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Poor adherence to daily inhaled corticosteroids (ICS) is an important factor contributing to asthma morbidity. Assessing adherence in clinical settings using self-reported adherence often overestimates actual adherence. Electronic monitoring devices (EMDs) are objective means of assessing adherence, but are not routinely used in practice. Here, we aimed to establish adherence rates to ICS using EMDs in an inner-city, minority population in the Bronx, NY, and to compare two methods of self-reported adherence with EMD-measured adherence.Patients with physician-confirmed persistent asthma and daily ICS prescription were recruited. Self-reported adherence to ICS was measured by parental report for children and self-report for adults and the Medication Adherence Report Scale for Asthma (MARS-A). Two weeks after enrollment, EMD data were accessed for analysis. Daily adherence was calculated based on the number of puffs actuated per day as captured by EMD divided by the prescribed number of puffs.41 children and 40 adults participated. Median EMD-measured ICS adherence was 41% (children) and 43% (adults). This was significantly lower than the median self-reported adherence (100% for children,Adherence to daily ICS as measured using EMD is low in this population. In both adults and children, self-reported adherence was a poor indicator of true adherence. Further efforts using objective measures of medication adherence for patients with high asthma morbidity may be warranted to guide therapeutic decisions.

Introduction The burden of asthma morbidity with co-existing atopy among the racial/ethnic minorities in the socio-economically disadvantaged NYC borough of the Bronx is unusually high. The multidisciplinary Montefiore Asthma Center (MAC) provides guideline-based treatment to this high-risk population through the joint efforts of Allergists/Immunologists, Pulmonologists, and on-site health educators. Methods The objective of this prospective, observational study was to define the demographic and clinical characteristics of severe asthma, evaluate improvement in asthma severity and lung function through the course of treatment at the MAC, and describe the asthma phenotypes of the patients managed at the MAC. Adults with severe asthma receiving treatment at the MAC were followed from their first to their last visit at the MAC. Patient demographics, along with asthma severity and co-existing allergies, were assessed. Possible phenotypes were defined (based on presence or absence of atopy, age at asthma onset, and blood eosinophil counts). Results 227 patients were included in the final analysis, of which 55.5% were Hispanic and 33.9% identified as non-Hispanic Black. Ninety-one percent (91%) of our cohort was found to be atopic and allergic rhinoconjunctivitis (ARC) was the most commonly identified co-existing allergic condition (86.3%). Mean Asthma Control Test (ACT) scores improved from 11.1 (± 4.9) at the initial visit to 14.8 (± 6.1) at the last visit. The spirometric values did not improve despite treatment at MAC. Conclusion A multidisciplinary severe asthma center is an ideal setting to phenotype patients and offer personalized guideline-based management and education to adults with severe asthma.

Background Young adults (ages 18‐44) have increased emergency department use for asthma and poor adherence to medications. The objective of this mixed‐methods study was to understand experiences with and approaches to managing asthma, of which little is known in this age group. Methods Surveys (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire) and 1:1 semi‐structured interviews were used to explore experiences with asthma, symptoms, self‐management behaviours, and relationship to asthma control and quality of life. Qualitative data were analysed using content analysis techniques. Descriptive statistics and bivariate correlations were used to examine distributive characteristics and associations between variables. Results Forty urban adults participated (mean age 32.7 ± 6.2, 1σ). Coughing was reported nearly 46% more often than wheezing, with 42.5% (17/40) coughing until the point of vomiting most days. Most participants delayed using medication for symptoms due to misperceptions about inhalers. Higher symptom frequency and worse asthma control were associated with greater use of non‐pharmacologic symptom management strategies (r = 0.645, P

The majority of adults with persistent asthma have chronically uncontrolled disease and interventions to improve outcomes are needed. We evaluated the efficacy, feasibility, and acceptability of a multi-component smartphone-telemedicine program (TEAMS) to deliver asthma care remotely, support provider adherence to asthma management guidelines, and improve patient outcomes. TEAMS utilized: (1) remote symptom monitoring, (2) nurse-led smartphone-telemedicine with self-management training for patients, and (3) Electronic medical record-based clinical decision support software. Adults aged 18-44 (N = 33) and primary care providers (N = 4) were recruited from a safety-net practice in Upstate New York. Asthma control, quality of life, and FEV1 were measured at 0, 3 and 6 months. Acceptability was assessed via survey and end-of-study interviews. Paired t-test and mixed effects modeling were used to evaluate the effect of the intervention on asthma outcomes. At baseline, 80% of participants had uncontrolled asthma. By 6-months, 80% classified as well-controlled. Improvements in control and quality of life were large (d = 1.955, d = 1.579). FEV%pred increased 4.2% (d = 1.687) with the greatest gain in males, smokers, and lower educational status. Provider adherence to national guidelines increased from 43.3% to 86.7% (CI = 22.11-64.55) and patient adherence to medication increased from 45.58% to 85.29% (CI = 14.79-64.62). Acceptability was 95.7%; In follow up interviews, 29/30 patients and all providers indicated TEAMS worked better than usual care, supported effective self-management, and reduced symptoms over time, which led to greater self-efficacy and motivation to manage asthma. Based on these findings, we conclude that smartphone telemedicine could substantially improve clinical asthma management, adherence to guidelines, and patient outcomes.

Background: Asthma is common among urban school-age children. Though teachers should be prepared to assist children during an asthma attack, studies show they lack self-efficacy in managing asthma....

