No systemic evaluation of asthma control in Jilin Province has been reported. Asthma control might provide the basis for asthma management in this region. A multicenter hospital-based cross-sectional study was performed to investigate the asthma control and related factors for severe asthma exacerbations in patients with moderate or severe asthma in Jilin Province, China.
The study enrolled 1546 patients in five grade one general hospitals from January to December 2013. Asthma medication, patient self-management, asthma control test (ACT) scores and frequency of severe asthma exacerbations during the follow-up (12 months) were collected via a follow-up questionnaire.
In the study, 889 patients provided a complete follow-up questionnaire. Severe asthma exacerbations occurred in 54.89 % of patients. ACT score ≤15, asthma medication ≤ 3 months, severe asthma, income level lower than average Per Capita Disposable Income (PCDI) and a lower educational level were risk factors of a severe exacerbation.
Poor adherence to asthma medication, poor asthma symptom control, lower income, a low educational level might be possible reasons for the high incidence of severe asthma exacerbations and poor asthma control in Jilin Province of China.
Asthma is a common disease of airway inflammation with a high prevalence worldwide . Asthma control refers to coming to a steady state after treatment. It has been reported that asthma has not been well-controlled in a large number of asthma patients, as defined by international guidelines [2–4]. A multicenter study of 10 large developed cities in China has reported that 28.7 % and 45.0 % of asthmatic patients achieve full and partial control, respectively, according to the guidelines of the Global Initiative for Asthma (GINA) . However, the data is not sufficient for evaluating the asthma control in China, because China is a large country in which the socioeconomic status, medical insurance coverage, climate and living environments vary considerably between different regions. All of these factors might influence asthma control. Therefore, additional studies on asthma control in different regions of China are needed.
Jilin Province is located in the northeast region of China and characterized by a cold climate, relatively low gross domestic product (GDP) and slow economic development. Until recently, there is few data on asthma control and risk factors for severe asthma exacerbations in Jilin Province. This study aimed to provide useful information in this field. In addition to asthma control test (ACT) questionnaire, we also investigated frequencies of asthma exacerbations. Because there is rare data on risk factors of asthma in China, the study also analyzed the effect of adherence, application of asthma medicine, severity and socioeconomic status on asthma control in Jilin Province so as to further explore the risk factors of asthma in China. This survey will provide useful guidelines for preventing and managing asthma in Jilin Province, China.
In this multi-center cross-sectional study, 1546 asthmatic patients were enrolled consecutively, who were hospitalized in five general hospitals with grade three in Jilin Province from January 2013 to December 2013.
The patient inclusion criteria were as follow: older than 18 years old; moderate asthma or severe asthma based on the GINA criteria (2012)  (that require high intensity treatment to maintain good control or where good control is not achieved despite high intensity treatment); longer than 1 month of diagnosed asthma; longer than 1 year of local residence. Patients with the following diseases were excluded from the survey: severe irreversible organ failure, such as heart, renal and liver failure; severe cerebrovascular disease with concomitant consciousness disturbance; advanced cancer; bronchiectasis; pulmonary embolism; interstitial lung disease; or active tuberculosis. Patients who were unable or unwilling to participate in the survey because of mental or neurological disorders were also excluded. The research protocol was approved by the ethics committee of the Second Hospital of Jilin University. Each patient gave their written informed consent before the survey.
According to the configuration and the ability of the hospital, hospitals in China are classified into grade one hospitals (primary hospitals providing basic health care in communities), grade two hospitals (secondary hospitals affiliated with a medium-size city or district), grade three (comprehensive or general hospitals providing specialist health services, medical education, and scientific studies), and village clinics/community health station . The five hospitals with grade three in the study were the Second Hospital of Jilin University, First Hospital of Jilin University, Jilin Province Hospital, 208th Hospital of the Chinese People's Liberation Army and China-Japan Union Hospital of Jilin University. These hospitals covered the majority of the geographic regions of Jilin Province. The reason why we enrolled patients with moderate to severe asthma from five hospitals with grade three was that physicians in hospitals with grade three in China have been trained comprehensively about GINA, and could diagnose and educate asthmatic patients correctly, thus the incidence of misdiagnosis and mistreatment would be minimized.
