RESUMEN
OBJECTIVE: To determine if parents are receptive to discussing firearm safety with their pediatrician. STUDY DESIGN: Parents completed a self-administered paper survey during a pediatric office visit. Responses of those who confirmed and denied household firearms were compared using Fisher exact test. RESULTS: Between March 23 and May 21, 2015, 1246 of 1363 eligible parents (91.4%) completed the survey (22.6% African American, 79.5% at least some college education); 36% of respondents reported household firearms (owners). An additional 14.3% reported that their child was often in homes that contained firearms. Of the 447 owners, 25.1% reported ≥1 firearm was stored loaded, and 17.9% carried a firearm when leaving the house. Seventy-five percent of parents thought the pediatrician should advise about safe storage of firearms (owners 71.1%, others 77.5%), 16.9% disagreed (owners 21.9%, others 13.4%), and 8.2% were uncertain. Sixty-six percent thought pediatricians should ask about the presence of household firearms (owners 58.4%, others 70.9%), 23.2% disagreed (owners 31.5%, others 17.8%), and 10.5% were uncertain. Differences in parental opinions between owners and other parents were statistically significant. Twenty-two percent of owners would ignore advice to not have household firearms for safety reasons, and 13.9% would be offended by such advice. Only 12.8% of all parents reported a discussion about firearms with the pediatrician. CONCLUSIONS: Avoiding direct questioning about firearm ownership and extending the discussion about why and how to ensure safe storage of firearms to all parents may be an effective strategy to decrease firearm-related injuries and fatalities in children.
Asunto(s)
Comunicación , Armas de Fuego , Padres , Pediatría , Relaciones Profesional-Familia , Seguridad , Adulto , Niño , Femenino , Humanos , Masculino , AutoinformeRESUMEN
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 ß2-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.
Asunto(s)
Ansiedad/complicaciones , Asma/tratamiento farmacológico , Broncodilatadores/uso terapéutico , Receptores del Polipéptido Activador de la Adenilato-Ciclasa Hipofisaria/genética , Estrés Psicológico/complicaciones , Adolescente , Ansiedad/diagnóstico , Ansiedad/etnología , Ansiedad/genética , Asma/complicaciones , Asma/etnología , Asma/genética , Estudios de Casos y Controles , Niño , Estudios Transversales , Regulación hacia Abajo , Femenino , Marcadores Genéticos , Genotipo , Humanos , Modelos Lineales , Masculino , Análisis Multivariante , Polimorfismo de Nucleótido Simple , Puerto Rico , Receptores Adrenérgicos beta 2/genética , Rhode Island , Factores de Riesgo , Estrés Psicológico/diagnóstico , Estrés Psicológico/etnología , Resultado del TratamientoRESUMEN
BACKGROUND: Genome-wide association studies have yet to identify the majority of genetic variants involved in asthma. We hypothesized that expression quantitative trait locus (eQTL) mapping can identify novel asthma genes by enabling prioritization of putative functional variants for association testing. OBJECTIVE: We evaluated 6706 cis-acting expression-associated variants (eSNPs) identified through a genome-wide eQTL survey of CD4(+) lymphocytes for association with asthma. METHODS: eSNPs were tested for association with asthma in 359 asthmatic patients and 846 control subjects from the Childhood Asthma Management Program, with verification by using family-based testing. Significant associations were tested for replication in 579 parent-child trios with asthma from Costa Rica. Further functional validation was performed by using formaldehyde-assisted isolation of regulatory elements (FAIRE) quantitative PCR and chromatin immunoprecipitation PCR in lung-derived epithelial cell lines (Beas-2B and A549) and Jurkat cells, a leukemia cell line derived from T lymphocytes. RESULTS: Cis-acting eSNPs demonstrated associations with asthma in both cohorts. We confirmed the previously reported association of ORMDL3/GSDMB variants with asthma (combined P = 2.9 × 10(-8)). Reproducible associations were also observed for eSNPs in 3 additional genes: fatty acid desaturase 2 (FADS2; P = .002), N-acetyl-α-D-galactosaminidase (NAGA; P = .0002), and Factor XIII, A1 (F13A1; P = .0001). Subsequently, we demonstrated that FADS2 mRNA is increased in CD4(+) lymphocytes in asthmatic patients and that the associated eSNPs reside within DNA segments with histone modifications that denote open chromatin status and confer enhancer activity. CONCLUSIONS: Our results demonstrate the utility of eQTL mapping in the identification of novel asthma genes and provide evidence for the importance of FADS2, NAGA, and F13A1 in the pathogenesis of asthma.
