Nejmoa1203229 Protocol

Protocol
This trial protocol has been provided by the authors to give readers additional information about their work.
Protocol for: Kelly HW, Sternberg AL, Lescher R, et. al. Effect of inhaled glucocorticoids in childhood on adult
height. N Engl J Med 2012;367:904-12. DOI: 10.1056/NEJMoa1203229
Childhood Asthma Management Program

Continuation Study/Phase 3
CAMPCS/3
Protocol
Repository:
CAMPCS/3 Coordinating Center
615 North Wolfe Street, Room W5010
Baltimore, Maryland 21205
(410) 955-8175
(410) 955-0932 (fax)
27 April 2011
CAMP Continuation Study/Phase 3 (CAMPCS/3) Protocol

Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1. Objective and specific aims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.1.
Objective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.
Specific aims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2. Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1.
Background for Specific Aim 1, Hypothesis 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.2.
2.3.
2.4.
2.5.
2.6.
Rationale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3. Preliminary data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.2.
Preliminary data from CAMP, CAMPCS, and CAMPCS/2. . . . . . . . . . . . . . . . . . . 12
3.2.1. Ages of participants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2.2. Determination of lung function and airway responsiveness (Specific Aims 14). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2.3. Determination of inflammatory-related phenotypes (Specific Aims 1, 3, and
4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2.4. Personal smoking in CAMP participants (Specific Aim 1). . . . . . . . . . . . . 13
3.2.5. Asthma symptoms/morbidity and medication use (Specific Aim 1). . . . . . 13
3.2.6. Environmental measures.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2.7. Patterns of growth and decline of lung function (Specific Aim 4, Hypothesis
5). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.2.8. Somatic Growth (Specific Aim 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.2.9. Preliminary data on genetic polymorphisms and lung function (Specific
Aims 2 and 4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4. Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Overview of CAMPCS/3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.
Consent and recruitment in CAMPCS/3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3.
Patient contact schedule and content of visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4.
Measurement and assessment methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4.1. Pre- and post-BD FEV1 and FEV1/FVC ratio.. . . . . . . . . . . . . . . . . . . . . . .
4.4.2. Airway responsiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4.3. Somatic growth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4.4. Symptoms/morbidity and medication use.. . . . . . . . . . . . . . . . . . . . . . . . . .
4.4.5. Environmental measures.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4.6. Atopy related phenotypes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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CAMPCS/3 Protocol
4.5.
4.6.
4.7.
4.8.
4.9.
4.10.
4.11.
4.12.
4.13.
4.14.
Contents
4.4.7. Pregnancy history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Patient retention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Data management for clinical data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Data management for genetic studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.7.1. Bioinformatics management system (ORAGEN).. . . . . . . . . . . . . . . . . . . . 22
4.7.2. Management of genotypic data.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.7.3. Management of phenotype data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Quality assurance.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Data monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Human subjects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4.10.1. Characteristics of the proposed study population.. . . . . . . . . . . . . . . . . . . . 24
4.10.2. Sources of research material.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4.10.3. Protection of human subjects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Data analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.11.1. General approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.11.2. Measurement of steroid treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.11.3. Analyses for Specific Aim 1, Hypothesis 1. . . . . . . . . . . . . . . . . . . . . . . . . 27
4.11.7. Analysis for Specific Aim 4, Hypothesis 5. . . . . . . . . . . . . . . . . . . . . . . . . 29
4.11.8. Sample size considerations - all Specific Aims. . . . . . . . . . . . . . . . . . . . . . 29
4.11.9. Statistical power for multistage whole genome association analysis, Specific
Aim 2, Hypothesis 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Study organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Use of comparison populations to describe abnormal patterns of growth and decline
of lung function (Specific Aims 4, Hypothesis 5). . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Methods for defining patterns of reduced lung function growth and early decline of
lung function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5. Appendices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5.1.
Design summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.2.
Data collection schedule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Literature cited.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

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CAMPCS/3 Protocol
Abstract
This protocol is for the CAMP Continuation Study/Phase 3 (CAMPCS/3), a 4-year
observational followup study of the participants in the Childhood Asthma Management Program
(CAMP) trial.
The CAMP trial was a multicenter randomized clinical trial designed to determine the effects of
three treatments (albuterol alone, albuterol with inhaled corticosteroid (ICS), albuterol with inhaled
non-steroid) in1041 children (ages 5-12 at initial screening) with mild to moderate asthma on
pulmonary function during a 3.5-5.5 year treatment phase. The cohort has been followed since the
end of the CAMP trial, first in the CAMP Continuation Study (CAMPCS) which lasted 4.5 years and
subsequently in the CAMP Continuation Study/Phase 2 (CAMPCS/2) which lasted 4 years and had
the purpose of determining the long term effects of the treatments on lung and somatic growth.
CAMPCS/3 is designed to follow the cohort for 4 additional years to study the determinants of lung
growth and progression of obstruction due to persistent childhood asthma.
Childhood asthma can result in significant lung disease in adulthood and possibly the
development of chronic obstructive pulmonary disease. None of the long-term followup studies of
childhood asthma have had the close followup needed to define determinants of outcomes in young
adulthood.
CAMPCS/3 has four specific aims: (1) Define the risk factors for reduced maximal attained
lung function and/or progression of obstruction in young adults with mild to moderate persistent
childhood asthma; (2) Identify genetic polymorphisms for reduced maximal attained lung function
and progression of obstruction in young adults with mild to moderate persistent childhood asthma;
(3) Determine effects into early adulthood of 4-6 years of prior continuous treatment with inhaled
anti-inflammatory medications; and (4) Define patterns of reduced lung function growth and early
decline of lung function in young adults with mild to moderate asthma.
Data collection procedures will be similar to those used in CAMP, CAMPCS, and CAMPCS2.
Patients will have a total of 4 visits for spirometry (approximately 1 per year) and a fifth visit for
methacholine challenge which may be scheduled at anytime in the latter half of year 1 through year
4. Procedures completed at the spirometry visits will include spirometry pre- and postbronchodilator, height and weight measurement, and interim history interview (information on
asthma symptoms, tobacco smoke exposure, medication use, and home environment will be
collected).
The methacholine challenge visit will include methacholine challenge, height and weight
measurement, and the same interim health history interview collected at the spirometry visits.