Demographic, socioeconomic, and clinical data were collected from hospital medical records. The demographic and socioeconomic data included age, gender, residence, education, occupation, medical insurance type and smoking history. Residence referred to rural or urban residence in China. In Jilin Province, the medical insurance mainly included Jilin provincial insurance (reimbursement ratio ≥80 %), city insurance-civil servants, retirement, employee (reimbursement ratio 70–80 %), city insurance-urban dweller (reimbursement ratio 50–70 %), New Rural Cooperative Medical Insurance (NRCMI, reimbursement ratio 30–50 %) and commercial medical insurance. The clinical data included asthma severity, FEV1 before discharge, hospital duration, atopic status (with clear allergic history or positive specific IgE or positive skin prick test), complications and comorbidities during the hospitalization. The complications and comorbidities consisted of allergic rhinitis, chronic obstructive pulmonary disease (COPD), pneumonia, respiratory failure, circulation system disease (pulmonary hypertension and cor pulmonale, hypertension, coronary heart disease and other heart diseases), nervous system disease, and digestive system disease (e.g., gastro-esophageal reflux disease, gastritis, digestive ulcers). Regular use of ICS (inhaled corticosteroid)/[ICS + LABA (Long-acting beta agonist)]/[ICS+ long-acting muscarinic antagonist (LAMA)] and asthma- associated education from a doctor during hospitalization were also included in clinical data.
Asthma control status and asthma medication during the first 12 months after discharge were collected via a follow-up questionnaire that was completed during each clinical visit (once every 3 months). During the visit, physicians asked the patients the questionnaire and filled in the answers. Review with a physician at least once every three months was defined as regular review or else defined as irregular review. The follow-up questionnaire included questions on several topics. (1) Household income. Because the Per Capita Disposable Income (PCDI) in Jilin Province in 2013 was reported to be 22274.60 Ren min bi (RMB) by the official data from Statistics Department (http://data.stats.gov.cn/), the income levels of the patients were classified into two groups: ≥PCDI group and < PCDI group. Residence referred to rural or urban residence. (2) Self-management of patients included the following information: regularity of a review, and regularity of writing in an asthma diary. (3) Performance of a pulmonary function test (once every three months) and peak flow meter (PFM) utilization. (4) Asthma medication, including the following information: types of medicines, time course of treatment, regularity of application of these medicines, and the reasons for using ICS/(ICS + LABA)/(ICS + LAMA) ≤3 months. (5) ACT scores. In addition to the patient-assessed level of control, ACT questionnaire consisted of four questions concerning symptoms or relief . Based on previous studies [8, 9], the ACT scores were evaluated as follows: ≥20, well-controlled asthma; 16–20, partially controlled asthma; and 5–15, poorly controlled asthma. (6) ACT scores were the mean value of twice testing results, which were completed in the middle and end of follow up year by each patient. A severe asthma exacerbation was defined as hospitalization and emergency department visit because of asthma . The study was conducted in the same way among all institutes.
This study used IBM SPSS Statistics 19.0 software (IBM, Somers, NY, USA) to conduct the statistical analyses. Data were presented as mean ± SD or percentage. A Chi-square test was used to perform a univariate analysis between demographic and clinical factors, and severe asthma exacerbations. A multivariate analysis was conducted using binary logistic regression (Forward: LR), with the significant factors identified from the univariate analysis. Factors were considered significant at p-value <0.05. The association was displayed as odds ratios (OR) with 95 % confidence intervals (CIs). A correlation between the ACT score and the frequency of severe exacerbations in asthma patients was tested using a Spearman Correlation Coefficient. Differences with a p-value <0.05 were considered significant.
Collectively, 1546 patients with moderate or severe asthma were enrolled in the study. Their mean age was 55.8 ± 16.8 years old. Baseline characteristics of the patients were shown in Table 1. Approximately 26.9 % of the patients were rural residents, 59.31 % were female patients, 31.82 % possessed middle school and lower education, and 97.67 % had a medical insurance. Former and current smokers were 39.78 % and 9.96 %, respectively.
Clinical data of the patients during the hospitalization were summarized in Table 2. The hospital duration was longer (10.15 ± 6.23 days). During the hospitalization, the ratio of the patients received systemic asthma-associated education and treatment with ICS/(ICS + LABA)/(ICS + LAMA) were higher (95.34 %, 92.24 %). Meanwhile, asthma patients got high morbidity rate of complication (81.18 %).
Of the 1546 patients, 889 patients provided a complete follow-up questionnaire. The other 657 patients could not answer all of the questions on the questionnaire because of death (57 cases), personal reasons or unknown causes.