The objective of this study was to evaluate the effects of using Community Health Workers (CHWs) to deliver the home-basedIn this randomized controlled trial of 151 children aged 2-9 years with persistent asthma, we assigned 75 to the intervention and 76 to the control. The primary outcome was caregiver-reported asthma symptom days. Secondary outcomes included asthma-related healthcare utilization, caregivers' asthma knowledge, illness perception and management behaviors, MDI-spacer administration technique, and home environmental triggers. Outcomes were collected at baseline, 3, 6, 9 and 12 months. A repeated measurements analytic approach with generalized estimating equations was used. To account for missing data, multiple imputation methods were employed.At 3 and 6 months, improvement in symptom days was not significantly different between groups. However, at 9 and 12 months, the reduction in asthma symptom days was 2.15 and 2.31 days more respectively for those in the intervention group compared to the control. Improvements in MDI-spacer technique, knowledge and attitudes were significant throughout follow-up. Improvement in habits regarding MDI use was significant at 3 and 6 months, and asthma routines were improved at 3 months. However, there was no change in asthma-related healthcare utilization or home environmental triggers.Using CHWs to deliver a home-based asthma education program to caregivers of children with persistent asthma led to improvements in symptom days and several secondary outcomes. Expanding the use of CHWs to provide home-based interventions can help reduce disparities in children's health outcomes.

Background Asthma is one of the most common chronic diseases of childhood affecting 6.2 million (8.4%) children (

OBJECTIVE: Physical education (PE) teachers may be the first to assist students with asthma attacks during PE class. This study explores the PE teachers’ perspectives on in-school asthma management and barriers to physical activity (PA) in children with asthma attending urban elementary schools. METHODS: We conducted qualitative semi-structured interviews with 16 PE teachers from 10 Bronx, NY elementary schools. Interviews were recorded, transcribed and independently coded. Content analysis was used to identify 10 major themes common across interviews which were then categorized into 3 domains. RESULTS: Three domains were identified: 1) school procedures and policies for asthma management; 2) role of PE teachers in asthma management; and 3) barriers to PA for students. Most PE teachers were unaware of written procedures for acute asthma management and did not receive asthma-specific training. Many PE teachers expressed confidence regarding asthma management. PE teachers identified students with asthma most commonly through communication with students. The PE teachers utilized various methods to manage asthma but all relied on the nurse to handle acute asthma symptoms. Several barriers to PA were determined, including PE teachers’ unawareness of NYS PE requirements, lack of gym facilities, inclement weather, inconsistent PE class time, asthma diagnosis, and having no asthma inhalers at the nurse’s office. CONCLUSIONS: PE teachers’ perspectives on asthma management may influence the way asthma is handled at school. The results from this study highlight several barriers that can be targeted in future interventions to improve asthma management.

Objective: A cross-sectional study was conducted to determine if in-school physical activity (PA) varied by age, gender, weight and asthma status, participation in physical education (PE), outdoor recess, and other in-school PA among urban schoolchildren with asthma. Methods: PA was measured by tri-axial accelerometers. Height and mass were measured and overweight defined as BMI ≥85th percentile. Asthma impairment and risk were assessed as per national guidelines, and asthma status variable with three categories (mild, moderate, and severe) was created. Multivariable generalized linear mixed models adjusting for clustering due to school and student were fitted to identify variables predictive of PA. Results: 108 children with asthma participated. Children spent 374 minutes in school, of which 253 minutes were sedentary, 105 minutes in light PA, and 16 minutes in moderate-to-vigorous PA (MVPA). Only 3 participants reached the recommended ≥30 minutes/day of MVPA. Multivariable analysis revealed age, gender, participation in PE class, outdoor recess, and other in-school PA as independent predictors of PA. BMI and asthma status were not associated with PA. Conclusions: Children with asthma were mostly sedentary at school. Older children and girls were particularly at risk for inactivity. PE, recess, and other in-school PA participation are modifiable factors that should be targeted in school-based interventions aimed at increasing PA in this population. Refereed/Peer-reviewed

Background Asthma and obesity are public health problems that disproportionately affect underserved children. Urban children with asthma may be limited in their participation in physical activity, further increasing their risk for overweight. Objective To determine the prevalence of overweight and obesity among high-risk children with persistent asthma, to assess physical activity and activity restrictions by level of asthma control, and to evaluate whether activity is associated with weight status. Methods We analyzed baseline data from 324 urban children with poorly controlled asthma (3–10 years old) enrolled in the School-Based Telemedicine Enhanced Asthma Management program in Rochester, New York. Caregivers reported their child's asthma symptoms, physical activity, and activity limitation, and height and weight were measured. Results Most children were black (59%), and 69% had Medicaid. Almost half (47%) of children had symptoms that indicated poorly controlled asthma, 15% were overweight, and 31% were obese. Few children (39%) participated in 1 or more hour of physical activity per day. In addition, most (85%) did not walk to and from school, 38% did not have any recess in school, and 35% reported no safe place to exercise. More children with very poorly controlled asthma symptoms, compared with children with more mild symptoms, reported limitation in gym class (58% vs 43%, P = .01) and even in mild activities (28% vs 14%, P = .004). Children with activity limitation were at significantly greater odds of being overweight or obese (odds ratio, 2.1; 95% confidence interval, 1.2–3.8). Conclusion Many children with persistent asthma are overweight or obese, have limited opportunity for activity, and experience activity limitations. Efforts are needed to optimize asthma control and provide opportunity for increased physical activity in and outside school. Trial Registration ClinicalTrials.gov Identifier: NCT01650844.