Abstract
4
CAMPCS/3 Protocol
1. Objective and specific aims

1.1.
Objective
CAMPCS/3 is an observational followup study of the children who participated in the

Childhood Asthma Management Program (CAMP) trial. CAMPCS/3 will extend the CAMP
Continuation Study/Phase 2 (CAMPCS/2) for 4 years and will thus continue the follow-up of the
CAMP cohort through a total of 16-18 years by the end of the planned extension.
The objective of CAMPCS/3 is to complete our studies of the determinants of lung growth and
progression of obstruction due to persistent childhood asthma. Several authors have commented on
deviations from normal patterns of change in pulmonary function with age that foreshadow evolution
of asthma into chronic airflow obstruction in adulthood (3, 7-9). Published data from the CAMP
cohort have provided detailed information about effects of persistent asthma on lung growth through
adolescence (10), and there are several studies of effects of asthma on decline in lung function in
older adults (11-13). However, there are no comprehensive data on lung growth and the progression
of obstruction due to asthma during young adulthood. CAMPCS/3 will determine clinical
characteristics, early changes in pulmonary function, inflammatory markers, and genetic
polymorphisms that put individual patients who had mild to moderate persistent childhood asthma at
risk for progression towards chronic airflow obstruction. CAMP is the largest, most
comprehensively phenotyped, genotyped, and best followed group of mild to moderate, persistent
childhood asthmatics in the modern era. CAMPCS/3 represents the only opportunity to definitively
determine the effects of persistent childhood asthma on lung function growth and decline in early
adult life, and to define subgroups of patients with persistent asthma who are at increased risk for
development of chronic airflow obstruction.
1.2.
Specific aims
Specific Aim 1: Define risk factors for reduced maximal attained lung function and/or
progression of obstruction in young adults with mild to moderate persistent childhood asthma.
Hypothesis 1: Increased airway lability (responsiveness to methacholine, reactivity to
bronchodilator), increased inflammatory markers (allergy skin tests, serum IgE level, peripheral
blood eosinophilia), and cigarette smoking (personal and passive) are related to the reduced
maximal attained lung function (FEV1, FVC), and progression of obstruction (FEV1/FVC).
Hypothesis 2: (a) The presence of symptoms independently predicts reduced maximal attained
lung function (FEV1 , FVC) and progression of obstruction (FEV1/FVC), and (b) the likelihood
of persistence of symptomatic asthma is predicted by increased airway lability, increased
inflammation (allergy skin tests, serum IgE level, peripheral blood eosinophilia), and cigarette
smoking (personal and passive).

Specific
5
CAMPCS/3 Protocol
1. Objective and specific aims

1.2. Specific aims
Specific Aim 2: Identify genetic polymorphisms for reduced maximal attained lung
function and progression of obstruction in young adults with mild to moderate persistent
childhood asthma.
Hypothesis 3: Maximally attained lung function (FEV1, FVC), and progression of obstruction
(FEV1 /FVC) will be associated with one or more specific Single Nucleotide Polymorphisms
(SNPs) from 550,000 whole genome tagging SNPs genotyped in the 400 Caucasian parent-child
trios in the CAMP cohort.
Specific Aim 3: Determine effects into early adulthood of 4-6 years of prior continuous
treatment with inhaled anti-inflammatory medications.
Hypothesis 4: Early continuous treatment lasting 4-6 years of patients with mild to moderate
childhood asthma with inhaled corticosteroids (ICS) compared to treatment with placebo (a) will
not influence maximally attained lung function (FEV1, FVC), progression of obstruction
(FEV1 /FVC), and increased airway lability in young adulthood; and (b) will have a small
(<1cm) effect on attained maximal height, controlling both (a) and (b) for age, gender, ethnicity,
and asthma duration and severity at baseline.
Specific Aim 4: Define patterns of reduced lung function growth and early decline of lung
function in young adults with mild to moderate persistent childhood asthma compared to
normal subjects, controlling for age, height, and gender.
Hypothesis 5: (a) Four consistent patterns of FEV1 growth and decline can be identified from
comparisons of CAMP persistent asthmatics to non-asthmatics from both longitudinal
(Vlagtwedde/Vlaardingen and CARDIA) and cross-sectional (NHANES III) studies: 1) Normal
lung growth and no decline, 2) Reduced lung growth, 3) Normal lung growth then early decline,
and 4) Reduced lung growth and early decline; and (b) These four patterns can be discriminated
from one another using clinical characteristics, early changes in pulmonary function,
inflammatory markers, and genetic polymorphisms.

