In clinic this week, when I asked a 13 year old boy what helps his asthma most, his mother interrupted with the response of “swimming, Tai Chi.”
He looked at his mother and said, “She’s asking me!” Then he said,
“Video games help my asthma the most.”
While I would never encourage kids to play just any video game for asthma, this 13 year old will be happy to know that there is now a video game that could help kids develop better understanding of their asthma.
Kids have the opportunity to take care of a pet who has asthma, helping the pet (who the child names) avoid triggers and remember to take her inhaler. Friends and siblings can also learn about asthma. This video game, Wellapets, is available in most app stores today.
Wellapets focuses on educational objectives for successful asthma management. These objectives include:
- Proper inhaler technique
- Using inhalers on time
- Avoiding asthma triggers
- Acting on asthma symptoms
If you decide to buy this game, I’d love to hear your input on the game. My kids just downloaded the game for $2.99 and are playing the game as I am posting this. They seem to like the new background music as I hear my son humming it.
A few screenshots…. (So glad there’s a spacer with the inhaler!)
This guy can blow fire!
I’ve been thinking a lot about smoking recently. We all know smoking has negative consequences for health, so why can’t we seem to keep people and smoking separate?
Despite what many people think, people who have asthma can exercise, and the exercise can be good for lung health. Many Olympic athletes have asthma.
My daughter who has asthma participates on a competitive gymnastics team, and practices 15 hours a week. Besides occasional coughing from the chalk, her asthma has not interfered with gymnastics.
This past weekend, her team competed at Twin Rivers Casino in Rhode Island. I thought this was a strange place for a girls gymnastics meet, but we received reassuring emails that we’d never have to walk through the casino.
What surprised me most at the meet was the strong smell of smoke in the convention hall. I caught many people in the audience breathing through their sleeves. There was just no way to escape from the odor. I tensed up wondering if this was going to affect Allison’s asthma. At the end of the meet, I asked Allison if the smoke affected her.
She responded, “what smoke?”
Remarkably, Allison has been sheltered so much from tobacco smoke, that she has no idea what tobacco smoke smells like. She stated she noticed an odor at the casino, but didn’t know what it was.
The following day in clinic, there was a theme to the responses to my typical question, “What would help your asthma most?”
The first patient was a 13 year old girl with moderate persistent asthma who was on Advair and Singulair for her asthma. When I asked “what would help your asthma most,” her first response was, “if people would stop smoking on the sidewalks.” Her mom added that she often asks her to go tell the smokers to stop smoking.
I told this mother-daughter pair that I’ve resolved that whenever I see somebody smoking outside the hospital entrance, I will ask them to stop. This 13 year old girl’s mom, said, “You and my daughter are the same.”
Then I walked into see a 5 year old boy who also had moderate persistent asthma and was on the same regimen. When I asked the same question, “what would help your asthma most,” before he could answer, his mother immediately responded,
“if I stopped smoking.”
Boy did that make me pause. I’m not accustomed to parents just telling me that they need to stop smoking, but this is the first step in smoking cessation.
Imagine what we could accomplish if everyone followed CVS/pharmacy and stopped selling cigarettes and tobacco products by October 2014.
- Have you every wanted to participate in research but didn’t want to be the subject?
- Have you ever wanted to be part of a research study and be part of the research team?
- Have you ever wanted to serve on an advisory board of a research project?
- Do you have asthma or are you the parent of a child with asthma?
If you answered yes to these questions, I might need your expertise.
I am planning a study focused on asthma video games in children with asthma.
If you have asthma or are the parent to a child with asthma and would consider being my research partner, please contact me (through Twitter, Facebook, my blog, or email: email@example.com).
Thanks for considering!
Today’s guest post is from Marina Reznik, M.D., M.S., attending physician, Department of Pediatrics, CHAM, and assistant professor of Pediatrics at Albert Einstein College of Medicine and reports the findings of a study she lead. She writes…
The majority of caregivers who administer their child’s asthma medication frequently use the incorrect technique, leading to poor health outcomes. The study found that only one of 169 caregivers accurately carried out 10 steps outlined in national guidelines as the appropriate method to deliver adequate medication for asthma management. Robust education efforts and training of caregivers could help to improve outcomes, reduce hospital admissions and healthcare costs.
Children with asthma usually depend on their caregivers to administer their medication, often via inhaler. To ensure the appropriate dose is inhaled, a spacer, which is a chamber with a mask that holds the medication and is placed between the inhaler and the child’s mouth, is often utilized. This approach is commonly prescribed for kids with asthma in the U.S., where as many as 7 million children suffer from the condition.
