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Exhaled nitric oxide during infancy as a risk factor for asthma and airway hyperreactivity.

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Exhaled nitric oxide during infancy as a risk factor for asthma and airway hyperreactivity.

Eur Respir J. 2014 Sep 26;

Authors: Chang D, Yao W, Tiller CJ, Kisling J, Slaven JE, Yu Z, Kaplan MH, Tepper RS

Abstract
Childhood asthma is often characterised by elevated exhaled nitric oxide (eNO), decreased lung function, increased airway reactivity and atopy; however, our understanding of when these phenotypic airway characteristics develop remains unclear. This study evaluated whether eNO, lung function, airway reactivity and immune characteristics during infancy are risk factors of asthma at age 5 years. Infants with eczema, enrolled prior to wheezy illness (n = 116), had eNO, spirometry, airway reactivity and allergen sensitisation assessed at entry to the study and repeated at age 5 years (n = 90). Increasing eNO at entry was associated with an increased risk of asthma (p = 0.037) and increasing airway reactivity (p = 0.015) at age 5 years. Children with asthma at 5 years of age had a greater increase in eNO between infancy and age 5 years compared with those without asthma (p = 0.002). Egg sensitisation at entry was also associated with an increased risk of asthma (p = 0.020), increasing eNO (p = 0.002) and lower forced expiratory flows (p = 0.029) as a 5 year-old. Our findings suggest that, among infants at high risk for developing asthma, eNO early in life may provide important insights into the subsequent risk of asthma and its airway characteristics.

PMID: 25261328 [PubMed - as supplied by publisher]

Exacerbation of asthma and airway infection: is the virus the villain?

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Exacerbation of asthma and airway infection: is the virus the villain?

J Pediatr (Rio J). 2014 Sep 24;

Authors: Costa LD, Costa PS, Camargos PA

Abstract
OBJECTIVE: to review the available literature on the association between acute viral respiratory tract infection and the onset of asthma exacerbations, identifying the most prevalent viruses, detection methods, as well as preventive and therapeutic aspects.
DATA SOURCE: a search was conducted in PubMed, Lilacs, and SciELO databases, between the years 2002 and 2013, using the following descriptors: asthma exacerbation, virus, child, and acute respiratory infection.
DATA SYNTHESIS: a total of 42 original articles addressing the identification of respiratory viruses during episodes of asthma exacerbation were selected, mostly cross-sectional studies. There was a wide variation in the methodology of the assessed studies, particularly in relation to the children's age and methods of collection and viral detection. The results indicate that, in up to 92.2% of exacerbations, a viral agent was potentially the main triggering factor, and human rhinovirus was the most frequently identified factor. The pattern of viral circulation may have been responsible for the seasonality of exacerbations. The association between viral infections and allergic inflammation appears to be crucial for the clinical and functional uncontrolled asthma, but few studies have evaluated other triggering factors in association with viral infection.
CONCLUSIONS: respiratory viruses are present in the majority of asthmatic children during episodes of exacerbation. The involved physiopathological mechanisms are yet to be fully established, and the synergism between allergic inflammation and viral infection appears to determine uncontrolled disease. The role of other triggering and protective agents is yet to be clearly determined.

PMID: 25261603 [PubMed - as supplied by publisher]

Comparison of US emergency department acute asthma care quality: 1997-2001 and 2001-2012.

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Comparison of US emergency department acute asthma care quality: 1997-2001 and 2001-2012.

J Allergy Clin Immunol. 2014 Sep 26;

Authors: Hasegawa K, Sullivan AF, Tsugawa Y, Turner SJ, Massaro S, Clark S, Tsai CL, Camargo CA, MARC-36 Investigators

Abstract
BACKGROUND: It remains unclear whether the quality of acute asthma care in US emergency departments (EDs) has improved over time.
OBJECTIVES: We investigated changes in concordance of ED asthma care with 2007 National Institutes of Health guidelines, identified ED characteristics predictive of concordance, and tested whether higher concordance was associated with lower risk of hospitalization.
METHODS: We performed chart reviews in ED patients aged 18 to 54 years with asthma exacerbations in 48 EDs during 2 time periods: 1997-2001 (2 prior studies) and 2011-2012 (new study). Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores at the patient and ED levels; these scores ranged from 0 to 100.
RESULTS: The analytic cohort comprised 4039 patients (2119 from 1997-2001 vs 1920 from 2011-2012). Over these 16 years, emergency asthma care became more concordant with level A recommendations at both the patient and ED levels (both P < .001). By contrast, concordance with non-level A recommendations (peak expiratory flow measurement and timeliness) decreased at both the patient (median score, 75 [interquartile range, 50-100] to 50 [interquartile range, 33-75], P < .001) and ED (mean score, 67 [SD, 7] to 50 [SD, 16], P < .001) levels. Multivariable analysis demonstrated ED concordance was lower in Southern and Western EDs compared with Midwestern EDs. After adjusting for severity, guideline-concordant care was associated with lower risk of hospitalization (odds ratio, 0.37; 95% CI, 0.26-0.53).
CONCLUSIONS: Between 1997 and 2012, we observed changes in the quality of emergency asthma care that differed by level of guideline recommendation and substantial interhospital and geographic variations. Greater concordance with guideline-recommended management might reduce unnecessary hospitalizations.