Specific
6
CAMPCS/3 Protocol
2. Background
2.1. Background for Specific Aim 1, Hypothesis 1
Importance of longitudinal follow-up of patients with persistent asthma: Deficits in growth of
lung function in childhood due to asthma are important to fully define, as asthma is an important
determinant of lung function (FEV1) in adults, independent of smoking (12). Individuals with asthma
are at risk for significant lung disease due to more rapid decline in lung function during adulthood
than non-asthmatics (11, 13). Longitudinal studies examining the effect of asthma or wheeze on lung
function growth from the early school years to adolescence provide conflicting findings (14-23), with
some reporting that abnormalities observed at ages 5-7 years did not increase during follow-up into
adolescence or early adulthood (14, 20-22, 24, 25), and with others finding decreasing lung function
during adolescence (16, 26). Discrepancies in findings of effects of asthma on long-term lung
function growth and decline are due in part to use of asthmatics nested within birth cohorts (21, 22)
or selected from school populations (27), most of whom have mild disease.
Factors identified as responsible for evolution of abnormalities in lung function: Airway
responsiveness and a low level of lung function are independent risk factors for a low level of FEV 1
in early adulthood, in both individuals with asthma (28) and individuals without diagnosed asthma
(4, 29, 30). A variety of other epidemiologic sources have confirmed that asymptomatic hyper
responsiveness is associated with accelerated decline in FEV1 in early adult life and is a risk factor
for the development of COPD and for mortality. Ongoing respiratory symptoms are also related to
decreases in lung function (17, 18, 31). However, children with asthma who become asymptomatic
during adolescence continue to have spirometric abnormalities and airway responsiveness to
methacholine or cold air challenge (32-36), significant airway inflammation and airway remodeling
on bronchial biopsy (37), and eosinophils in bronchoalveolar lavage fluid (38). The finding that
abnormalities are present when symptoms have remitted presents a strong argument for collection
and analysis of levels of lung function and airway responsiveness longitudinally in young adulthood.
Timing of decline from maximum values and factors that may be responsible for this abnormal
pattern: In normal individuals, FEV1 reaches a maximal level in late adolescence or early adulthood
and remains stable for several years before declining throughout the rest of life. These patterns of
growth and decline of lung function are important determinants of lung function in later adulthood,
and both low maximal levels and early decline are associated with development of chronic airway
obstruction in later adult life (39, 40). Because of the relationship between the abnormalities in
patterns of growth and decline of lung function and subsequent development of chronic airway
obstruction, there has been increasing interest in factors that influence pulmonary function in
children as they approach and reach adulthood, particularly in high-risk populations. Determinants
of abnormalities in patterns of growth and decline of lung function are multifactorial and complex,
and data obtained longitudinally to determine factors associated with timing of decline from maximal

Backgrd
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CAMPCS/3 Protocol
2. Background
levels of lung function are sparse. The best studies are CARDIA (13) and Vlagtwedde/Vlaardingen
(4, 30, 41). CARDIA studied risk factors for cardiac disease with measurements of FEV1 at 3 to 5
year intervals up to 10 years and collection of information about doctor diagnosis of asthma and
cigarette smoking. Individuals were enrolled at ages 18 to 30. Maximal FEV 1 levels were achieved
starting at age 19 and lasted a shorter time in males (to 24 years) than females (to about 27-28 years).
Maximal FEV1 was lower and deteriorated more rapidly in participants with asthma. Cigarette
smoking was also a factor and particularly important among asthmatics. Dr. Weiss analyzed data
from the Vlagtwedde/Vlaardingen study with very similar results (42).
Effects of smoking on lung function: Timing of active cigarette smoking with regard to lung
function is critical in determining an effect. Children who smoke at the level of 1 cigarette per day
between the ages of 10-16 can reduce their maximally attained level of FEV1 by 10% (43-45).
Comparable figures for childhood asthmatics are not available. Active cigarette smoking by
asthmatics in adolescence and early adulthood is associated with increased hospitalizations,
emergency department visits, and respiratory symptoms; lower levels of lung function; and increased
levels of airways responsiveness (43-45). The extent to which the combination of asthma and
smoking can lead to early decline in FEV1 and, hence, the development of chronic airflow
obstruction, is currently unknown.
2.2.
Background for Specific Aim 1, Hypothesis 2
The course of asthma is recognized to be quite variable over time, and long-term consequences
of this disease differ for affected individuals. The adult outcomes resulting from childhood asthma
can only be evaluated from large, longitudinal, well-retained cohorts who are followed from
childhood into adulthood. Studies of remission of asthma and subsequent relapse are highly variable
in nature and have focused on small numbers of individuals with mild disease. Most studies have
employed questionnaires sent to patients, with estimates of asthma obtained by report of symptoms in
the past 12 months. Some of the studies examined patients at the time of follow-up; however, even
these studies used self-report of symptoms in the past 12 months or 3 years to obtain information
about the status of asthma. It is possible to make some estimates of the percentages of children who
improve and those who remain with symptoms as they grow into adulthood; however, no long-term
study of childhood asthma has included a comprehensive, longitudinal evaluation of risk factors for
persistence of symptoms, abnormalities in pulmonary function in the absence of symptoms, and
relapse of symptoms after periods of remission. No long-term follow-up study has included an
evaluation of the role of environmental exposures on outcome, either in absolute terms or relative to
specific sensitivities. Furthermore, whether prior asthma controller therapy should be considered as
a modifying factor or as an independent marker of symptom persistence has also not been determined
in previous studies.