Introduction Technology-based interventions that can function within real-world practice and improve outcomes without increasing provider burden are needed, yet few successfully cross the research-to-practice divide. This paper describes the process of developing a clinically integrated smartphone-telemedicine program for adults with asthma and results from proof-of-concept testing. Methods We used a contextually grounded intervention development approach and May's implementation theory to design the intervention, with emphasis on systems capabilities and stakeholder needs. The intervention incorporated symptom monitoring by smartphone, smartphone telemedicine visits and self-management training with a nurse, and clinical decision-support software, which provided automated calculations of asthma severity, control and step-wise therapy. Seven adults (aged 18–40 y) engaged in a 3-month beta-test. Asthma outcomes (control, quality of life, FEV1) and healthcare utilisation patterns were measured at baseline and end-of-study. Results Each participant averaged four telemedicine visits (94% patient satisfaction). All participants had uncontrolled asthma at baseline; end-of-study 5/7 classified as well-controlled. Mean asthma control improved 1.55 points (CI = 0.59–2.51); quality of life improved 1.91 points (CI = 0.50–3.31), FEV1 percent predicted increased 14.86% (CI = −3.09–32.80): effect sizes of d = 1.16, 1.09, and 0.96, respectively. Preventive healthcare utilisation increased significantly (1.86 visits/year vs. 0.28/year prior, CI 0.67–2.47) as did prescriptions for controller medications (9.29 prescriptions/year vs. 1.57 prescriptions/year, CI 4.85–10.58). Discussion Smartphone telemedicine may be an effective means to improve outcomes and deliver asthma care remotely. However, careful attention to systems capabilities and stakeholder acceptability is needed to ensure successful integration with practice. Clinical Trials registration #: NCT03648203

Background Asthma severity and level of control classification is the first step in asthma management. To optimize asthma management, screening must be done routinely and in a standardized manner at the time of patient’s visit with the health care provider. Objectives 1) To develop and implement asthma severity and control screening within electronic health record (EHR) system of a large urban health system to improve pediatric asthma care; 2) To increase asthma screening from 0% to 80% by December 2020. Methods We developed an algorithm for asthma screening in EHR based on national guidelines that asked about medications taken at home, exercise-induced symptoms, medication adherence, daytime and night-time symptoms, use of rescue medication and interference with activity in the past 4 weeks, and use of oral corticosteroids in the past year. Screening was conducted by the nursing staff prior to patient being seen by the provider. Based on responses to the screening questions, severity/control classification is calculated and displayed in EHR for provider to then treat patient accordingly. Classic Quality Improvement tools such as the Model for Improvement and Plan Do Study Act (PDSA) cycles were used to incorporate changes into daily workflow. Practice Advisory Board met monthly to discuss barriers to implementation and identify solutions. The Board made decisions on adopting successful strategies and brainstormed new strategies to address barriers. Results This project is ongoing and preliminary results are available from 3 practices: small pediatric, large pediatric and family medicine practices. The ultimate goal is to improve care and clinical outcomes of children with asthma. To date, a total of 4,057 screenings have been completed at these sites. Screening rates improved from 0% to 78.6% in a small pediatric practice, from 0% to 66.7% in a large pediatric practice, and from 0% to 38.7% in a family practice. Several problems were encountered during the process of change: competition with other nurse-completed screenings; screening questions are available in English only within EHR; nursing staff shortages; nurses forgetting to conduct screening; and caregiver not knowing information about child’s asthma or disagreeing with asthma diagnosis. Conclusion We developed an asthma screening algorithm within EHR, trained nursing staff and implemented patient screening at the time of clinic visit allowing providers take action on asthma management based on the screening result. Further collaborative efforts are needed to improve and sustain screening rates with the ultimate goal of improving patient clinical outcomes.

Providers commonly rely on parent reports of a child's asthma symptoms; however, children as young as 7 years can report on their own health. Our study compared parent and child reports of asthma symptoms with exercise, worries about developing an asthma attack, and confidence in disease management.We recruited children ages 7 to 10 years with asthma from 4 Bronx, NY, schools, as well as their parents. The parents and children completed interview surveys with parallel questions regarding perceived asthma symptoms, asthma-related worries, and confidence in disease management. We used McNemar tests for paired data to compare parent and child responses.We analyzed data for 105 parent-child pairs. Mean child age was 8.5 years (standard deviation, 0.99); 53% were male, and 82% were Hispanic. Children were more likely than their parents to report ever having an exercise-induced asthma attack (85% vs 48%; P.001) and that they "worry a lot" about developing an asthma attack during exercise (63% vs 45%; P = .01). Children felt more confident about using an inhaler correctly (76% of the children were "very sure" vs 60% of the parents; P = .009) and were more likely to report having an inhaler available in case of an attack (38% of the children were "very sure" vs 20% of the parents; P = .003).In this school-based sample of urban children with asthma, we found disagreement between parent and child reports of symptoms with exercise, worry about developing an attack, and confidence in medication use. These findings suggest that including child reports during history taking could help providers identify children in need of enhanced asthma management.

