middle-income countries (LMICs), as an input to help better understand the roots of respiratory health disparities.

METHODS

We conducted a narrative review of relevant literature published in electronic databases from inception to February 2023 that present data on disparities in prevalence and outcomes of respiratory disease in LMICs. Additionally, we included studies that describe and discuss challenges for providing optimal treatment to pediatric patients with respiratory diseases living in LMICs.

RESULTS

A number of early life exposures have been associated with adverse respiratory outcomes in later life. Several studies have shown marked geographical variations in the prevalence and burden of pediatric asthma, with consistently lower prevalence rates but significantly higher burdens and worse outcomes in LMICs. There is a wide range of challenges that adversely affect the efficient care of children with respiratory diseases that can be classified into three categories: patient-related factors, social/environmental factors, and factors related to healthcare providers or the healthcare system.

CONCLUSIONS

Respiratory health disparities in children living in LMICs represent a global public health issue mainly explained by an unequal distribution of preventable and modifiable risk factors for respiratory diseases across different demographic groups.

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.

Trends in US Pediatric Asthma Hospitalizations, by Race and Ethnicity, 2012-2020

Introduction

Some racial and ethnic minority communities have long faced a higher asthma burden than non-Hispanic White communities. Prior research on racial and ethnic pediatric asthma disparities found stable or increasing disparities, but more recent data allow for updated analysis of these trends.

Methods

Using 2012-2020 National Inpatient Sample data, we estimated the number of pediatric asthma hospitalizations by sex, age, and race and ethnicity. We converted these estimates into rates using data from the US Census Bureau and then conducted meta-regression to assess changes over time. Because the analysis spanned a 2015 change in diagnostic coding, we performed separate analyses for periods before and after the change. We also excluded 2020 data from the regression analysis.

Results

The number of pediatric asthma hospitalizations decreased over the analysis period. Non-Hispanic Black children had the highest prevalence (range, 9.8-36.7 hospitalizations per 10,000 children), whereas prevalence was lowest among non-Hispanic White children (range, 2.2-9.4 hospitalizations per 10,000 children). Although some evidence suggests that race-specific trends varied modestly across groups, results overall were consistent with a similar rate of decrease across all groups (2012-2015, slope = -0.83 [95% CI, -1.14 to -0.52]; 2016-2019, slope = -0.35 [95% CI, -0.58 to -0.12]).

Conclusion

Non-Hispanic Black children remain disproportionately burdened by asthma-related hospitalizations. Although the prevalence of asthma hospitalization is decreasing among all racial and ethnic groups, the rates of decline are similar across groups. Therefore, previously identified disparities persist. Interventions that consider the specific needs of members of disproportionately affected groups may reduce these disparities.

Health Care Access and Use Among U.S. Children Exposed to Neighborhood Violence

INTRODUCTION

Neighborhood violence is an adverse childhood experience which impacts millions of U.S. children and is associated with poor health outcomes across the life course. These effects may be mitigated by access to care. Yet, the ways in which exposure to neighborhood violence shapes children's health care access have been understudied.

METHODS

This is a cross-sectional analysis of 16,083 children (weighted N=67,214,201) ages 1 to <18 years from the 2019 and 2021 National Health Interview Survey. Guardians were asked about preventive care access, unmet health needs, and health care utilization in the last year. Changes associated with exposure to neighborhood violence were estimated using marginal effects from multivariable logistic regression models adjusted for year, age, sex, race/ethnicity, parental education, family structure, rurality, income, insurance type, insurance discontinuity, and overall reported health.

RESULTS

Of 16,083 sample children, 863 (weighted 5.3% [95% CI 4.8-5.7]) reported exposure to neighborhood violence, representing a weighted population of ∼3.5 million. In adjusted analyses, exposure to violence was associated with forgone prescriptions (adjusted difference 1.2 percentage-points (pp) [95%CI 0.1-2.3]; weighted national population impact 42,833 children), trouble paying medical bills (7.7pp [4.4-11.0]; 271,735), delayed medical (1.5pp [0.2-2.9]; 54,063) and mental health care (2.8pp [1.1-4.6]; 98,627), and increased urgent care (4.5pp [0.9-8.1]; 158,246) and emergency department utilization (6.4pp [3.1-9.8]; 227,373).