Asunto(s)
Asma , Linfocitos T CD4-Positivos/inmunología , Ácido Graso Desaturasas , Estudio de Asociación del Genoma Completo , Polimorfismo de Nucleótido Simple , alfa-N-Acetilgalactosaminidasa , Asma/epidemiología , Asma/genética , Asma/inmunología , Asma/patología , Linfocitos T CD4-Positivos/patología , Niño , Preescolar , Costa Rica , Método Doble Ciego , Ácido Graso Desaturasas/genética , Ácido Graso Desaturasas/inmunología , Femenino , Humanos , Masculino , alfa-N-Acetilgalactosaminidasa/genética , alfa-N-Acetilgalactosaminidasa/inmunologíaRESUMEN
OBJECTIVE: To identify factors associated with asthma associated with increased sickle cell anemia (SCA). STUDY DESIGN: Children with SCA (N = 187; mean age 9.6 years, 48% male) were classified as having "asthma" based on parent report of physician diagnosis plus prescription of asthma medication (n = 53) or "no asthma" based on the absence of these features (n = 134). Pain and acute chest syndrome (ACS) events were collected prospectively. RESULTS: Multiple variable logistic regression model identified 3 factors associated with asthma: parent with asthma (P = .006), wheezing causing shortness of breath (P = .001), and wheezing after exercise (P < .001). When ≥2 features were present, model sensitivity was 100%. When none of the features were present, model sensitivity was 0%. When only 1 feature was present, model sensitivity was also 0%, and presence of ≥2 of positive allergy skin tests, airway obstruction on spirometry, and bronchodilator responsiveness did not improve clinical utility. ACS incident rates were significantly higher in individuals with asthma than in those without asthma (incident rate ratio 2.21, CI 1.31-3.76), but pain rates were not (incident rate ratio 1.28, CI 0.78-2.10). CONCLUSIONS: For children with SCA, having a parent with asthma and specific wheezing symptoms are the best features to distinguish those with and without parent report of a physician diagnosis of asthma and to identify those at higher risk for ACS events. The value of treatment for asthma in the prevention of SCA morbidity needs to be studied.
Asunto(s)
Síndrome Torácico Agudo/complicaciones , Anemia de Células Falciformes/complicaciones , Asma/complicaciones , Asma/diagnóstico , Ruidos Respiratorios/diagnóstico , Niño , Salud de la Familia , Femenino , Estudios de Seguimiento , Humanos , Masculino , Padres , Estudios ProspectivosRESUMEN
OBJECTIVE: To describe pediatric primary care providers' attitudes toward retail clinics and their experiences of retail clinics use by their patients. STUDY DESIGN: A 51-item, self-administered survey from 4 pediatric practice-based research networks from the midwestern US, which gauged providers' attitudes toward and perceptions of their patients' interactions with retail clinics, and changes to office practice to better compete. RESULTS: A total of 226 providers participated (50% response). Providers believed that retail clinics were a business threat (80%) and disrupted continuity of chronic disease management (54%). Few (20%) agreed that retail clinics provided care within recommended clinical guidelines. Most (91%) reported that they provided additional care after a retail clinic visit (median 1-2 times per week), and 37% felt this resulted from suboptimal care at retail clinics "most or all of the time." Few (15%) reported being notified by the retail clinic within 24 hours of a patient visit. Those reporting prompt communication were less likely to report suboptimal retail clinic care (OR 0.20, 95% CI 0.10-0.42) or disruption in continuity of care (OR 0.32, 95% CI 0.15-0.71). Thirty-six percent reported changes to office practice to compete with retail clinics (most commonly adjusting or extending office hours), and change was more likely if retail clinics were perceived as a threat (OR 3.70, 95% CI 1.56-8.76); 30% planned to make changes in the near future. CONCLUSIONS: Based on the perceived business threat, pediatric providers are making changes to their practice to compete with retail clinics. Improved communication between the clinic and providers may improve collaboration.