Objective: To evaluate how asthma-related emergency department visits (AREDV), air pollutant levels, pollen counts, and weather variables changed from 2001 to 2008 in the Bronx, NY. Methods: 42,065 daily AREDV values (1 January 2001 to 31 December 2008) were collected using our institution’s Clinical Looking Glass software. Daily values of sulfur dioxide (SO2), carbon monoxide (CO), ozone (O3), nitrogen dioxide (NO2), temperature, and humidity were obtained from the National Climatic Data Center's Bronx station. Daily tree pollen counts were obtained from the Armonk counting station near the Bronx. Median values for each variable were analyzed using the Mann-Whitney test to compare 2001–2004 and 2005–2008 values. Simple linear regression examined associations between AREDV and individual pollutants. Due to seasonal variations of the variables, each season was considered separately. Results: There were significant decreases for AREDV, SO2, CO, and humidity for all seasons, and for NO2 in the spring and winter. Significant increases occurred for O3 in the spring, fall, and winter; for temperature in the summer and winter; and for tree pollen in the spring. Significant positive associations were found between AREDV and SO2, CO, NO2, and humidity, respectively, while significant negative associations were found between AREDV and O3 and temperature, respectively. Conclusions: From 2001 to 2008, significant: a) decreases in AREDV, SO2, CO, and humidity for all seasons, and decreases in NO2 for the spring and winter; and b) increases in O3, temperature, and spring tree pollen were observed. By tracking and anticipating environmental and pollutant changes, efforts can be made to minimize AREDV.

Classroom teachers play an important role in facilitating asthma management in school but little is known about their perspectives around asthma management. We examined the perspectives of classroom teachers around barriers to school asthma management.We conducted key informant interviews with 21 inner-city classroom teachers from 3rd to 5th grades in 10 Bronx, New York elementary schools. Sampling continued until thematic saturation was reached. Interviews were recorded, transcribed, and independently coded for common themes. We used thematic and content review to analyze interview data.Seven themes representing teachers' perspectives on in-school asthma management emerged: (1) the problematic process of identifying students with asthma; (2) poor familiarity with the city health department's asthma initiative and poor general knowledge of school policies on asthma management; (3) lack of competency in managing an acute asthma attack in the classroom and poor recognition of symptoms of an asthma attack; (4) lack of confidence in dealing with a hypothetical asthma attack in the classroom; (5) lack of quick access to asthma medication in school; (6) limited communication between school staff; and (7) enthusiasm about learning more about asthma management.Our results revealed several barriers contributing to suboptimal in-school asthma management: ineffective ways of identifying students with asthma, lack of teacher knowledge of guidelines on asthma management, lack of comfort in managing students' asthma, inadequate access to asthma medication in school, and limited communication between school staff. These issues should be considered in the design of interventions to improve in-school asthma management.

Clinical pathways for asthma management decrease hospital cost and length of stay; however little is known about the educational impact of pathways on residents. Pediatric residents at a children’s hospital (N=114) were invited to complete a 22-item computerized, anonymous survey 6 months before and 6 months after asthma pathway implementation. The survey assessed pathway use and residents (1) pathway knowledge, (2) attitudes and experiences with managing asthma, and (3) perceived educational benefits. Mean pathway knowledge score increased from the case before to the case after implementation [1.5±1.0 versus 2.6±1.3, p<0.001], as did high preparedness to manage asthma [61% versus 91%, p<0.001] and electronic order set use [28% versus 80%, p<0.001]. The top three educational benefits of the pathway endorsed by residents were application of evidence-based medicine (57%), ability to assess exacerbations (52%), and skill at communicating respiratory status (47%). After implementation, residents’ knowledge and preparedness to manage asthma improved as well as many endorsed educational benefits.

Background. School officials and nurses play an important role in facilitating asthma management in schools. Little is known about their perspectives on in-school asthma management and barriers to physical activity (PA) at school. Aims. The goal of this study is to explore school officials’ and nurses’ perspectives on asthma care and barriers to PA in children with asthma attending New York City schools. Method. We conducted qualitative, semistructured interviews with 10 principals, 3 assistant principals, and 9 nurses in 10 Bronx, New York elementary schools. Sampling continued until thematic saturation was reached. Interviews were recorded, transcribed, and coded for common themes. The thematic and content review was subsequently used to analyze interview data. Emerging themes were discussed and agreed on by both investigators. Results. Three main categories arose from the analysis: (1) procedures and policies around asthma management in school, (2) barriers to effective medication administration in school, and (3) barriers to PA in children with asthma. Discussion. Participants identified gaps to in-school asthma management and barriers to PA participation: ineffective ways of identifying students with asthma; lack of written procedures for asthma management; difficulty in meeting the administrative requirements to administer asthma medication; lack of knowledge and training on asthma management for the parents, students, and school staff; parental limitation of children’s PA; and schools not meeting the state physical education requirement. Conclusions. Our findings suggest the need for policy reform on asthma management and PA in urban schools and should be considered in the design of future interventions.

OBJECTIVE: Physical activity (PA) levels are low in today’s youth and may even be lower in those with asthma. Barriers to PA have not been well studied in inner-city, minority children with asthma. We conducted a qualitative study to characterize parental perceptions of barriers to PA and ways to improve PA levels in children with asthma. METHODS: We used the socio-ecological model (SEM) to inform development of our interview guide. Questions fell into two SEM domains: 1) interpersonal (parent, family) barriers and 2) community (neighborhood, school) barriers. Qualitative semi-structured interviews were conducted with 23 parents (21 mothers, 2 fathers) of inner-city children with asthma (ages 8–10 years) from 10 Bronx, New York (NY) elementary schools. Sampling continued until thematic saturation was reached. Interviews were recorded, transcribed, and independently coded for common themes. Emerging themes were discussed and agreed upon by investigators. RESULTS: Three themes surrounding interpersonal barriers to PA emerged: 1) parental fear of exercise-induced asthma due to lack of child symptom awareness; 2) non-adherence and refusal to take medications; and 3) challenges with asthma management. Four themes around community barriers to PA emerged: 1) lack of trust in school management of asthma; 2) lack of school PA facilities; 3) unsafe neighborhoods, and 4) financial burden of PA. CONCLUSIONS: Our results indicate a complex multi-level set of barriers to PA in children with asthma. Addressing these barriers by involving stakeholders at the family, school and community levels may improve PA levels in children with asthma.