CONCLUSIONS

In this nationally representative study, neighborhood violence exposure among children was associated with unmet health needs and increased acute care utilization. Evidence-based interventions to improve access to care and reduce economic precarity in communities impacted by violence are needed to mitigate downstream physical and mental health consequences.

Association between property investments and crime on commercial and residential streets: Implications for maximizing public safety benefits

Physical property investments enhance public safety in communities while alleviating the need for criminal justice system responses. Policy makers and local government officials must allocate scare resources for community and economic development activities. Understanding where physical property investments have the greatest crime reducing benefits can inform decision making to maximize economic, safety, and health outcomes. This study uses Spatial Durbin models with street segment and census tract by year fixed effects to examine the impact of physical property investments on changes in property and violent crime over an 11-year period (2008-2018) in six large U.S. cities. The units of analysis are commercial and residential street segments. Street segments are classified into low, medium, and high crime terciles defined by initial crime levels (2008-2010). Difference of coefficients tests identify significant differences in building permit effects across crime terciles. The findings reveal there is a significant negative relationship between physical property investments and changes in property and violent crime on commercial and residential street segments in all cities. Investments have the greatest public safety benefit where initial crime levels are the highest. The decrease in violent crime is larger on commercial street segments, while the decrease in property crime is larger on residential street segments. Targeting the highest crime street segments (i.e., 90th percentile) for property improvements will maximize public safety benefits.

Asthma and Rhinitis Through the Lifespan of Nonpregnant Women

Increasingly, clinical practice guidelines advocate a precision medicine-based approach to care for asthma. This focus requires knowledge of not only different asthma phenotypes and their associated biomarkers but also sex and gender differences through the lifespan. Evidence continues to build in favor of different lifetime prevalence, clinical presentations, responses to management, and long-term prognosis of asthma. Women transition through many biological and psychosocial phases in their lives, all of which may interact with, and influence, their health and well-being. Historically, explanations have focused on hormonal effects on asthma in reproductive life, but a greater understanding of mechanisms starting before birth and changing over a lifetime is now possible, with immunologic, inflammatory, and hormonal factors playing a role. This article describes the evidence for the differences in asthma and rhinitis between men and women at different stages of life, the potential underlying mechanisms that contribute to this, and the implications for management and research. Future research studies should systematically report sex differences in asthma so that this knowledge can be used to develop a personalized approach to care, to achieve best possible outcomes for all.

Identifying asthma-related risks during hospitalization using the child asthma risk assessment tool

Objective: The Child Asthma Risk Assessment Tool (CARAT) identifies risk factors for asthma morbidity. We hypothesized that CARAT-identified risk factors (using a CARAT adapted for inpatient use) would be associated with future healthcare utilization and would identify areas for intervention.Methods: We reviewed CARAT data collected during pediatric asthma admissions from 2010-2015, assessing for risk factors in environmental, medical, and social domains and providing prompts for inpatient (specialist consultation or social services engagement) and post-discharge interventions (home care visit or home environmental assessment). Confirmatory factor analysis identified groups of CARAT-identified risk factors with similar effects on healthcare utilization (latent factors). Structural equation models then evaluated relationships between latent factors and future utilization.Results: There were 2731 unique patients admitted for asthma exacerbations; 1015 (37%) had complete CARAT assessments and were included in analyses. Those with incomplete CARAT assessments were more often younger and privately-insured. CARAT-identified risk factors across domains were common in children hospitalized for exacerbations. Risks in the environmental domain were most common. Inpatient asthma consults by pulmonologists or allergists and home care referrals were the most frequent interventions indicated (62%, 628/1015, and 50%, 510/1015, respectively). Two latent factors were positively associated with healthcare utilization in the year after index stay - social stressors and known/suspected allergies (both p < 0.05). Stratified analyses analyzing data just from those children with prior healthcare utilization also indicated known/suspected allergies to be positively associated with future utilization.Conclusions: Inpatient interventions to address social stressors and allergic profiles may be warranted to reduce subsequent asthma morbidity.

Sociome Data Commons: A scalable and sustainable platform for investigating the full social context and determinants of health

Background/Objective

Non-clinical aspects of life, such as social, environmental, behavioral, psychological, and economic factors, what we call the sociome, play significant roles in shaping patient health and health outcomes. This paper introduces the Sociome Data Commons (SDC), a new research platform that enables large-scale data analysis for investigating such factors.