Asunto(s)
Instituciones de Atención Ambulatoria/organización & administración , Actitud del Personal de Salud , Pediatría/organización & administración , Médicos/psicología , Calidad de la Atención de Salud , Adulto , Anciano , Atención Ambulatoria , Comercio , Comunicación , Continuidad de la Atención al Paciente , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medio Oeste de Estados Unidos , Prioridad del Paciente , Atención Primaria de Salud/organización & administración , Encuestas y CuestionariosRESUMEN
OBJECTIVES: To examine parent-reported signs and symptoms as antecedents of wheezing in preschool children with previous moderate to severe wheezing episodes, and to determine the predictive capacity of these symptom patterns for wheezing events. STUDY DESIGN: Parents (n = 238) of children age 12 to 59 months with moderate-to-severe intermittent wheezing enrolled in a year-long clinical trial completed surveys that captured signs and symptoms at the start of a respiratory tract illness (RTI). Sensitivity, specificity, negative predictive value, and positive predictive value (PPV) for each symptom leading to wheezing during that RTI were calculated. RESULTS: The most commonly reported first symptom categories during the first RTI were "nose symptoms" (41%), "significant cough" (29%), and "insignificant cough" (13%). The most reliable predictor of subsequent wheezing was significant cough, which had a specificity of 78% and a PPV of 74% for predicting wheezing. CONCLUSIONS: Significant cough is the most reliable antecedent of wheezing during an RTI. It may be useful to consider individualized symptom patterns as a component of management plans intended to minimize wheezing episodes.
Asunto(s)
Astenia/diagnóstico , Ruidos Respiratorios/etiología , Infecciones del Sistema Respiratorio/diagnóstico , Acetatos/uso terapéutico , Adulto , Albuterol/uso terapéutico , Antiasmáticos/uso terapéutico , Astenia/complicaciones , Broncodilatadores/uso terapéutico , Budesonida , Causalidad , Preescolar , Tos/etiología , Ciclopropanos , Método Doble Ciego , Femenino , Glucocorticoides/uso terapéutico , Humanos , Lactante , Masculino , Quinolinas/uso terapéutico , Ruidos Respiratorios/diagnóstico , Infecciones del Sistema Respiratorio/complicaciones , Sensibilidad y Especificidad , Factores Socioeconómicos , Sulfuros , Encuestas y CuestionariosRESUMEN
OBJECTIVES: To determine whether long-term, continuous use of inhaled anti-inflammatory medications affects asthma outcomes in children with mild to moderate asthma after use is discontinued. STUDY DESIGN: Of the 1041 participants in the Childhood Asthma Management Program randomized clinical trial, 941 (90%) were followed to determine whether 4.3 years of twice-daily budesonide or nedocromil administration (each compared with placebo) affected subsequent asthma outcomes during a 4.8-year posttrial period in which treatment was managed by the participants' physicians. RESULTS: The groups treated continuously during the trial with either budesonide or nedocromil did not differ from the group given placebo in terms of lung function, control of asthma, or psychological status at the end of 4.8 years of posttrial follow-up. However, the decreased mean height in the budesonide group relative to the placebo group at the end of the trial (1.1 cm; P = .005) remained statistically significant (0.9 cm; P = .01) after an additional 4.8 years and was more pronounced in girls (1.7 cm; P = .001) than in boys (0.3 cm; P = .49). Participants in all groups used inhaled corticosteroids during 30% of the posttrial period. CONCLUSIONS: Clinically meaningful improvements in the control of asthma and in airway responsiveness achieved during continuous treatment with inhaled corticosteroids do not persist after continuous treatment is discontinued.