Regular physical activity (PA) is an important component of pediatric asthma management. No studies have examined how in-school asthma management influences PA from children's perspectives. The aim of this study was to explore children's perceptions of the impact of in-school asthma management on PA.Qualitative interviews with 23 inner-city minority children with asthma (aged 8-10 yrs; 12 girls, 11 boys) were conducted in 10 Bronx, New York elementary schools. Sampling continued until saturation was reached. Interviews were recorded, transcribed and independently coded for common themes.Interviews produced five themes representing students' perceptions about (1) asthma symptoms during in-school PA; (2) methods to control asthma episodes during school PA; (3) methods to prevent asthma episodes during school; (4) limited accessibility of asthma medications; and (5) negative feelings about asthma and medication use. The majority of students experienced asthma symptoms while performing PA during school. Primary methods of managing asthma symptoms were sitting out during activity, drinking water, and visiting the nurse. Students lacked awareness or adherence to action plans to prevent or control asthma. Students reported limited access to medication during school and feelings of embarrassment and/or concerns of teasing when medicating in front of others.Our results indicate inappropriate in-school management of asthma symptoms, poor asthma control, lack of accessible medication, and stigma around publicly using asthma medication. Thus, students often missed or were withheld from PA. Interventions to improve in-school asthma care must consider ways to address these issues.

Objective We previously developed a Clinical Encounter Card (CEC) for use in medical student feedback. However, no prior studies have investigated the effectiveness of the CEC. The objective of our study was to determine whether use of the CEC would increase medical students' perception of the feedback they received. Methods We conducted a time-series repeated-measures experimental study at a pediatric clerkship site. The study included a crossover design with experimental and control arms. Third-year medical students on the ambulatory rotations were the experimental arm, and inpatient students were the control arm. Students and faculty in the experimental arm received the CEC, which listed 7 feedback domains: history and interviewing, physical examination, oral presentation, written notes, patient assessment, management plan, and professionalism. We used a 10-point Likert-type scale to record responses of students weekly regarding their perceptions of having received feedback in the 7 domains. Multivariate analysis of variance for repeat measures tested mean differences in continuous variables, and Mann-Whitney U rank order sum tested ordinal rank differences. Results We received 504 reports from students regarding the feedback they received. We found statistically significant improvements in 6 feedback domains for experimental subjects: history/interviewing, physical examination, oral presentation, written notes, patient assessment, and management plan. There was no improvement in feedback received about professionalism. Conclusions Use of the CEC resulted in students' perceiving increased feedback as evidenced by significant improvements in several medical student feedback domains.

Keywords: Asthma; children; systematic review; randomised controlled trial; complementary and alternative medicine

Psychosocial factors can limit one's ability to effectively manage asthma. This can result in asthma morbidity that limits quality of life. While self-perceptions of asthmatic children and parents have been studied, less is known about self-perceptions of inner-city adolescents with asthma.To examine perceptions and attitudes to treatment among inner-city adolescents with asthma.We conducted a multistaged stratified sample survey at a high school located in the Bronx, NY. First, an asthma-screening survey was administered to 3800 registered students. Then, we identified a subset of 200 children with the most positive screening results for asthma. Next, a 32-item self-completion questionnaire was administered to this cohort. Students were surveyed regarding severity of asthma, perceptions and attitudes, and demographic information. Differences in proportions were tested by Chi-square analyses. Pearson rank-order correlation and multiple logistic regression were used to assess the relationship between perceptions and attitudes to self-treatment.A total of 160 (80%) students participated. Mean age was 15.7 years. Of the respondents, 63% were female. 68% were Hispanic, 26% were African American. 33% had weekly symptoms, and 14% had daily symptoms. Additionally, 41% did not know the name of their asthma medicine. Only 38% reported bringing an "asthma pump" when leaving the house. While 70% reported feeling in control over their asthma symptoms, 63% reported feelings of anxiety and 39% could remember a time when they felt like they were going to die from asthma. Subjects who reported feeling in control over their asthma were more likely to take an asthma pump with them when leaving the house (r = 72, p = 0.004). Only 39% had disclosed their asthma to their friends, and 29% felt embarrassed about having an asthma attack in front of their friends. Subjects who felt embarrassed about their asthma were significantly less likely to take their asthma pumps with them (r = 0.98, p0.001) and less likely to use their medications in front of their friends (r = .87, p0.001).Adolescents in this study reported feelings of anxiety, fear, and embarrassment about their asthma. Feelings of control over asthma symptoms were associated with positive attitudes toward self-treatment, while embarrassment was correlated with negative attitudes. These findings have implications for counseling adolescents with asthma about self-management strategies.