Backgrd
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CAMPCS/3 Protocol
2.3.
2. Background
Allergic asthma in childhood, as seen in the mild-to-moderate subjects enrolled in CAMP,

is clearly a heritable disease. The lambda S, or recurrence risk to relatives (a measure of
heritability), for allergic asthma is thought to vary between 3 and 5 (46). When one considers twin
studies, the proportion of phenotypic variants attributed to genetic factors ranges from 36-79% (47).
The significant heritability estimates have been demonstrated for all of the allergic and inflammatory
intermediate phenotypes for this condition (48, 49). There are now a total of 13 studies
demonstrating linkages of an asthma phenotype to more than 34 chromosomal regions of the human
genome (50-55). At least eight of these regions are highly replicable and have occurred in many
studies (50-55). Four of these linked regions have been fine mapped using LD mapping and specific
candidate genes identified (G protein-coupled receptor for asthma susceptibility [GPR154]) on
chromosome 7p, chromosomes 13q14 (PDH finger protein 11 [PHF11]), 2q14 (dipeptidylpeptidase
10 [DPP10]), and 20p13 (disintegrin and metalloprotease 33 [ADAM 33]). Although there are more
than 500 genetic association studies for asthma, most suffer from methodological problems. Given
strict criteria with regard to replication, most of these studies do not replicate. To date, there have
been reports of positive associations between variants in over 70 genes and asthma phenotypes (56).
Of these, 30 associations were replicated in at least two populations and 9 associations were
replicated in at least five populations, but the number of candidate genes that are linked to lung
function level is very small. To date, no whole genome association study in asthma has been
reported. Whole genome association studies offer a unique opportunity to assess association at a
whole genome level rather than focus on individual genes. We have an opportunity in CAMP to
relate 550,000 SNPs to the unique longitudinal lung function phenotypes being collected as part of
this continuation study because of newly funded P01-HL083069 (ST Weiss PI) that includes funds
for a whole genome association study of the 400 Caucasian trios in CAMP with a strong replication
strategy. No whole genome study has been done for asthma or its lung function phenotypes, and
CAMP provides the best longitudinal phenotype data on lung function in asthma in the world.
2.4.
Numerous short-term studies of ICS therapy (up to 1 year) have reported improvements in
measures of spirometry. Prior to CAMP, there had been no controlled study to examine longer term
effects. In CAMP, children treated continuously with ICS (budesonide) demonstrated a rise in FEV1
compared to children in the placebo group over the first 6-12 months of the trial (57). But by
completion of the 4-6 years of continuous treatment, the initial increase in the ICS-treated patients
had waned, and the ICS and placebo groups did not differ in terms of FEV1 (57). The lack of longterm effect of ICS on post bronchodilator FEV 1 was surprising.

Backgrd
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CAMPCS/3 Protocol
2. Background
In contrast to the transient-only benefit on post-bronchodilator FEV1, ICS treatment in CAMP

resulted in significant and continued improvement in airway responsiveness and bronchodilator
reactivity throughout the 4-6 year treatment interval (57). All previous studies demonstrating that
ICS improved airway lability were short in duration (up to 1 year). In these short-term studies, the
extent of improvement varied considerably among patients (58-60). Factors predictive of
improvement in lability with ICS have been largely unknown.
While there have been many studies of ICS on somatic growth, most have been short-term (up to
1 year). Most articles published from the early 1980s did not find any effect of ICS on growth (6166), but 4 reports in the 1990s did find a decrease in growth from beclomethasone given for periods
up to 1 year (67-70). Two long-term follow-up studies without placebo control demonstrated that
neither the duration of treatment nor cumulative dose of ICS influenced final height (71) (72).
CAMP was the first long-term placebo-controlled study with 3.3-5.5 years of continuous treatment
demonstrating a decrease in growth in the ICS-treated group, with an effect in the first year similar to
that found in previous short-term studies, but also at the end of the 4-6 year treatment interval
(decrease of 1.1 cm, P=0.005). These results were less concerning because of the observation that
growth velocity was reduced primarily in the first year of the study, suggesting that height might
catch up even with continued use of the drug. However, height in the previously ICS-treated CAMP
patients remains lower than in the placebo group more than 4 years after discontinuation of the
CAMP study treatment.
2.5.
While it is not feasible to identify a concurrent cohort of otherwise similar normal subjects for
longitudinal comparison to the CAMP cohort, there are three populations with non-asthmatic subsets
of subjects that can be separately compared with the mild-to-moderate asthmatics in CAMP to define
consistent abnormal patterns of growth and decline of lung function within the 20-30 year old age
range of CAMPCS/3: Vlagtwedde/Vlaardingen (4, 30, 41, 42), NHANES III (73), and CARDIA (13).
Sensitivity analyses using three relevant and generalizable control groups will define the range of
effects of persistent asthma on abnormal patterns of growth and decline in lung function.

Backgrd
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CAMPCS/3 Protocol
2.6.
2. Background
Rationale
As shown in the accompanying figure, there are several patterns by which individuals acquire
fixed airflow obstruction as adults: (1) reduced lung function growth, (2) early decline, or (3) rapid
decline, or (4) some combination of (1), (2), and (3). No study has addressed the impact of persistent
asthma on abnormalities in lung growth and decline in early adulthood or defined determinants of
these abnormalities among persistent
asthmatics. In fact, the information on the
natural history of childhood asthma available in
the literature is sparse. Although others have
followed large cohorts of asthmatics, these
studies are in the pre-ICS era, do not take into
account treatment, and do not have the size or
completeness of CAMP to assess the relevant
questions; additionally, others have studied
individuals contained within birth cohorts with
wheeze or asthma diagnosis who had mild or
intermittent disease and thus were unable to
address issues that arise from more persistent
disease. Information on genetics of asthma is
expanding at an exponential rate. Linking the
extensive genetic information available on
CAMP individuals with the thorough phenotype information obtained over the 15-17 years of followup offers significant opportunity to understand more completely the role of candidate genes in this
disease. The effects of CAMP treatment on asthma outcomes has already provided information to
help practicing physicians with their uncertainties regarding the effect of long-term treatment on
outcome of the disease (both symptoms and growth of the lung) and on somatic growth. Practicing
physicians continue to need information that can come only from a longer-term follow-up of the
CAMP cohort. The NAEPP Guidelines have provided a basis of treatment, but their authors
acknowledged many areas in which evidence is lacking, including the continued questions and
controversies regarding treatment in children due to the lack of long-term, prospective studies. The
data obtained in CAMPCS/3 will provide answers to these questions and better evidence on which to
base future recommendations, including long-term effects of early and continuous anti-inflammatory
therapy and appropriate methods to track changes in pulmonary function to monitor asthma
progression. The concept of careful tracking for patterns of changes over time when following
patients with asthma is new, and could be a critical tool in assessing early signs of chronic airflow
obstruction and for evaluating response to treatments designed to prevent or resolve asthma
progression.