Methods

This platform focuses on "hyper-local" data, i.e., at the neighborhood or point level, a geospatial scale of data not adequately considered in existing tools and projects. We enumerate key insights gained regarding data quality standards, data governance, and organizational structure for long-term project sustainability. A pilot use case investigating sociome factors associated with asthma exacerbations in children residing on the South Side of Chicago used machine learning and six SDC datasets.

Results

The pilot use case reveals one dominant spatial cluster for asthma exacerbations and important roles of housing conditions and cost, proximity to Superfund pollution sites, urban flooding, violent crime, lack of insurance, and a poverty index.

Conclusion

The SDC has been purposefully designed to support and encourage extension of the platform into new data sets as well as the continued development, refinement, and adoption of standards for dataset quality, dataset inclusion, metadata annotation, and data access/governance. The asthma pilot has served as the first driver use case and demonstrates promise for future investigation into the sociome and clinical outcomes. Additional projects will be selected, in part for their ability to exercise and grow the capacity of the SDC to meet its ambitious goals.

Workplace Harassment and Health: A Long Term Follow up

OBJECTIVE

We examine relationships between workplace harassment (WH) and onset of health conditions over a 23-year period.

METHODS

Participants were surveyed at seven points between 1997-2006 and again in 2020. Regression analyses (n = 921) assessed effects of chronic WH exposure on onset or recent health conditions by 2020.

RESULTS

Growth mixture modeling revealed infrequent and chronic classes of generalized workplace harassment (GWH; 33.39% chronic) and sexual harassment (SH; 32.32% chronic). Prevalence of health conditions ranged from 3.71% for myocardial infarction to 43.06% for hypertension. Analysis via propensity score matching showed chronic WH class membership increased odds of coronary heart disease (GWH, odds ratio [OR] = 3.42, P < 0.05), arthritic/rheumatic conditions (SH, OR = 1.56, P < 0.05), and recent migraine (SH, OR = 1.68, P < 0.05).

CONCLUSIONS

Workplace harassment is associated with coronary heart disease, arthritic/rheumatic conditions, and migraine. Worker health can be protected through strengthening and enforcing organizational and social antiharassment policies and laws.

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

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

Home-based pulmonary rehabilitation for adults with severe asthma exposed to psychosocial chronic stressors

OBJECTIVE

To evaluate the effects of a home-based pulmonary rehabilitation (PR) programme on hyperventilation symptoms, anxiety and depressive symptoms, general fatigue, health-related quality of life (HRQoL) and exercise capacity in adults with severe asthma who have been exposed to psychosocial chronic stressors.

METHODS

Data on 111 non-selected consecutive adults with severe asthma who enrolled in an 8-week home-based PR programme (weekly supervised 90-min session) was retrospectively analysed. Chronic stressors included physical, sexual and psychological violence and/or a traumatic experience related to an intensive care unit stay. Hyperventilation symptoms (Nijmegen questionnaire), Hospital Anxiety and Depression Scale, Fatigue Assessment Scale, COPD Assessment Test, Six-Minute Stepper Test and Timed-Up and Go test were assessed at baseline and after PR.

RESULTS

At baseline, participants who have been exposed to chronic stressors (n = 48, 43.2%) were younger, more often female, more often treated for anxiety and depressive disorders, and had a higher score for anxiety symptoms, hyperventilation symptoms and a poorer HRQoL, compared to those who had not been exposed to chronic stressors (p < 0.05). All the study assessments were statistically improved after PR for both groups (p < 0.001). Anxiety and depressive symptoms, fatigue and health-related quality of life questionnaires were also clinically improved based on the minimal clinically important difference.

CONCLUSION

A large proportion of adults with severe asthma, mainly women, have been exposed to chronic stressors at the time of starting a PR programme, resulting in higher anxiety symptoms and hyperventilation symptoms. However, it did not prevent these individuals from benefiting from PR.

Asthma and Chronic Obstructive Pulmonary Disease

In the United States, asthma and chronic obstructive pulmonary disease (COPD) disproportionately affect African Americans, Puerto Ricans, and other minority groups. Compared with non-Hispanic whites, minorities have been marginalized and more frequently exposed to environmental risk factors such as tobacco smoke and outdoor and indoor pollutants. Such divergent environmental exposures, alone or interacting with heredity, lead to disparities in the prevalence, morbidity, and mortality of asthma and COPD, which are worsened by lack of access to health care. In this article, we review the burden and risk factors for racial or ethnic disparities in asthma and COPD and discuss future directions in this field.