Asthma is a chronic respiratory disease affecting nearly 9.6% of United States children.1 Asthma disproportionately burdens children from poor and minority backgrounds.2 Children with asthma have high rates of school absenteeism.3 With children spending nearly half of their day at school, appropriate school asthma management can help optimize care for students with asthma. Successful school asthma management involves individual case identification and provision of medications to students when needed.4 New York City (NYC) schools require caregiver submission of a Medication Administration Form (MAF; a physician-completed order form that must be renewed every school year) to confirm asthma diagnoses and allow school nurses to administer medication for asthma exacerbations.5 Without an MAF, due to systems-based regulations, the nurse cannot administer medication, even if a student is having an asthma attack. Many NYC schools struggle with individual asthma case identification6 and have difficulty obtaining MAFs for students, making acute asthma management challenging. Therefore, the objectives of this study were to 1) compare asthma prevalence in four NYC schools based on caregiver and school report; and 2) identify asthma morbidity factors associated with MAF submission. We conducted a cross-sectional survey of caregivers of children attending 2nd-4th grades in four Bronx, New York (NY) elementary schools as the first step in preparation for a school-based intervention study. The NYC Department of Education and the university's Institutional Review Board (IRB) approved this study. We developed a 6-item self-administered English-Spanish asthma survey based on prior surveys7,8 and NYC DOE guidelines for MAF.5 The survey was field-tested with 10 caregivers of children with and without asthma at routine office visits to ensure questions were clear and easy to comprehend. The survey is available in an online supplement. Surveys and return envelopes were sent home with students during the fall of 2012. Caregivers were instructed to return completed surveys to the classroom teachers in the sealed envelopes. We then collected envelopes from the teachers. Children received a small gift (e.g. stickers, tattoos) for reminding caregivers to return the surveys. Schools were asked to report the number of students with asthma in the same grades. Schools use several Board of Education forms, such as health examination forms and MAFs sent to all students, to identify asthma cases. We performed descriptive statistics for all variables. Differences in proportions were tested by Chi-square. A two-sided α

The National Asthma Education and Prevention Program recommends that providers demonstrate and assess metered-dose inhaler–spacer (MDI-S) technique at each medical visit. To examine practice behaviors and perceived barriers to demonstrating and assessing MDI-S technique, we surveyed pediatric providers (n = 114) at an inner-city academic medical center. While 82% of providers demonstrated MDI-S technique, only 5% of providers demonstrate the technique at every visit. Although 67% of providers assessed MDI-S technique, only 13% assess the technique at every visit. None of the providers used MDI-S checklist for assessment. Attendings were more likely than residents to demonstrate with illustrations (24% vs 6%, P = .01) and when patient’s asthma was not well controlled (68% vs 47%, P = .05). Provider-identified barriers included limited access to MDI-S device, lack of time, and inadequate knowledge. Suggestions to address barriers include in-service training, device access, and nurse/health educators to alleviate the time constraints. Clinic modifications and education are needed.

Incorrect Metered-Dose Inhaler (MDI)-spacer technique can result in decreased drug delivery to distal airways and poor asthma outcomes. There is lack of research to examine whether the caregivers utilize proper technique when applying an MDI-spacer delivery system for young minority children with persistent asthma in the United States. The objective of this study was to evaluate MDI-spacer utilization and technique among the caregivers of Bronx minority children with persistent asthma and to determine characteristics associated with correct use.We analyzed data from 169 caregivers of urban minority children with persistent asthma (aged 2-9 years). MDI-spacer device technique was assessed using a 10-step checklist derived from the national guidelines, literature and manufacturers' instructions. Based on the median MDI-technique score of six steps demonstrated accurately, caregivers were categorized as correct (seven or more) or incorrect (six or less) users.Of the 169 caregivers, 95% were mothers, mean age 32.3 years (SD 7.6), 56% were unemployed; 74% of the children were Hispanic, 87% had either "not well controlled" or "very poorly controlled" asthma, 92% had a spacer at home and 71% used it "all" or "most" of the time. Only one caregiver correctly demonstrated all 10 steps of the MDI-spacer technique. Child's having one or more asthma-related hospitalizations in the past 12 months and higher caregiver educational level were independent predictors of correct MDI-spacer technique.The caregivers of urban, minority children with persistent asthma lack proper MDI-spacer technique, suggesting the potential value of both targeted short- and long-term educational interventions.

Fast food originated in the 1950s and now pervades almost every community in the world. Fast food is easy to get, affordable, tasty, and appealing to most children. Eating fast food has been linked to childhood obesity, but what about asthma, eczema, and allergies? Prior studies have explored the

A peanut butter and jelly sandwich is a popular snack for many children and even some adults, but the shadow of death lurks between the bread slices for peanut allergy sufferers. About 8% of U.S. children have food allergies, with peanut being the most common allergen that triggers fatal food-induced anaphylaxis. Peanut allergy is less commonly outgrown than are allergies to other foods and requires lifelong changes in dietary habits. To date, no safe therapeutic options exist for patients with peanut allergy. Now, Fleischer et al . examine the clinical effects and safety profile of peanut sublingual immunotherapy (SLIT) in a multicenter, randomized, placebo-controlled trial. The authors recruited 40 participants aged 12 to 37 years from 5 U.S. cities. The study subjects underwent a baseline oral food challenge with up to 2 g of peanut powder and were then randomized to receive either peanut or placebo SLIT. The peanut SLIT dose was gradually escalated to a maintenance dose. At week 44, the placebo group crossed over to receive peanut SLIT. The primary end point was the percentage of desensitized participants measured with a 5-g peanut powder oral challenge after 44 weeks of therapy. Subjects successfully consuming 5 g or at least 10-fold more peanut powder than at baseline were considered responders. After 44 weeks of SLIT, a significantly higher response rate was noted in the active treatment group: 14 (70%) of 20 subjects receiving peanut SLIT were responders versus only 3 (15%) of 20 subjects receiving placebo. Desensitization was also observed in placebo subjects who were crossed over and received higher-dose peanut SLIT. The study demonstrated that treatment of allergy patients with peanut SLIT induces a modest level of desensitization as compared with that of placebo. Longer duration of SLIT therapy in a subset of subjects showed a significant increase in the successfully consumed dose of allergen, suggesting that long-term therapy with SLIT might confer additional benefits in reducing reactivity to peanut. This study was limited by a high dropout rate and by enrollment of patients with peanut allergy without a history of life-threatening reactions, which may have introduced a bias. About 40% of subjects receiving active SLIT reported allergic symptoms during the therapy, which could have affected the blinding of the study. Although further studies are needed to determine whether SLIT therapy is a safe and clinically useful treatment option for all peanut allergy sufferers, these findings are an important step toward deciphering peanut SLIT effects and safety in the treatment of peanut allergy. D. M. Fleischer et al. , Sublingual immunotherapy for peanut allergy: A randomized, double-blind, placebo-controlled multicenter trial. J. Allergy Clin. Immunol . 131 , 119–127.e7 (2013). [[PubMed]][1] [1]: http://www.ncbi.nlm.nih.gov/pubmed/23265698