Backgrd
11
CAMPCS/3 Protocol
3. Preliminary data
3.1.
CAMP phases
Study of the CAMP cohort has occurred in 3 phases: CAMP (trial), CAMPCS
(observational study, 1st phase), and CAMPCS/2 (observational study, 2nd phase). During the CAMP
trial, we studied 1041 children with mild to moderate persistent asthma in a clinical trial to determine
if lung growth, as assessed by the change in FEV1, improved with regular use of inhaled antiinflammatory agents over a 4-6 year period. CAMP children were aged 5-13 years at randomization
(5-12 at initial screening) and from 8 clinics across the United States and Canada. 60% were male,
and 32% were from minority populations. Median age at asthma onset was 2.5 years. 41% had at
least one parent with a diagnosis of asthma, and 88% were atopic with at least one positive skin test.
During a 28-day interval on bronchodilator only before randomization, there were, on average, 18
days with asthma symptoms or a peak flow <80% personal best. 30% of children were living in
homes with a smoking parent and 70% reported having pets. These data document the
representativeness of the CAMP sample and the relatively frequent environmental exposure and
prevalence of atopy. The patients had completed an average of 4.3 years (range, 3.5-5.5) of followup as of the end of the trial. Only 5% of patients had missed more than 2 study visits in a row. Of
the 1,371,018 diary days expected during the CAMP trial, 93% were returned and, of those returned,
88% had data. We reported in the New England Journal of Medicine in 2000 (57) that neither
budesonide (an inhaled corticosteroid) nor nedocromil (an inhaled non-steroid) was better than
placebo in terms of lung function, but inhaled budesonide improved airway responsiveness and
provided better control of asthma than placebo or nedocromil. The side effects of budesonide were
limited to a small, but significant reduction in growth that occurred during the first year of treatment
without further effect.
The observational phase, known as the CAMP Continuation Study (CAMPCS), began in 1999.
During the initial phase of observational followup, we successfully followed 90% of the children
randomized in CAMP, with mean time of follow-up since randomization of 9.2 years as of the close
of CAMPCS and missed visit rate of only 2%. In CAMPCS we focused on the effects of the initial
4-6 years of anti-inflammatory therapy on the rate of increase of maximal level of lung function,
height, bone density, airway responsiveness, and occurrence, relapse, or remission of respiratory
symptoms. 5,378 clinic visits and 5,100 telephone visits were completed in CAMPCS, with postbronchodilator FEV1 obtained at 94% of spirometry visits, and FEV1PC20 obtained at 87% of
methacholine visits. Quality grades for spirometry and methacholine challenges were as high as or
higher in CAMPCS than in CAMP (3.9 for spirometry, 3.8 for methacholine, on a scale of 0-4). The
missed visit rate in CAMPCS was 0.01 missed visits per 6 months of follow-up. 23 (2.5%) patients
missed 1 or more in-person visits.

Prelimin
12
CAMPCS/3 Protocol
3. Preliminary data
3.1. CAMP phases
The 2nd phase of the observational followup (CAMPCS/2) began in May 2004. 879 (84%) of
the original cohort of 1041 children participated in CAMPCS/2. 4029 in person visits and 4250
telephone visits were completed.
3.2.
Preliminary data from CAMP, CAMPCS, and CAMPCS/2

3.2.1.
Ages of participants
By the end of CAMPCS/2 in 2007,

participants were age 17-26 years, and 62%
of females and 59% of males were 21 years
of age or older (Figure). By the end of the
proposed CAMPCS/3 in 2011, all
participants will be at least 20 years of age,
with over 50% of the cohort at least 25 years
old. This will allow analyses that will clearly
answer many remaining questions on effects
of asthma and its treatment on maximal
growth of the lungs and assess the roles of
other factors such as inflammatory markers
(allergy skin test positivity, serum IgE level, and peripheral blood eosinophilia) and environmental
exposure on lung and somatic growth.
3.2.2.
Determination of lung function and airway responsiveness (Specific Aims 14)
In CAMP and CAMPCS, spirometry was done pre- and post-BD at least annually and pre-BD
before methacholine annually. In CAMPCS/2, spirometry was done pre- and post-BD annually and
an additional time (pre-BD) before methacholine testing. CAMP-certified pulmonary function
technicians performed tests of airway responsiveness to methacholine using a modified Chai protocol
with the Wright nebulizer-tidal breathing technique (74). In CAMP and CAMPCS, airway
responsiveness was determined annually. In CAMPCS/2, airway responsiveness was measured once,
during year 3 or year 4.
3.2.3.
Determination of inflammatory-related phenotypes (Specific Aims 1, 3, and