Health Equity and Respiratory Diseases in Low- and Middle-Income Countries

Over 80% of the morbidity and mortality related to acute and chronic respiratory diseases occur in low- and middle-income countries (LMICs), a reflection of vast disparities in care for these conditions. Over the next decade, the prevalence of respiratory diseases is expected to increase, as population growth in LMICs exceeds high-income countries (HICs). Pediatric morbidity and mortality from lower respiratory tract infections and asthma occur almost exclusively in LMICs, contributing to a greater loss of quality adjusted life years from these conditions when compared with HICs.

Advances in pulmonary rehabilitation for children with bronchial asthma

Bronchial asthma is a heterogeneous disease characterized by chronic airway inflammation and airway hyperresponsiveness. With the development of the whole-life-cycle health concept, the focus of treatment for bronchial asthma in children has gradually shifted from pharmacological control to an integrated management model of functional rehabilitation and pharmacological assistance. As a non-pharmacological integrated approach, pulmonary rehabilitation plays an equally important role in the management of childhood asthma as pharmacological treatments. Breathing techniques such as Buteyko breathing, pursed lip breathing, diaphragmatic breathing training, threshold-pressure inspiratory muscle training and yoga breathing can improve lung function indicators such as forced expiratory volume in first second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF) and maximal voluntary ventilation (MVV) in children. Comprehensive pre-exercise assessment, development of exercise prescriptions, and implementation and evaluation of exercise effects can improve physical fitness, neuromuscular coordination, and self-confidence of children with asthma. The comprehensive interventions of health education, psychological support and nutritional intervention can improve the compliance and effectiveness of rehabilitation training. This article reviews the research progress on respiratory training, physical exercise, and comprehensive interventions in the pulmonary rehabilitation of asthmatic children, to provide theoretical basis and practical guidance for the scientific and rational management of pulmonary rehabilitation of asthmatic children in clinical settings.

Neighborhood violence and socioeconomic deprivation influence associations between acute air pollution and temperature on childhood asthma in New York city

Ambient air pollution, temperature, and social stressor exposures are linked with asthma risk, with potential synergistic effects. We examined associations for acute pollution and temperature exposures, with modification by neighborhood violent crime and socioeconomic deprivation, on asthma morbidity among children aged 5-17 years year-round in New York City. Using conditional logistic regression in a time-stratified, case-crossover design, we quantified percent excess risk of asthma event per 10-unit increase in daily, residence-specific exposures to PM2.5, NO2, SO2, O3, and minimum daily temperature (Tmin). Data on 145,834 asthma cases presenting to NYC emergency departments from 2005 to 2011 were obtained from the New York Statewide Planning and Research Cooperative System (SPARCS). Residence- and day-specific spatiotemporal exposures were assigned using the NYC Community Air Survey (NYCCAS) spatial data and daily EPA pollution and NOAA weather data. Point-level NYPD violent crime data for 2009 (study midpoint) was aggregated, and Socioeconomic Deprivation Index (SDI) scores assigned, by census tract. Separate models were fit for each pollutant or temperature exposure for lag days 0-6, controlling for co-exposures and humidity, and mutually-adjusted interactions (modification) by quintile of violent crime and SDI were assessed. We observed stronger main effects for PM2.5 and SO2 in the cold season on lag day 1 [4.90% (95% CI: 3.77-6.04) and 8.57% (5.99-11.21), respectively]; Tmin in the cold season on lag day 0 [2.26% (1.25-3.28)]; and NO2 and O3 in the warm season on lag days 1 [7.86% (6.66-9.07)] and 2 [4.75% (3.53-5.97)], respectively. Violence and SDI modified the main effects in a non-linear manner; contrary to hypotheses, we found stronger associations in lower-violence and -deprivation quintiles. At very high stressor exposures, although asthma exacerbations were highly prevalent, pollution effects were less apparent-suggesting potential saturation effects in socio-environmental synergism.

The Impact of Climate Change on Asthma and Allergic-Immunologic Disease

PURPOSE OF REVIEW

This review discusses climate change-related impacts on asthma and allergic-immunologic disease, relevant US public health efforts, and healthcare professional resources.