We monitored caregivers’ administering technique using a 10-step checklist and determined that if caregivers conducted seven or more steps accurately, they had a good technique; however if they administered six or fewer steps correctly, the technique was deemed poor. Five of the 10 steps were deemed essential for adequate delivery of medication.
As only one caregiver could do all steps accurately and fewer than four percent were able to complete five essential steps, we believe that regular education efforts would be beneficial to caregivers and their children. We also learned that caregivers whose children had been admitted for asthma in the past year were more likely to exhibit correct use, suggesting they had been retrained during the hospitalization and as a result were better able to perform the steps.
We surveyed and evaluated 169 caregivers of urban minority children, aged between two and nine years old, with persistent asthma whose doctor prescribed the medication to be taken via inhaler on a daily basis. By taking the medication daily, the goal is to control the underlying inflammation of the airways, reducing asthma symptoms and preventing attacks. Caregivers were asked questions to determine how well the child’s asthma was controlled and whether they had been instructed and/or shown by a medical professional how to administer the medication properly.
More than 90 percent of caregivers said they had received a verbal explanation of how to administer the medication, but only 54 percent were asked by a medical professional to demonstrate that they could actually do it themselves.
This first-of-its-kind study was conducted in the Bronx, a region where rates of asthma are high and low-income Hispanic and African American children are largely affected. Sufferers in this area frequently experience exacerbations that require hospital care and intense therapy.
Our study results further support the fact that caregivers need regular demonstration and evaluation of the correct technique, which could lead to improved clinical outcomes as well as reduced hospitalizations and healthcare costs. We want to keep our kids healthy and education will help make that happen.
Today’s guest post is from Christian Rosas-Salaza, MD MPH, from the Division of Allergy, Immunology, and Pulmonary Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt. He writes…
Multiple studies have noticed that children born prematurely are at a higher risk of developing asthma than those born at term. However, it is unclear if there are other factors that modify the association between prematurity and asthma. In a recent study published in the Journal of Allergy and Clinical Immunology, we examined if individual or sociodemographic factors (such as gender, household income, allergic status, family history of asthma, or passive smoking) modify the risk of asthma in children born prematurely. The study was conducted in over 600 school-age Puerto Rican children, an ethnic group that is at high risk for both prematurity and asthma.
In our study, we found that the risk of asthma was very high in children who were born prematurely and who tested positive for environmental allergies. On the other hand, premature children who were non-allergic did not have an increased risk for this disease. These results suggest that prematurity per se is not enough to induce asthma in children, but that the presence of environmental allergies is an important determinant of the risk of asthma in premature children. We speculate that this may be related to a “two-hit hypothesis”, where you need at least two risk factors to develop a certain disease.
Our study is limited by the fact that we lacked information about the specific gestational age, maternal or child infections, chronic lung disease of prematurity, or the need of mechanical ventilation (all of which can affect the association between prematurity and asthma.) As it can happen with any observational study, confounding by other measured or unmeasured factors is also possible. Furthermore, because our study was conducted in Puerto Rican children, the results may not apply to other ethnic groups.
In summary, the key findings of our study are:
- The presence of environmental allergies modifies the effect of prematurity on asthma in Puerto Rican children.
- Prematurity is strongly associated with asthma, but only in allergic Puerto Rican children.
Numerous strategies to prevent premature delivery have been developed. These include adequate prenatal care, prevention and treatment of maternal illnesses during pregnancy, and avoidance of environmental exposures (such as smoking and drinking). It is conceivable that these strategies may also be effective in preventing asthma, particularly in populations with high prevalences of allergic diseases. More studies are needed to further understand the complex relationship between prematurity, environmental allergies, and asthma.
Most pharmacogenetic studies conducted to date have focused on populations of non-Hispanic white subjects of European descent. My research is no exception.
This bothers a lot of people, including me, but there’s a reason for this. Because gene variants remain co-inherited in subjects of European descent, there is less genetic diversity.
Today’s blog post focuses on a recent article published by Victor Ortega and Deb Meyers. It’s a review article on the implications of race and ethnicity on defining genetic profiles for personalized medicine.
I really liked two figures in this paper. The first appears simple, but important concept.
This figure shows the frequency of a genetic variant from very rare to common on the x-axis and the effect size on the y-axis. The effect size is the measure of the strength of outcome. This figures is based on the “common disease-common allele hypothesis,” where many common genetic variants with smallish effect sizes contribute additively to common diseases, such as asthma.
On the other hand, rare genetic variants with large effect sizes contribute to the risk for common diseases, and this is the “common disease-rare allele hypothesis.” Rare variants require different methods to be identified.