Benzalkonium chloride (BAC) added to nebulized albuterol may induce bronchospasm. The objective of this study was to determine the availability of BAC-containing nebulized albuterol in the Bronx, New York pharmacies. A cross-sectional telephone survey of pharmacies was conducted. Overall, 158 (80%) pharmacies participated in the survey; 133 (84%) carried BAC-containing albuterol; 25 (16%) dispensed BAC-containing albuterol solution when presented with a prescription written for generic albuterol. Only 14 (9%) pharmacists had seen a prescription for nebulized albuterol where a physician specified “without BAC.” Despite availability of BAC-free albuterol, pharmacies in the Bronx still carried and dispensed BAC-containing product.

A cup of joe may do more than give you a caffeinated jump start to the day; it may help lower the risk of diabetes. Prior research found an inverse association between coffee and tea consumption—major sources of caffeine—and type 2 diabetes (T2D). Now, Bhupathiraju et al. examine the association of caffeinated versus caffeine-free beverages with T2D risk, to see if caffeine is the beneficial factor. The authors specifically compared caffeinated and noncaffeinated forms of coffee, tea, sugar-sweetened beverages (SSBs), and carbonated, artificially sweetened beverages. They prospectively observed 74,749 women from the Nurses’ Health Study (1984–2008) and 39,059 men from the Health Professionals Follow-up Study (1986–2008) who were free of diabetes, cardiovascular diseases, and cancer at baseline. Consumption of SSBs, irrespective of the caffeine content, was significantly associated with a higher risk of T2D in women and in men, with relative risk per serving ranging from 11 to 23%. Consumption of coffee, either caffeinated or decaffeinated, was associated with a lower risk of T2D in men and women (relative risk per serving ranging from 4 to 8%). Caffeinated tea consumption affected the groups differently: It was associated with a 5% lower T2D risk in women, but not men. The association between higher SSB consumption and a higher risk of T2D may be due to the high content of sucrose and high-fructose corn syrup of SSBs that increase blood glucose and insulin concentrations. The protective effects of coffee and tea on T2D may be explained by the content of flavonoids in tea and chlorogenic acid in coffee—antioxidants that prevent oxidative stress, which has been linked to the development of diabetes. This study is limited by the use of an observational study design and self-reported measure of beverage intake. How the different beverages affect T2D is also speculation, with the link between caffeine and diabetes yet unresolved. Despite limitations, these findings by Bhupathiraju et al. could have an impact on public health: All SSBs—caffeinated or not—contribute to a higher risk of T2D; conversely, encouraging people to stick to their morning coffee or tea, rather than replacing with an SSB, may protect the body and thus lower the risk of T2D. S. N. Bhupathiraju et al. , Caffeinated and caffeine-free beverages and risk of type 2 diabetes. Am. J. Clin. Nutr. , published online 14 November 2012 (10.3945/ajcn.112.048603). [[Full Text]][1] [1]: http://ajcn.nutrition.org/content/early/2012/11/14/ajcn.112.048603.long

OBJECTIVES: To determine if physical activity (PA) during the school day varied by school, grade level, gender, weight status, and physical education (PE) and recess participation among urban kindergarten and first-grade students. METHODS: Cross-sectional study at 4 Bronx, NY, schools. Student PA was measured by a Yamax Digi-Walker pedometer, an objective and validated measure of PA in children. Each student wore a sealed pedometer during school for 5 consecutive days. Hierarchical models were fit to identify variables predictive of PA. RESULTS: A total of 916 had valid pedometer data (53% male, 70% Hispanic, mean age 5.98 years [SD 0.66], 45% overweight). PA varied by school (P < .0001). First-grade students took a significantly greater mean number of steps during school than kindergarten students. Overall, students took an average of 2479.7 (SD 961.8) steps/school day. PA did not differ by BMI status. Students took on average 724 more steps on PE days than on non-PE days and 490 more steps on days with outdoor recess than nonrecess days (P < .05 for both). Fewer than 1% of all students achieved lower cut points for previously published mean range of steps/school day for boys and girls. Multivariable analysis revealed higher grade level, participation in PE class, and outdoor recess as independent predictors of PA. CONCLUSIONS: PA levels were low in kindergarten and first-grade students. Future interventions incorporating classroom-based PA and outdoor recess may increase PA in resource-poor urban schools with limited PE facilities.