RECENT FINDINGS

Climate change can impact people with asthma and allergic-immunologic disease through various pathways, including increased exposure to asthma triggers (e.g., aeroallergens, ground-level ozone). Climate change-related disasters (e.g., wildfires, floods) disrupting healthcare access can complicate management of any allergic-immunologic disease. Climate change disproportionately affects some communities, which can exacerbate disparities in climate-sensitive diseases like asthma. Public health efforts include implementing a national strategic framework to help communities track, prevent, and respond to climate change-related health threats. Healthcare professionals can use resources or tools to help patients with asthma and allergic-immunologic disease prevent climate change-related health impacts. Climate change can affect people with asthma and allergic-immunologic disease and exacerbate health disparities. Resources and tools are available to help prevent climate change-related health impacts at the community and individual level.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exposure to intimate partner violence and lack of asthma control in adults: a cross-sectional study

BACKGROUND

Asthma is a chronic airway disease that affects 339 million people worldwide. It is a heterogeneous disease with different risks, including in family environments, where intimate partner violence occurs.

OBJECTIVE

This study aimed to investigate the possible association between psychosocial factors and asthma control in adults exposed to intimate partner violence.

DESIGN AND SETTING

This cross-sectional study was conducted at a Brazilian public higher education institution in Salvador, Bahia, Brazil.

METHODS

The study population consisted of adults clinically diagnosed with severe asthma and those with mild/moderate asthma identified at an asthma referral outpatient clinic. The sample comprised 492 participants who underwent clinical evaluation and completed questionnaires to assess asthma control, depression, stress, and resilience. The Conflict Tactics Scale, which measures tactics for managing marital conflicts, was used to estimate the level of intimate partner violence.

RESULTS

Of the 492 participants, 76.2% were women and 91% self-referenced color black/brown, 37.8% reported low family income, 87.4% reported low education level, 71.7% reported high stress, 32.5% reported low resilience, 18.5% reported moderate or severe depression, 83.3% reported resolute negotiation, 49.4% reported major psychological aggression, 19.6% reported major physical aggression, 15.5% reported major injury, and 7.3% reported major sexual coercion. Regression analysis revealed that sex was an effect modifier.

CONCLUSION

Women in situations of social vulnerability, with low income and poor education, with depression, severe asthma, and those who used aggression to resolve marital conflicts had a profile associated with a lack of asthma control.

Intimate Partner Violence and Children: Essentials for the Pediatric Nurse Practitioner

Intimate partner violence (IPV) is a public health problem of epidemic proportions. IPV often starts early in adolescence and continues throughout an individual's lifespan. IPV is defined as abuse or aggression occurring in the context of a romantic relationship that is perpetrated by a current or former partner. IPV victims often experience severe psychological trauma, physical injury, and even death. The direct recipient of the violence is often not the only individual impacted. Children are often peripheral victims of IPV. It is vital that pediatric health care providers, including pediatric nurse practitioners, recognize that IPV is indeed a pediatric health care crisis requiring strategies for both identification and intervention. This continuing education article will discuss IPV and its impact on children from conception to adolescence while exploring implications for practice.

Disparities in Disease Burden and Treatment of Patients Asthma and Chronic Obstructive Pulmonary Disease

Lung health reflects the inequities of our society. Asthma and chronic obstructive pulmonary disease are 2 lung conditions commonly treated in general clinical practice; each imposes a disproportionate burden on disadvantaged patients. Numerous factors mediate disparities in lung health, including air pollution, allergen exposures, tobacco, and respiratory infections. Members of racial/ethnic minorities and those of low socioeconomic status also have inferior access to high-quality medical care, compounding disparities in disease burden. Physicians can work against disparities in their practice, but wide-ranging policy reforms to achieve better air quality, housing, workplace safety, and healthcare for all are needed to achieve equity in lung health.

Child maltreatment, anxiety and depression, and asthma among British adults in the UK Biobank

BACKGROUND

Child maltreatment is associated with asthma in adults. We examined whether lifetime major depressive disorder (MDD) or lifetime generalised anxiety disorder (GAD) mediate an association between child maltreatment and current asthma among 81 105 British adults in the UK Biobank who completed a mental health survey and had complete data on child maltreatment, GAD, MDD, asthma and relevant covariates but no diagnosis of chronic obstructive pulmonary disease.