4)
Skin prick testing with a core battery of antigens (D pteronyssus, D farinae, cat, dog, American
cockroach, German cockroach, Penicillium mix, Aspergillus mix, Timothy grass, and short ragweed),
as well as a clinic-specific battery of locally relevant antigens, was performed twice in CAMP and

Prelimin
13
CAMPCS/3 Protocol
3. Preliminary data
3.2. Preliminary Data from CAMP, CAMPCS, and CAMPCS/2

3.2.3. Determination of inflammatory-related phenotypes (Specific Aims 1, 3, and 4)
once in CAMPCS, in accordance with the CAMP skin test protocol (75). Total serum IgE was
performed by the DACI Laboratory at Johns Hopkins University, using standard
radioimmunoabsorbant testing twice in both CAMP and CAMPCS and once by the local clinic
laboratory during CAMPCS/2. Peripheral blood eosinophil count was measured by the local clinic
laboratory twice in both CAMP and CAMPCS and once in CAMPCS/2.
3.2.4.
Personal smoking in CAMP participants (Specific Aim 1)
There has been a substantial increase in cigarette smoking during CAMPCS/2 as patients have
become older, with 21% currently smoking or reported smoking on at least one interim history form,
with onset of starting smoking at age 17.0 +/- 2.1 years (mean +/-SD). These percentages are
comparable to national rates (76). We also have data on maternal-reported smoking in utero and
during the first 2 years of life from the original CAMP data for use in analyses of effects of these
exposures on lung function growth and decline.
3.2.5.
Asthma symptoms/morbidity and medication use (Specific Aim 1)
During CAMP, patients recorded daily symptoms, exacerbations requiring prednisone for
rescue, and physician contacts because of asthma via daily diary. During CAMPCS and CAMPCS/2,
patients were interviewed during clinic visits and twice yearly phone visits about symptoms and
medications used in the 7 days prior to the interview, as well as other types of asthma medication (eg,
prednisone) used since the last interview, and health care utilization for asthma. Information on
nasal steroid use was also recorded. Asthma morbidity has been assessed by: 1) numbers of times
that a physician or a physician's office was telephoned because of asthma symptoms, that the patient
was seen at a physician's office because of asthma symptoms, that the patient was seen at an
emergency department or urgent care facility because of asthma symptoms, and that the patient was
hospitalized overnight because of asthma symptoms; 2) number of days the patient was absent from
school or work because of asthma symptoms; 3) numbers of times in the past 7 days the patient
awakened during the night because of asthma, used albuterol because of asthma symptoms or low
peak flow, or used albuterol for preventive use before exercise; and 4) frequency of coughing,
congestion, and wheezing and association with colds and exercise.
3.2.6.
Environmental measures
House dust was collected by a standardized protocol for quantitative measurements of major
allergens (D pteronyssus, D farinae, cat, dog, and cockroach) once in the first 6 months of CAMP
and a second time after the 3 year visit. Questions about the environment have been asked at each
visit in CAMP, CAMPCS, and CAMPCS/2 using the same questionnaire. The detailed
environmental data from early in CAMP will be used in analyses to examine effects of early life
exposures in later life on maximally attained lung function. Relationships to other clinical
characteristics will also be explored.
Prelimin
14
CAMPCS/3 Protocol
3. Preliminary data
3.2. Preliminary Data from CAMP, CAMPCS, and CAMPCS/2
3.2.7.
Patterns of growth and decline of lung function (Specific Aim 4,

Hypothesis 5)
Data from the 44 CAMP participants age 23 or older were plotted with data from NHANES III
(73) participants of the same sex and height (prebronchodilator for both CAMP and NHANES
III). Four typical patterns are apparent (see
Figure for examples from 4 patients): 1) Normal
growth, no decline (32% of participants had this
pattern), 2) Reduced growth (27%), 3)
Normal growth then early decline (14%),
and 4) Reduced growth, then early decline
(27%). Overall, 41% (16 of 44) of the
participants in this small subset have already
started to decline -- an extremely abnormal
pattern of lung function growth.
3.2.8.
Somatic Growth (Specific Aim 3)
Linear growth was assessed 3 times per year in CAMP, 2 times per year in CAMPCS, and once
per year in CAMPCS/2 (twice during the year when methacholine was done).
3.2.9.
Preliminary data on genetic polymorphisms and lung function (Specific

Aims 2 and 4)
The CAMP Genetics Ancillary Study Group has developed an approach to the multiple
comparisons problem of looking at multiple SNPS and genes. Recently, the Family Based
Association Test (FBAT)-approach has also been shown to be applicable to genome-wide association
studies (77), outperforming standard multiple testing approaches such as FDR (78-80) by factors up
to 40. Its application to a 100K-scan of the Framingham Heart Study revealed only the replicated
association for BMI so far (81). We have utilized the screening algorithm of Lange and Van Steen
(77, 82, 83) to generate preliminary data on the genetic determinants of FEV 1/FVC ratio for this
grant application. This algorithm, which will serve a vital role in the proposed candidate gene
evaluation, begins with estimation of the conditional power of the FBAT statistic, which depends on
the effect size, all parental genotypes, and all phenotypic values (84). SNPs with highest conditional
power are used for the subsequent FBAT testing, which is independent of the screening step. Thus,
only SNPs with reasonable power are used for subsequent family-based analysis; SNPs with low
power increase the multiple testing problem with minimal chance of demonstrating association. For
Prelimin
15
CAMPCS/3 Protocol
3. Preliminary data
3.2. CAMP and CAMPCS performance
3.2.9. Preliminary data on genetic polymorphisms and lung function
this application we performed a preliminary analysis of our first 168 genes in CAMP to determine
which, if any, were significantly related to FEV1 /FVC ratio. Four genes, DPP10, GPRA, PTH11 and
SERPINE2, all had multiple SNPs significantly associated with FEV1/FVC in CAMP.