Follow-up data (Table 3) on asthma control, asthma medication and severe asthma exacerbations revealed that 36.33 % of the patients lived with an income below the average PCDI, and only 8.66 % kept in touch with physicians and reviewed regularly. The percentage of patients taking a pulmonary function test, utilizing PFM and writing in an asthma diary regularly were 7.87 %, 3.60 % and 5.29 %, respectively. Only 38.47 % of the patients took ICS/(ICS + LABA)/(ICS + LAMA) regularly for longer than 3 months after discharge regardless of whether they had received asthma education or not. The percentage of patients with an unsatisfactory syndrome control (ACT scores ≤ 20) in Jilin Province was 71.88 %. Severe asthma exacerbations occurred in 54.89 % of the patients, and 11.59 % were admitted to the hospital again within 12 months of discharge. Moreover, ACT scores (it were the mean value of twice testing results, which were completed in the middle and end of follow up year by each patient) were negatively correlated with the frequencies of severe asthma exacerbations (r = −0.716, p < 0.001, Fig. 1).
A univariate analysis was performed to explore the risk factors of severe asthma exacerbations (Table 4). The multivariate analysis with a binary logistic regression (Forward: LR) was applied to exclude the mutual interference between the risk factors. Nine risk factors were identified for severe asthma exacerbations in Jilin Province (Table 5). The use of ICS/(ICS + LABA)/(ICS + LAMA) ≤ 3 months was the greatest risk factor for severe asthma exacerbations. The risk factor for poor adherence to treatment was further analyzed. Lower income and education, medical insurance with low reimbursement ratio, female, elderly, and following up irregularly were risk factors for usage of ICS/(ICS + LABA)/(ICS + LAMA) ≤ 3 months (Table 6).
It was the first multicenter hospital-based cross-sectional study to comprehensively investigate status of asthma control and risk factors for severe asthma exacerbations in patients with moderate or severe asthma in Jilin Province in northeast China. Based on the ACT scores, the current study found good asthma control in 31.61 % of the patients with moderate or severe asthma; partial asthma control in 40.27 %; and poor asthma control in 28.12 %. The percentage of the patients with severe asthma exacerbations during the follow-up period was 54.89 %. These findings suggest unsatisfactory asthma control. Moreover, the study found that the ACT scores were negatively correlated with the frequency of severe asthma exacerbations during the follow-up period, and ACT scores ≤ 15 was identified as an important risk factor for severe asthma exacerbations. The finding was in accordance with the data presented by Haselkorn T . The differences between ACT scores and frequency of severe asthma exacerbations were that ACT scores were often required from the patient's subjective feeling, and revealed four recent weeks of asthma control rather than one year.
Poor adherence was shown in our study. Only 38.4 % of the patients continued their medication for more than 3 months after discharge, and only 8.66 % of the patients were reviewed regularly by physicians, which is lower than the data found in a study conducted in USA . The study also showed that within one year after discharge, severe asthma, rural and poor patients tended to have lower ACT scores and higher frequencies of severe asthma exacerbations.
Asthma control assessments contain symptom control assessment and risk factor assessment. It has been reported that overestimating asthma control based on ACT scores will result in inadequate treatment or even termination of medication [13–15]. Thus, we not only studied ACT scores, but also investigated the frequency and risk factors of severe asthma exacerbations in the patients in the current study. The use of ICS/(ICS + LABA)/(ICS + LAMA) ≤ 3 months was found to be the greatest risk factor for severe asthma exacerbations, which was in line with previous findings [16–19]. In addition to ICS/(ICS + LABA)/(ICS + LAMA) ≤ 3 months, the study found that ACT scores ≤15, asthma severity, a junior high school and lower educational level, an income level lower than PCDI, hospital days ≥15 days, rural residence and FEV1 ≤ 50 % predicted were also risk factors for severe asthma exacerbations. Previous studies have reported that FEV1 < 60 % predicted is a risk factor for exacerbations [20, 21]. However, the study found that FEV1 < 50 % predicted was a more significant criterion than FEV1 < 60 % predicted for severe asthma exacerbations. This difference might be attributed to the fact that the pulmonary function testing has primarily been conducted in convalescence, immediately following an acute exacerbation, when pulmonary function is not totally recovered. In the study, 71.48 % of the patients who did not take the ICS/(ICS + LABA)/(ICS + LAMA) for more than 3 months complained that the medicines were too expensive (300–600 RMB per month). Our study revealed that lower income and education, and medical insurance with low reimbursement ratio were main risk factors for poor adherence of asthma treatment, and 71.48 % of patients stopped the therapy of ICS/(ICS + LABA)/(ICS + LAMA) ahead of schedule, due to expensive price of medicines. So reduced out-of-pocket expenses  or free drugs may improve medication adherence from the government level. Otherwise, 45.89 % of asthma patients used other drugs to instead of ICS/(ICS + LABA)/(ICS + LAMA), for example theophylline, which has been recently shown to have antiinflammatory effects in asthma at lower concentrations, is used commonly in China for cheaper price . Meanwhile, some traditional Chinese medicine had been used irregularly. So a multi-center, cross-sectional study about certain cheaper drugs for asthma control to improve adherence to self-administered medications should be designed well in further.