METHODS

Child maltreatment was ascertained based on answers to the five questions in the Childhood Trauma Screener. Two mediators, lifetime MDD and GAD, were assessed based on the Composite International Diagnostic Interview Short Form. Current asthma was defined as physician-diagnosed asthma and wheeze or whistling in the chest in the previous year. Logistic regression was used for the multivariable analysis of child maltreatment and current asthma, and a mediation analysis was conducted to estimate the contributions of lifetime MDD and lifetime GAD to the child maltreatment-current asthma association.

RESULTS

In a multivariable analysis, any child maltreatment was associated with asthma (adjusted OR 1.22, 95% CI 1.15-1.28; p<0.01). In a mediation analysis adjusted for household income, educational attainment, smoking status, pack-years of smoking and other covariates, lifetime GAD and lifetime MDD explained 21.8% and 32.5%, respectively, of the child maltreatment-current asthma association. Similar results were obtained after excluding current smokers and former smokers with ≥10 pack-years of smoking from the mediation analysis.

CONCLUSION

Our findings suggest that GAD and MDD mediate an association between child maltreatment and asthma in adults, independently of smoking.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Further Understanding of Neuro-Immune Interactions in Allergy: Implications in Pathophysiology and Role in Disease Progression

The complicated interaction between the central and the autonomic (sympathetic, parasympathetic, and enteric) nervous systems on the one hand and the immune system and its components, on the other hand, seems to substantially contribute to allergy pathophysiology, uncovering an under-recognized association that could have diagnostic and therapeutic potentials. Neurons connect directly with and regulate the function of many immune cells, including mast cells, the cells that have a leading role in allergic disorders. Proinflammatory mediators such as cytokines, neurotrophins, chemokines, and neuropeptides are released by immune cells, which stimulate sensory neurons. The release of neurotransmitters and neuropeptides caused by the activation of these neurons directly impacts the functional activity of immune cells and vice versa, playing a decisive role in this communication. Successful application of Pavlovian conditioning in allergic disorders supports the existence of a psychoneuroimmunological interplay in classical allergic hypersensitivity reactions. Activation of neuronal homeostatic reflexes, like sneezing in allergic rhinitis, coughing in allergic asthma, and vomiting in food allergy, offers additional evidence of a neuroimmunological interaction that aims to maintain homeostasis. Dysregulation of this interaction may cause overstimulation of the immune system that will produce profound symptoms and exaggerated hemodynamic responses that will lead to severe allergic pathophysiological events, including anaphylaxis. In this article, we have systematically reviewed and discussed the evidence regarding the role of the neuro-immune interactions in common allergic clinical modalities like allergic rhinitis, chronic rhinosinusitis, allergic asthma, food allergy, atopic dermatitis, and urticaria. It is essential to understand unknown – to most of the immunology and allergy experts – neurological networks that not only physiologically cooperate with the immune system to regulate homeostasis but also pathogenetically interact with more or less known immunological pathways, contribute to what is known as neuroimmunological inflammation, and shift homeostasis to instability and disease clinical expression. This understanding will provide recognition of new allergic phenotypes/endotypes and directions to focus on specialized treatments, as the era of personalized patient-centered medicine, is hastening apace.

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.

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 in the Americas: An Update: A Joint Perspective from the Brazilian Thoracic Society, Canadian Thoracic Society, Latin American Thoracic Society, and American Thoracic Society

Asthma affects a large number of people living in the Americas, a vast and diverse geographic region comprising 35 nations in the Caribbean and North, Central, and South America. The marked variability in the prevalence, morbidity, and mortality from asthma across and within nations in the Americas offers a unique opportunity to improve our understanding of the risk factors and management of asthma phenotypes and endotypes in children and adults. Moreover, a better assessment of the causes and treatment of asthma in less economically developed regions in the Americas would help diagnose and treat individuals migrating from those areas to Canada and the United States. In this focused review, we first assess the epidemiology of asthma, review known and potential risk factors, and examine commonalities and differences in asthma management across the Americas. We then discuss future directions in research and health policies to improve the prevention, diagnosis, and management of pediatric and adult asthma in the Americas, including standardized and periodic assessment of asthma burden across the region; large-scale longitudinal studies including omics and comprehensive environmental data on racially and ethnically diverse populations; and dissemination and implementation of guidelines for asthma management across the spectrum of disease severity. New initiatives should recognize differences in socioeconomic development and health care systems across the region while paying particular attention to novel or more impactful risk factors for asthma in the Americas, including indoor pollutants such as biomass fuel, tobacco use, infectious agents and the microbiome, and psychosocial stressor and chronic stress.