Obesity has reached epidemic proportions, affecting the health of more than one-third of U.S. adults and 17% of children and adolescents. Prior studies suggest that chronic obesity may trigger compensatory physiological responses that promote the state of constant positive energy balance. Although

Dietary intake of magnesium has a protective effect on childhood asthma.

Molds are ubiquitous in our environment. Some types of molds are valuable—for example, in the synthesis of antibiotics or to help make cheese and fertilize gardens. However, when it comes to asthma, which affects some 22 million U.S. adults and children, exposure to certain mold species has been linked to life-threatening asthma exacerbations. Recent research has supported the role of mold in triggering the development of asthma. However, specific mold species and timing and durations of exposure that may be contributory to the pathogenesis of asthma are unknown. Reponen et al. further investigated the relationship of early exposure to specific molds on the development of childhood asthma. The authors hypothesized that specific mold exposures are associated with childhood asthma development. Dust samples were collected from homes of 289 infants when they were ~8 months of age and analyzed for concentrations of 36 molds that are part of the Environmental Relative Moldiness Index (ERMI). For infants to be eligible for the study, at least one of the parents had to be classified as atopic. Children were evaluated at age 7 years for asthma based on clinical symptoms and spirometric testing, an objective measure of lung function. The children also underwent skin prick test to aeroallergens and mold. Asthma was diagnosed in 24% of the children examined. Mold exposure in infants’ homes correlated with a child having asthma at age 7 years: A 10-unit increase in the ERMI scale raised the risk of asthma by 80%. Indeed, infant exposure to three specific mold species usually found in water-damaged homes was significantly associated with asthma development at age 7 years. Although the findings of this study are intriguing, they do not yet prove that three specific molds can cause asthma. However, they may provide a starting point for targeted laboratory studies. Limitations of this study include small sample size and evaluation of a fraction of the total existent molds in the samples. Future prospective studies may address these limitations. In the meantime, expectant parents with a family history of asthma or atopy may want to consider correcting any water or mold problems in the home before their baby’s arrival. T. Reponen et al. Infant origins of childhood asthma associated with specific molds. J. Allergy Clin. Immunol. 130 , 639–644 (2012). [[PubMed]][1] [1]: http://www.ncbi.nlm.nih.gov/pubmed/22789397

If you eat grape seeds, vines will grow in your stomach, or so says an old wives’ tale. Although eating some seeds may be harmful, researchers are now discovering that health benefits of eating grapes may actually come from their seeds. In fact, proanthocyanidins found in the grape seeds have greater antioxidant activity than other well-known antioxidants like vitamins C and E. Recent research has supported the important role of oxidative stress in the pathogenesis of asthma, which affects some 22 million Americans. Indeed, severe asthma and enhanced oxidative stress have been linked to steroid insensitivity, persistent inflammation, and airway remodeling, all of which result in decreased lung function. Lee et al. further investigated the connection between oxidative stress and asthma severity by examining whether grape seed proanthocyanidin extract (GSPE) has a therapeutic effect on allergic airway inflammation in acute and chronic murine models of asthma. The authors found that GSPE treatment reduced airway inflammation, airway hyperresponsiveness, and oxidative stress. In addition, airway fibrosis, one of the most important components of airway remodeling in asthma, was reduced in the GSPE-treated chronic asthma model as compared with controls. The results of this study suggest that GSPE may be effective in reducing the inflammation and alleviating airway remodeling, probably because of its antioxidant properties. Although further animal and clinical studies are needed to confirm these findings and clearly identify the mechanism of GSPE effects, this study illustrates a novel therapeutic potential of GSPE in asthma. T. Lee et al ., Grape seed proanthocyanidin extract attenuates allergic inflammation in murine models of asthma. J. Clin. Immunol., 27 July 2012 (10.1007/s10875-012-9742-8). [[PubMed]][1] [1]: http://www.ncbi.nlm.nih.gov/pubmed/22836658

Breathing is a daily struggle for the over 7 million children currently living with asthma in the United States. Recent research suggests that there may be a connection between asthma and obesity in these children. Indeed, obesity worsens asthma symptoms and lung function, increases hospitalization risk, and impairs response to asthma therapy. Conversely, being underweight is also a risk factor for developing asthma. However, little is actually known about the connection between extremes in weight status and asthma phenotype in children. Lang et al. investigated the associations between being underweight and obesity with asthma severity, risk of exacerbation, lung function, and intensity of controller therapy prescribed in a cross-sectional study of 10,559 children ages 5 to 17 years from one pediatric asthma clinic over a period of 10 years. Participants were grouped into one of three cohorts based on body mass index (BMI) percentile: 95th percentile (obese). The authors used a multivariable logistic model to evaluate the associations between BMI percentile cohort group and asthma outcomes. Underweight status was rare (2.5%) compared with prevalence of obesity (26.2%) in this population. However, underweight asthmatics had significantly lower lung function, greater asthma severity, and higher treatment burden as compared with normal/overweight participants. Obesity was associated with greater odds for severe asthma and airflow obstruction compared with normal weight asthmatics. Surprisingly, obesity was not found to be a risk factor for asthma exacerbation or a major contributor to treatment burden. Despite the limitations of the cross-sectional nature of the design, the authors demonstrate that both extremes in weight affect characteristics and management of children with asthma. Although the exact mechanism of the effect of weight status on pediatric asthma remains to be explained, this study sheds light on this relationship. J. E. Lang et al ., Asthma severity, exacerbation risk, and controller treatment burden in underweight and obese children. J. Asthma 49, 456–463 (2012). [[PubMed]][1] [1]: http://www.ncbi.nlm.nih.gov/pubmed/22530959