These findings suggested that lower socioeconomic and educational levels and limited reimbursement from insurance were the primary obstacles to regularly using their asthma medicine. These were in accordance with previous data showing that socioeconomic problems are major risk factors for asthma-related deaths . One explanation is that government revenue, education and medical expenditures of Jilin Province are relatively low in China . Furthermore, a low household income and low educational level were shown to not only decrease the adherence of asthma medication but also independently increase the risk of severe asthma exacerbations in the present study. Similarly, it has been shown that the risk of severe life threatening asthma (SLTA) increases with the lack of formal income . This indicated that higher household income, increased education and medical expenditures, and higher reimbursement from insurance might aid in prevention of severe asthma exacerbations and contribute to asthma control improvement.
Atopic status and infection are both important factors for acute attack of asthma. We found 36.67 % of patients had atopic status in our study, but atopic status of patients was not risk factor for severe asthma exacerbations in the follow-up period. The comorbidity of pneumonia, which reflected partly infection in lung, was not associated with severe asthma exacerbations in the follow-up period.
Smoking has been reported to be a risk factor for poorly controlled asthma and an impaired corticosteroid response . In contrast, smoking was not a significant risk factor for severe asthma exacerbations in our survey, which might be due to the lower percentage (9.96 %) of asthma patients who were currently smoking compared with other studies. The percentage of former smoker was 39.78 %. This suggested that many patients might quit smoking after diagnosis of asthma. Another reason might be difference patient resources.
The study has some limitations. There may be a selection bias because the asthma patients were enrolled only from five first-class hospitals in Jilin Province. Another limitation is the high dropout rate that 889 of 1546 patients provided a complete follow-up questionnaire. Furthermore, it is difficult to evaluate the effect of season and airway infection on severe asthma exacerbation each time, because we collected the data of severe asthma exacerbations of patients in follow up visit per three months retrospectively, but not immediately when the acute exacerbations happened. And some information in detail was not complete because the hospitalization and emergency department visit of patients were not in original hospitals sometimes. Otherwise, it is difficult to evaluate the infection situation each time, due to the partly abuse of antibiotics in China. Thus, increasing the frequency of follow-up visits and establishing the network of hospitals with different grades would be solutions. Finally, follow-up studies after discharge might increase the understanding and condition of asthma control. Further large-scale studies are warranted to validate the findings of this study.
Collectively, this study found unsatisfactory asthma control and a high frequency of severe asthma exacerbation in Jilin Province, which were mainly due to poor adherence to asthma medication, poor asthma symptom control, low income, a low educational level and a low proportion of reimbursements from insurance companies. Our results provide basic data for improving asthma control in Jilin Province and will help physicians instruct patients on how to avoid the risk factors associated with asthma exacerbation.
Bing-di Yan and Shan-shan Meng share first authorship.
This work was supported by National Natural Science Foundation of China (Nr: 81300014) and Norman Bethune Medical Scientific Research Fundation-Youth Foundation (Nr:2013206039).
JL conceived and designed the research. BDY, SSM, JR wrote and edited the manuscript. BDY, SSM, JR, ZL, QHZ, JYY, RG, CMS, CFW, CLL, JZ, ZSM, JL make data collection and analyzation. ZL, QHZ, JYY, RG, CMS, CFW, CLL collected the literature. JZ, ZSM, JL, reviewed and revised it critically for important intellectual content. JL gave final approval of the version to be published. All authors read and approved the final manuscript.
The research protocol was approved by the ethics committee of the Second Hospital of Jilin University. Each patient gave their written informed consent before the survey.
Global Initiative for Asthma. Global Strategy for asthma management and prevention. http://www.ginasthma.org. Accessed 2012 update.