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.

Investigating adjustment profiles in children exposed to intimate partner violence using a biopsychosocial resilience framework: A Canadian population-based study

BACKGROUND

The variability observed across different profiles of adjustment in children exposed to intimate partner violence (IPV) and the factors associated with resilience in this population are not yet well understood.

OBJECTIVE

Within a biopsychosocial framework, this study aimed to identify and describe profiles of adjustment in a cohort of children who had previously experienced IPV exposure, as well as the specific risk and promotive factors that significantly predicted membership in the identified adjustment profiles. The moderating effect of children's biological sex was also tested.

PARTICIPANTS AND SETTING

Population-based administrative data on all residents of the Province of Manitoba (Canada) over a 12-year period (2006-2017) were used to create a cohort of 3886 children aged 6-11 years who experienced IPV exposure and to extract information on these children and their mothers.

METHOD

Within a retrospective cohort study design, all study variables were extracted by linking multiple administrative health, social and justice datasets that were available in the Manitoba Population Research Data Repository.

RESULTS

Person-centered latent class analysis revealed four distinct adjustment profiles in the cohort of children, which differed for boys and girls. These included a resilient profile in which children showed no adjustment problems, as well as three profiles showing different combinations of children's externalizing problems and physical health problems. Positive maternal mental and physical health were the strongest predictors of resilient profile membership in both boys and girls.

CONCLUSIONS

Study results suggest interconnectedness among biological, psychological and social domains in shaping the adjustment of children exposed to IPV and corroborate existing evidence on the key role that mothers play in promoting the resilience of these children. Thus, future resilience research with this group and resilience-promoting programming for IPV-affected families would benefit from adopting a multisystemic biopsychosocial resilience framework that simultaneously accounts for factors at all levels of human ecologies.

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.

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

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

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.

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.

Understanding the heart-brain axis response in COVID-19 patients: A suggestive perspective for therapeutic development

In-depth characterization of heart-brain communication in critically ill patients with severe acute respiratory failure is attracting significant interest in the COronaVIrus Disease 19 (COVID-19) pandemic era during intensive care unit (ICU) stay and after ICU or hospital discharge. Emerging research has provided new insights into pathogenic role of the deregulation of the heart-brain axis (HBA), a bidirectional flow of information, in leading to severe multiorgan disease syndrome (MODS) in patients with confirmed infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Noteworthy, HBA dysfunction may worsen the outcome of the COVID-19 patients. In this review, we discuss the critical role HBA plays in both promoting and limiting MODS in COVID-19. We also highlight the role of HBA as new target for novel therapeutic strategies in COVID-19 in order to open new translational frontiers of care. This is a translational perspective from the Italian Society of Cardiovascular Researches.

Improving lung health in low-income and middle-income countries: from challenges to solutions

Low-income and middle-income countries (LMICs) bear a disproportionately high burden of the global morbidity and mortality caused by chronic respiratory diseases (CRDs), including asthma, chronic obstructive pulmonary disease, bronchiectasis, and post-tuberculosis lung disease. CRDs are strongly associated with poverty, infectious diseases, and other non-communicable diseases (NCDs), and contribute to complex multi-morbidity, with major consequences for the lives and livelihoods of those affected. The relevance of CRDs to health and socioeconomic wellbeing is expected to increase in the decades ahead, as life expectancies rise and the competing risks of early childhood mortality and infectious diseases plateau. As such, the World Health Organization has identified the prevention and control of NCDs as an urgent development issue and essential to the achievement of the Sustainable Development Goals by 2030. In this Review, we focus on CRDs in LMICs. We discuss the early life origins of CRDs; challenges in their prevention, diagnosis, and management in LMICs; and pathways to solutions to achieve true universal health coverage.

Health Disparities in Environmental and Occupational Lung Disease

Pulmonary health disparities disproportionately impact disadvantaged and vulnerable populations. This article focuses on disparities in disease prevalence, morbidity, and mortality for asthma, chronic obstructive pulmonary disease, pneumoconiosis, and lung cancer. Disparities are categorized by race, age, sex, socioeconomic status, and geographic region. Each category highlights differences in risk factors for the development and severity of lung disease. Risk factors include social, behavioral, economic, and biologic determinants of health (occupational/environmental exposures, psychosocial stressors, smoking, health literacy, health care provider bias, and health care access). Many of these risk factors are complex and inter-related; strategies proposed to decrease disparities require multilevel approaches.