Prelimin
16
CAMPCS/3 Protocol
4. Methods
4.1.
Overview of CAMPCS/3
CAMPCS/3 is designed as an extension of CAMPCS/2, which was an extension of CAMPCS,

which was an extension of the transition phase of CAMP. The CAMP trial concluded with a
transition phase, a 4-month period when study medication was withdrawn and children were
monitored for lung function, airway responsiveness, growth, and asthma control. At the end of the
transition phase, care for asthma was transferred to the physician who cared for the child prior to
enrollment in CAMP. The CAMP study physician provided recommendations for asthma care to the
family and the physician at this time. In CAMPCS/3, we are continuing followup and monitoring
after the transfer of care. While the participants physician administers care, the CAMPCS/3
physician will provide recommendations and is a resource for advice about asthma care.
All CAMP participants are eligible to enroll in CAMPCS/3, including those who did not
participate in CAMPCS or CAMPCS/2. We anticipate that 80% or more of those participating in
CAMP will enroll in CAMPCS/3. Thus, we expect to have 830 participants in CAMPCS/3, aged 1726 years, of whom 1/4 to 1/3 will be minority.
CAMPCS/3 will be a multicenter, cohort observational study with treatment for asthma
managed by the participants physician. Recommendations for treatment in accordance with
National Asthma Education and Prevention Program Expert Panel Report (NAEPP Guidelines) will
be provided to the family and, if permitted by the family, to the child's physician. While the
provision of medications was a benefit to patients during CAMP, we know from CAMPCS and
CAMPCS/2 that lack of provision of medications will not be a major deterrent to participation. The
bond between staff and patients is very strong, and many of the CAMP/CAMPCS/CAMPCS/2
physicians are the patients' asthma physicians to whom care was "transferred" following the close of
CAMP.
CAMPCS/3 visits with patients will begin on 1 January 2008 and end on 31 March 2012.
Patients will have one clinic visit each calendar year starting on 1 January 2008. In 2012, the clinic
visits will be completed by 31 March 2012. These will all be spirometry visits. Patients will have
one additional visit for methacholine testing between 01 July 2008 and 31 March 2012. The
CAMPCS/3 visits will allow patients and families to sustain the contact with the CAMP staff and
will provide the reassurance of a second opinion on the asthma care received, while reducing the
obligations of participation. The proposed data collection schedule is presented in Appendix 5.2.
The centers participating in CAMPCS/3 include the 8 clinics, the Data Coordinating Center
(DCC), and the NHLBI project office. The Genetics Ancillary Study, initiated during CAMP, will
continue with analysis of the DNA collected previously and will correlate the genotypic data with
phenotypic data collected in CAMPCS/3.

M ethodsCS3
17
CAMPCS/3 Protocol
4.2.
4. Methods
Consent and recruitment in CAMPCS/3
CAMPCS/3 participants may be as young as age 17 at enrollment. Consent and assent

statements will be used in CAMPCS/3 as required by each clinics IRB and their definition of
adulthood. If a participant is considered not of an age to provide consent, the participants parent or
guardian will be required to sign the consent statement for the participant to enroll in CAMPCS/3.
The consent statement will specify the purpose of CAMPCS/3, the general design, the expected
duration of the study, the data collection procedures and schedule, the risks and benefits associated
with participation, the protections against risks, the alternatives to participation, the incentives to be
provided, and the protections for confidentiality of the data provided by the patient and family. The
assent statement will provide similar information in an age appropriate fashion. As in previous
phases, prototype consent and assent statements will be developed and distributed to clinics, with the
understanding that information thought to be essential to informed consent may not be deleted. IRB
approval of the CAMPCS/3 protocol and consent and assent statements will be required at a clinic
before patient activities may begin at the clinic. The DCC will collect copies of all approved consent
and assent statements and will review them for completeness of information. The DCC will monitor
for initial IRB approval at each center and annual renewal of approval, as has been done in CAMP,
CAMPCS, and CAMPCS/2. The only exclusion criterion for participation in CAMPCS/3 is refusal.
4.3.
Patient contact schedule and content of visits
The four yearly patient visits will be timed around the anniversary of the patients
randomization in CAMP. Visit procedures will include spirometry, height and weight measurements,
and interim health history and environmental exposures interview. There will be a fifth visit for
methacholine testing that may be scheduled for any date during the latter half of year 1 through year
4.
One week prior to each clinic visit, the study coordinator will contact the patient to remind the
patient to bring all medications prescribed or in use for asthma to the visit, and to arrange for holding
short-acting bronchodilator for 4 hours and long-acting bronchodilator for 12-24 hours before the
visit.
At each visit patients will be queried about asthma medications taken in the past 7 days in detail
(medication taken, dose, and number of doses taken) and types of asthma medication used since the
last interview. Use of medications for other problems will also be recorded. Questions about chest
symptoms, upper airway symptoms and treatment (rhinitis and sinusitis), and tobacco smoke and
other environmental exposures will be asked. Pregnancy history will be queried since pregnancy
may affect lung function assessment. Height and weight will be measured at each in-person visit.
At each clinic visit, symptoms and medication use will be used to recommend treatment in
accordance with the NAEPP Guidelines to be used until the next clinic visit. The treatment
recommendation will be transmitted to the asthma care physician via a letter to be sent after each
M ethodsCS3
18
CAMPCS/3 Protocol
4. Methods
4.3. Patient contact schedule and content of visits
visit (if the patient has given permission for release of his/her information to the primary asthma care
physician). This letter will also transmit information about the results of the pulmonary function
tests and any information about the interval clinical course.
4.4.
Measurement and assessment methods