Latitude and longitude coordinates are: 59.105751, 18.042084.
Tungelsta is a small southern neighborhood of Stokholm, the capital city of Sweden, situated about 22 miles from Stockholm city center. It is the area with plenty of summer houses of those who reside in the city. Local natural setting, amazing green forests and clean air are among the factors that attract city population, so year by year new houses are being built in the town.
The latitude of Tungelsta, Sweden is 59.105751, and the longitude is 18.042084. Tungelsta, Sweden is located at Sweden country in the Towns place category with the gps coordinates of 59° 6' 20.7036'' N and 18° 2' 31.5024'' E.
Tungelsta, Sweden elevation is 33 meters height, that is equal to 108 feet.
Coordinates of Tungelsta, Sweden is given above in both decimal degrees and DMS (degrees, minutes and seconds) format. The country code given is in the ISO2 format.


text:
Bahr al-Ghazāl () ist eine Region und ehemalige Provinz im Sudan (im heutigen Südsudan), benannt nach dem Fluss Bahr al-Ghazal.

Sie besteht aus Sumpfgebieten und eisensteinhaltigen Ebenen und wird hauptsächlich vom Volk der Dinkas bewohnt, die von Viehzucht und Subsistenzwirtschaft leben.

Geschichte
Über viele Jahre hinweg war die Region Überfällen aus der Nachbarregion Darfur durch arabische und Fur-Sklavenhändler ausgesetzt. Der Sklavenhandel wurde 1864 vom Khediven von Ägypten verboten, konnte sich aber durch den Einfluss mächtiger einheimischer Händler wieder durchsetzen. Diese setzten sich selbst als Fürsten mit eigenen Armeen in der Region ein. Der mächtigste der Fürsten, al-Zubayr, bekämpfte erfolgreich die gemeinsamen türkisch-ägyptische Streitkräfte, die 1873 nach Bahr al-Ghazal geschickt wurden. Der Khedive gestand daraufhin seine Niederlage ein und machte die Region zu einer offiziellen ägyptischen Provinz, mit al-Zubayr als Gouverneur. Die ägyptische Herrschaft brach nach 1881 im Mahdi-Aufstand zusammen, wurde aber nach der Niederlage der Mahdisten 1898 mit britischer Hilfe restauriert. Während der Faschoda-Krise erhob Frankreich Ansprüche auf das Gebiet und einen schmalen Zugang zum Nil, gab sie aber im britisch-französischen Sudanvertrag 1899 auf.

Später wurde die Region mit dem britisch-ägyptischen Sudan vereinigt und gehörte bis 1948 zur Provinz Äquatoria. Im Jahr 1948 wurde die Region dann als eigenständige Provinz abgespalten und blieb auch nach 1956 eine Provinz in der unabhängigen Republik Sudan. 1976 wurde die Provinz al-Buhairat abgespalten, die das Gebiet der heutigen Bundesstaaten al-Buhairat und Warab umfasste. Von 1991 bis 1994 wurde Bahr al-Ghazal ein Bundesstaat, der in den Grenzen der Provinz Bahr al-Ghazal von 1948 bis 1976 glich. Am 14. Februar 1994 wurde erneut Bahr al-Ghazal aufgespalten, diesmal aber in vier Bundesstaaten: al-Buhairat, Gharb Bahr al-Ghazal, Schamal Bahr al-Ghazal und Warab.