The second figure that I find fascinating is this one:
This figure shows that migration patterns from 50,000 years ago affect the genetic variation seen in current research. Approximately 40,000-50,000 years ago, when the first modern humans migrated from sub-Saharan Africa to colonize Europe, the human population experienced a “bottleneck” or collapse of genetic diversity.
There were relatively fewer recombination events so gene variants were co-inherited through linkage equilibrium, and gene variants were more likely inherited together. For tens of thousands of years, there were no other major migration patterns that allowed potential for admixture.
More recently, in the past 400 generations, the population has experienced increased growth and recent mixing between more genetically diverse ancient African ancestral populations with European white and Native American subjects. The blue arrow represents the first human colonization of the Americas. The green arrows represent the African slave trade. The red arrows represent the European colonization of the Americas.
With the admixed ethnic groups, we see varying degrees of genetic diversity. The authors conclude that future pharmacogenetic approaches will need to enroll a larger number of subjects from underrepresented ethnic groups into clinical trials and use methods that account for genetic diversity of different ancestral backgrounds. Some of these methods include genome-wide association studies, admixture mapping, genotype-stratified trials based on comprehensive whole-genome genotyping platforms.
So, in the near-future, we should see an increase in the number of genetic studies conducted in admixed ethnic groups.
During a routine search of PubMed, I came across this article, “Factors Influencing Mothers’ Compliance with a Medication Regimen for Asthmatic Children.” This article seemed relevant to my research interests. And then I looked at the date.
The article is from 1978.
When I showed the article to a colleague, he said, “Ann, you didn’t invent this field! It’s been around for a long time.”
For context, in 1978, the major medication used to treat asthma was theophylline; however, much of the factors associated with compliance or noncompliance were similar to ones we think about currently.
In this study, the investigators interviewed mothers of children with asthma. The 45-minute interviews were designed to obtain mothers’ general health motivations and perceptions, their views on asthma, consequences of asthma, and compliance with medicines. Of the mothers interviewed, 94% were black, and the children were ages 9 months to 17 years of age.
Amazingly, much of the information reported by the investigators is still relevant.
- Compliance with medication regimens is low. Noncompliance rates were reported to be >60%.
- Non-compliance was higher in low-income patient groups.
The following factors were found to be associated with compliance:
- Higher educational attainment
- Being married
- Mothers’ confidence in providers
- Mothers who understood her child had asthma even when he or she were asymptomatic
- Believing the medication works well
- Believing that medicine can help but not cure asthma
- A perception that severity of child’s asthma interferes with mother’s activities, child’s schooling, or is a cause of embarrassment
Some things have changed.
- The title of the article refers to “mothers,” whereas current research would refer to “parents.”
- The response rate for participation in the study was 95%. (Amazingly high!)
- The researchers cite “forgetfulness” as the reason that a few patients did not have theophylline levels drawn. (Blood levels of theophylline were drawn to assess adherence to the asthma medicine, theophylline.) I’m not sure I’ve seen any researcher cite “forgetfulness.”
Sigh. So have we learned much since 1978? What has changed since 1978?
- I think concerns about side effects of medications are greater now. I don’t know if it’s related to more medications being available or more knowledge on side effects. Or maybe most of the concern about side effects are related to inhaled steroids.
- Having too many competing priorities as a reason for not being able to be compliant seems to be recognized more commonly now.
I’m not sure what my conclusion of this post is. Perhaps the conclusion is that research on adherence was pretty sophisticated in 1978. Perhaps the summary is that we haven’t learned a lot in 36 years. Perhaps the summary is some things never change (or they only change with baby steps.)
And here’s the first page of the article….
The parent of a 5 year old with asthma I saw today wished “more people would be aware.” When I asked her what she meant, she said she wished smokers would be aware what smoke did to her 5 year old.
Her 5 year old has moderate persistent asthma, is taking Advair and Montelukast, and has required oral steroids 9 times in the past year. She has no problem remembering to give his asthma medicines because she has asthma too, so they take their medicines together. Besides, giving his medicines is crucial and something she can actually control.
She cannot control the smoke that he is exposed to. Smoke is one of his biggest triggers making him cough and wheeze.
She lives in temporary housing and the neighbor downstairs smokes. Walking to the hospital, she counted seven people smoking, even right outside the hospital.
I wondered if there were really smokers outside of the hospital. There are signs all around the hospital entrance and around the medical school that surrounds the hospital, stating “A Smoke Free Zone” or “Smoke Travels farther than you think.”
On my way out that night, I saw these signs that I see regularly. I didn’t see any smokers. But when I looked down, I saw many cigarette butts in the crevices of the sidewalk right outside the hospital.
What are people doing smoking right outside the entrance of Children’s Hospital, Boston?