Asunto(s)
Antiinflamatorios/uso terapéutico , Asma/tratamiento farmacológico , Broncodilatadores/uso terapéutico , Budesonida/uso terapéutico , Nedocromil/uso terapéutico , Adolescente , Estatura , Utilización de Medicamentos , Urgencias Médicas , Femenino , Estudios de Seguimiento , Volumen Espiratorio Forzado , Humanos , Masculino , Nebulizadores y Vaporizadores , Evaluación de Resultado en la Atención de Salud , Prednisona/uso terapéutico , Índice de Severidad de la Enfermedad , Factores Sexuales , Capacidad VitalRESUMEN
OBJECTIVE: We reexamined asthma prevalence in urban public elementary school children after 12 years, during which time poverty had worsened. STUDY DESIGN: We surveyed 152 children in 1992 and 331 in 2004 attending fourth- and fifth-grade classrooms in a low-income area of St. Louis, Missouri. Prevalences of phenotypes (current asthma, previous diagnosis without current asthma, and frequent wheezing without diagnosis) were based on standard published questions. We assessed age, sex, percentage below poverty level, and asthma experience (household member with asthma; friend, relative, or neighbor with asthma; or ever having seen someone have an attack). RESULTS: Prevalences were similar in 1992 and 2004 for current asthma (18% and 20%) and frequent wheezing without diagnosis (24% and 26%), despite higher 2004 percentage below poverty level (40% vs 18%). Prevalences of phenotypes were not associated with demographics or percentage below poverty level but were associated with asthma experience. In multivariate analysis, current asthma was associated with household member with asthma and ever having seen someone have an attack, and previous diagnosis was associated with household member with asthma. CONCLUSIONS: For these fourth- and fifth-grade urban public school children, self-reported asthma prevalence was similar after 12 years despite worsening poverty.
Asunto(s)
Asma/epidemiología , Pobreza/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Niño , Estudios Transversales , Femenino , Humanos , Masculino , Missouri/epidemiología , Prevalencia , Estudiantes/estadística & datos numéricos , Encuestas y CuestionariosAsunto(s)
Anemia de Células Falciformes/fisiopatología , Hipertensión Pulmonar/fisiopatología , Hipertrofia Ventricular Derecha/fisiopatología , Enfermedades Pulmonares/fisiopatología , Disfunción Ventricular Derecha/fisiopatología , Adulto , Niño , Humanos , Proyectos de Investigación , Pruebas de Función Respiratoria , Resistencia Vascular/fisiologíaRESUMEN
OBJECTIVE: To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families. STUDY DESIGN: A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance. RESULTS: We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups. CONCLUSIONS: Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations.
Asunto(s)
Asma/terapia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Pobreza , Atención Primaria de Salud/métodos , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Pacientes no Asegurados , Padres , Alta del Paciente , Población UrbanaRESUMEN
OBJECTIVES: We sought to determine whether mild-moderate persistent asthma sufficient to produce a decrease in baseline lung function is associated with an adverse effect on growth and bone mineral density (BMD) in children. METHODS: This was a cross-sectional study of 1041 children, 5 to 12 years old (32% ethnic/racial minorities and 40% female), enrolled into the Childhood Asthma Management Program (CAMP). Measures of asthma severity included: Spirometry; bronchial hyperresponsiveness; duration of asthma symptoms; and symptom-based assessment of severity. Multiple regression analyses were used to relate the asthma severity on the primary outcome variables: Height by stadiometry and BMD by dual energy radiographic absorptiometry. RESULTS: The mean +/- SD height percentile was 56.0 +/- 28.5 percentile for the population. The only significant relationship between asthma severity and height percentile was with methacholine bronchoprovocation in girls (beta 2.98, P =.019, covariate multiple regression). The mean +/- SD BMD was 0.65 +/- 0.10 g/cm(2) for the population. The past use of corticosteroids did not adversely affect either growth or BMD. CONCLUSIONS: We found that mild-moderate asthma of as long as 4 to 7 years duration in children does not produce an adverse effect on linear growth or BMD.