Association between Asthma and Internet Addiction Status in Korean Adolescents

Background

Problematic Internet addiction (IA) has been shown to be associated with a variety of psychological comorbidities, but its relationship with adolescent asthma has not yet been investigated in detail.

Methods

We analyzed 18,473 adolescent patients with physician-diagnosed asthma and 205,069 non-asthmatic adolescent patients from the Korean Youth Risk Behavior Web-based Survey. Socioeconomic factors, health behavior factors, psychological factors, and IA status were assessed using the Korean Internet Addiction Proneness Scale. Multiple logistic regression analysis was performed, with adjustment for multiple cofounders, to explore the association between IA and adolescent asthma.

Results

Comparison between the adolescent asthma group and non-adolescent asthma group indicated higher rates of probable IA (13.7% vs. 12.1%, respectively, P<0.001), IA (4.8% vs. 3.1%, respectively, P<0.001), and problematic IA (18.5% vs. 15.2%, respectively, P<0.001) in the adolescent asthma group. After adjustment for multiple confounders, probable IA [odds ratio (OR): 1.16, 95% confidence interval (CI): 1.08–1.26] and IA (OR: 1.07, 95% CI: 1.02–1.12) were significantly associated with increased risk of adolescent asthma, compared to non-problematic Internet use.

Conclusions

IA is associated with an increased rate of asthma in Korean adolescents. So, IA has attracted minimal attention in relation to the treatment of asthma.

The Age, Sex, and Geographical Distribution of Self-Reported Asthma Triggers on Children With Asthma in China

Background: Asthma can be exacerbated by many triggers, and the heterogeneity of asthma triggers is clear among children with asthma. This study describes asthma triggers using a large-scale electronic dataset from the smartphone-based Chinese Children's Asthma Action Plan (CCAAP) app and aims to examine the difference in asthma triggers among different subgroups of children with asthma. Methods: Data from the smartphone-based CCAAP app between February 22, 2017, and November 23, 2020, were reviewed, and children with asthma who reported their asthma triggers were enrolled. Eight common asthma triggers were listed in the software: upper respiratory infection (URI), allergen sensitization, exercise, emotional disturbances, pungent odors, air pollution/smog, weather change, and tobacco smoke. We compared the incidence of asthma triggers among different subgroups (<6 years vs. 6-17 years; boy vs. girl; eastern region vs. central region vs. western region). Results: We enrolled 6,835 patients with self-reported asthma triggers. When compared by sex, boys had a higher proportion of exercise-triggered asthma than girls (boys vs. girls, 22.5 vs. 19.7%, p < 0.05). The proportion of patients <6 years of age with URI-triggered asthma was higher than that of patients 6-17 years of age (<6 vs. 6-17 years, 80.9 vs. 74.9%, p < 0.001). Patients 6-17 years of age were more likely than patients <6 years of age to report five of the asthma triggers: allergen sensitization (<6 vs. 6-17 years, 26.6 vs. 35.8%, p < 0.001), exercise (<6 vs. 6-17 years, 19.3 vs. 23.7%, p < 0.001), pungent odors (<6 vs. 6-17 years, 8.8 vs. 12.7%, p < 0.001), air pollution/smog (<6 vs. 6-17 years, 9.4 vs. 16.2%, p < 0.001), and tobacco smoke (<6 vs. 6-17 years, 3.5 vs. 5.3%, p < 0.001). In subgroups based on geographical distribution, asthma triggering of allergen sensitization was reported to be the most common in patients from the eastern region (eastern region vs. central region vs. western region, 35.0 vs. 24.6 vs. 28.0%, p < 0.001). Exercise-triggered asthma was found to be the most prevalent among patients from the central region (eastern region vs. central region vs. western region, 21.6 vs. 24.8 vs. 20.4%, p < 0.05). However, the proportion of patients with air pollution/smog as an asthma trigger was the lowest among those from the western region (eastern region vs. central region vs. western region, 14.1 vs. 14.1 vs. 10.8%, p < 0.05). Conclusion: Children with asthma present different types of asthma triggers, both allergenic and nonallergenic. Age, sex, and geographical distribution affect specific asthma triggers. Preventive measures can be implemented based on a patient's specific asthma trigger.

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.