Die Region ist von langjährigen Bürgerkriegen geprägt. 1982 formierte sich die Sudanesische Volksbefreiungsarmee (SPLA), um die Regierung in der Hauptstadt Khartum zu bekämpfen. Der Konflikt dauerte bis 2003 an und forderte mehr als 2 Millionen Todesopfer.

Weblinks

Region in Afrika
Geographie (Südsudan)

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Home/Trending posts/Middle school teacher caught saying 'conservative Christians need to get COVID and die' while in a school hallway, resigns
Cindy Carey Send an email March 5, 2022
Teachers take major part in the development process of our children and they are required to be as neutral as possible while at schools. Discussions about political views and other sensitive topics should be left out of school in an effort to keep schools safe and secure environment for students.
A middle school teacher last week resigned from her position after a video appeared online where she is heard saying that 'conservative Christians need to get COVID and die' while she was talking in the school hallway with two other women arguing the Covid-19 vaccination process since the very beginning.
Once the video appeared online on the Canadian video platform Rumble, the parents, and later the school district, identified the teacher as Lisa Grimes. When the school learned about the video, Grimes, who taught eighth grade discoveries and English language arts, was placed on administrative leave, but the very next day she resigned from her position.
The incident reportedly happened at the beginning of last week at the CMS in Texas. From what is seen in the video, the teacher was talking with two other women in a hallway about vaccines and her frustration with how they've become political. The teacher argues the whole Covid-19 vaccination process blaming the officials for giving out the corona vaccines the same was as the flu vaccines. Grimes is heard saying that if the vaccines were given out immediately, the virus would be gone.
"We have a political system that will not allow us to [inaudible] so we're vaccinating like the flu … which is, you know … get the flu vaccine if you want but you can't — don't 'tread on me.' [crosstalk] But it's too late. It would have had to have been immediate. If we would have done it immediately, it'd already be gone," Grimes said.
"The rest of my life is impacted because of politics?" Grimes added. "Because of conservative Christian crap? I'm telling you, those conservative Christian people, they need to die, they need to get COVID and die," Grimes is heard saying.
The video, later re-published on Youtube, attracted a lot of online attention and many people commented below expressing their views about the incident. "Wow. What a wicked thing to wish on more than half the country. She has no business teaching children. She needs to find a different job working with her own kind – snakes," one user commented.
The parents of the CMS students, understandably, became very upset which forced the school district to write a letter to them explaining that Grimes' statements don't reflect the views of the school district or the school. In addition to the letter, the school board president issued a statement rejecting teacher's statements and said the board supported the school's decision to place Grimes on administrative leave last Wednesday.
Grimes didn't wait long and she resigned the very next day, on Thursday. The information was confirmed by the school district noting that 'the Colleyville Middle School teacher whose words were captured in a widely circulated online video has resigned and will not be returning to the classroom.' Meanwhile, the school was working to ensure that her students experience as little disruption in their learning as possible.
Cindy Carey
27-year-old trans woman, who was placed to serve three-decades-long sentence in a female-only prison, was transferred to men's facility after impregnating two inmates
Man is accused of killing longtime wife for a $5m insurance payout while they were on a holiday and later confessed to his longtime lover that "he did it for her", new evidence shows
Woman was diagnosed with stage 4 bowel cancer and was given no more than four months to live, but beat the odds and recovered; explains how swollen stomach and sluggish feeling signs were dismissed as menopause
Volunteers needed for COVID-19 vaccine trial in N. Charleston
Saturday evening crash on Johns Island resulted with 1 killed and 8 other injured, driver arrested for driving under influence
From Antiques to the Latest High-End Fashion, Charleston is a Shopper's Dream
'No Thru Truck' ordinance to be considered for two roads on Johns Island, Charleston County to discuss on Tuesday
Friday Covid-19 report: Almost 850 new positive cases with 2 deaths

redpajama_set_name: RedPajamaCommonCrawl


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