PMID: 25263233 [PubMed - as supplied by publisher]

Childhood asthma in the Emergency Department: An audit.

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Childhood asthma in the Emergency Department: An audit.

Int Emerg Nurs. 2014 Sep 6;

Authors: Wilder C, Shiralkar S

Abstract
INTRODUCTION: The prevalence of asthma has been rising, particularly in younger age groups. In the 12-month period from February 2012 there were 28 deaths due to asthma in children under 18 in the United Kingdom, the majority of which were preventable. The purpose of this audit was to determine how effective our Emergency Department is at managing children presenting with acute asthma.
METHOD: We undertook a retrospective audit of 50 consecutive presentations to Huddersfield Royal Infirmary Emergency Department between 1 August 2013 and 31 March 2014 that met the inclusion criteria. Whether each patient had initial vital signs, timely initial management, vital signs after initial management, and appropriate further management were audited.
RESULTS: The majority of patients were male; mean age was 8.5 years. There were deficiencies in measurements for systolic blood pressure (14%), conscious level (30%), and peak flow (46%). Most patients received the correct dose of β2 agonist (96%) and oral or IV steroid (82%). Approximately 50% had further vital signs recorded. Thirty-six per cent were discharged with the correct dose of prednisolone.
CONCLUSION: Certain aspects of the management of childhood asthma are being overlooked. We have suggested an improved integrated care pathway that we feel will improve the deficiencies highlighted.

PMID: 25263689 [PubMed - as supplied by publisher]

Association of Antibiotics in Infancy With Early Childhood Obesity.

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Importance: Obesity in children and adults is associated with significant health burdens, making prevention a public health imperative. Infancy may be a critical period when environmental factors exert a lasting effect on the risk for obesity; identifying modifiable factors may help to reduce this risk.

Objective: To assess the impact of antibiotics prescribed in infancy (ages 0-23 months) on obesity in early childhood (ages 24-59 months).

Design, Setting, and Participants: We conducted a cohort study spanning 2001-2013 using electronic health records. Cox proportional hazard models were used to adjust for demographic, practice, and clinical covariates. The study spanned a network of primary care practices affiliated with the Children's Hospital of Philadelphia including both teaching clinics and private practices in urban Philadelphia, Pennsylvania, and the surrounding region. All children with annual visits at ages 0 to 23 months, as well 1 or more visits at ages 24 to 59 months, were enrolled. The cohort comprised 64 580 children.
Exposures: Treatment episodes for prescribed antibiotics were ascertained up to 23 months of age.
Main Outcomes and Measures: Obesity outcomes were determined directly from anthropometric measurements using National Health and Nutrition Examination Survey 2000 body mass index norms.

Results: Sixty-nine percent of children were exposed to antibiotics before age 24 months, with a mean (SD) of 2.3 (1.5) episodes per child. Cumulative exposure to antibiotics was associated with later obesity (rate ratio [RR], 1.11; 95% CI, 1.02-1.21 for ≥4 episodes); this effect was stronger for broad-spectrum antibiotics (RR, 1.16; 95% CI, 1.06-1.29). Early exposure to broad-spectrum antibiotics was also associated with obesity (RR, 1.11; 95% CI, 1.03-1.19 at 0-5 months of age and RR, 1.09; 95% CI, 1.04-1.14 at 6-11 months of age) but narrow-spectrum drugs were not at any age or frequency. Steroid use, male sex, urban practice, public insurance, Hispanic ethnicity, and diagnosed asthma or wheezing were also predictors of obesity; common infectious diagnoses and antireflux medications were not.

Conclusions and Relevance: Repeated exposure to broad-spectrum antibiotics at ages 0 to 23 months is associated with early childhood obesity. Because common childhood infections were the most frequent diagnoses co-occurring with broad-spectrum antibiotic prescription, narrowing antibiotic selection is potentially a modifiable risk factor for childhood obesity.

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