4.4.1.
Pre- and post-BD FEV1 and FEV1 /FVC ratio
Rationale: FEV1 , a stable phenotype, is highly predictive of asthmatic attacks, is correlated

with airway responsiveness and bronchodilator response, and predicts asthma severity. FEV1/FVC
ratio decreases as a consequence of lung growth. Lower than normal ratios are thought to represent
the degree of airflow obstruction in asthma and can be used to represent exaggeration of dysanapsis
caused by asthma. Airflow obstruction, assessed by pulmonary function testing, is one of the
defining characteristics of subjects with bronchial asthma. Therefore, spirometric measures,
including FEV1 and FEV1/FVC, are essential physiologic phenotypes in the study of potential genetic
influences in the development of bronchial asthma (116). Data collection: Spirometry will be
assessed by methods used in CAMP (117). Spirometry is carried out by study-certified pulmonary
function technicians. Pre-bronchodilator spirometry is performed at least 4 hours after the last use of
a short-acting bronchodilator and 12-24 hours after the last use of a long-acting bronchodilator. In
CAMPCS/3 spirometry will be measured pre- and post-bronchodilator during years 1-4 and prebronchodilator before the methacholine challenge.
4.4.2.
Airway responsiveness
Rationale: The definition of asthma clearly emphasizes the central role of increased airway
responsiveness. Characterization of asthma severity requires methods to ascertain this phenotypic
trait (116). Data collection: Study-certified pulmonary function technicians perform tests of airway
responsiveness to methacholine using a modified Chai protocol with the Wright nebulizer-tidal
breathing technique (117). In CAMPCS/3 airway responsiveness will be measured one time only, to
decrease participant burden and cost.
To minimize the effects of various factors and the course of asthma on methacholine
responsiveness, determinations will not be made within 4 weeks of use of oral steroids for an asthma
exacerbation, within 4 hours after the last use of a short-acting bronchodilator and 12-24 hours after
the last use of a long-acting bronchodilator, or if the FEV1 at baseline is less than 70% of predicted.
Patients will be screened for other contraindications to performance of methacholine challenge prior
to initiation of the challenge. If the patient has had a upper respiratory infection in the previous 4
weeks, this is noted on the form. If the patient has consumed caffeine within 4 hours of the
methacholine challenge, the test is done and the consumption of caffeine is noted on the form. Effort
will be made to do methacholine challenge testing on any one patient at the same time of day as the
M ethodsCS3
19
CAMPCS/3 Protocol
4. Methods
4.4 Measurement and assessment methods
4.4.2 Airway responsiveness
child was assessed in CAMP, CAMPCS, and CAMPCS/2; the time the test ended will be noted on
the form. Two 90 g puffs of albuterol will be administered after methacholine challenge testing if
the FEV1 is less than 90% of pre-diluent baseline. The patient will not be allowed to leave until the
FEV1 is at least 90% of baseline. Methacholine solutions will be prepared at each clinic with
Provocholine and according to the package insert for Provocholine.
4.4.3.
Somatic growth
Rationale: Linear growth is an important outcome of asthma. Results in the literature are
mixed, and no study using randomized assignment to ICS and placebo has followed patients
longitudinally into adulthood. Data collection: A protocol was established in CAMP to standardize
measurement of height and weight (117). Standing height is measured with the Harpenden
stadiometer (Holtain model #602 or #603). Weight is measured with the Detecto scale (model #337)
with the patient wearing light clothing and socks or barefoot. In CAMPCS/3 linear growth will be
assessed at each clinic visit.
4.4.4.
Symptoms/morbidity and medication use
Rationale: Need for medication to control asthma symptoms is an important outcome as well
as a modifier of the clinical course, and is needed as a covariate of all outcomes of the study. Data
collection: During CAMP patients collected information on symptoms, exacerbations requiring
prednisone, physician contacts, urgent care visits, and hospitalizations for asthma via daily diaries
and/or interviews during visits. During CAMPCS and CAMPCS/2, patients were interviewed during
clinic and telephone visits to determine symptoms and medications used (dose and number of doses
taken) in the 7 days prior to the interview, as well as all types of asthma medication used since the
last interview. The same questions used in CAMPCS/2 will be used in CAMPCS/3. Questions about
what the patient is taking will be asked in a nonjudgmental manner. Use of prednisone since the last
contact will be queried. Information on nasal steroid use since the last contact will be recorded.
Morbidity will be assessed as follows: 1) by contact with a physician: numbers of times that a
physician or a physician's office was telephoned because of asthma symptoms, that the patient was
seen at a physician's office because of asthma symptoms, that the patient was seen at an emergency
department or urgent care facility because of asthma symptoms, and that the patient was hospitalized
overnight because of asthma symptoms (these are answered with the number of relevant events in the
interval since the last interview); 2) by absence from school or work: number of days the patient was
absent from school or work because of asthma symptoms (these are answered with the number of
relevant events in the interval since the last interview; 3) by asthma symptoms: how many times in
the past 7 days the patient awakened during the night because of asthma, used albuterol because of
asthma symptoms or low peak flow, used albuterol for preventive use before exercise; and 4) by
symptoms precipitated by upper respiratory infections and exercise: questions about coughing,
congestion, and wheezing (frequency and association with colds and exercise).
M ethodsCS3
20
CAMPCS/3 Protocol
4. Methods
4.4 Measurement and assessment methods
4.4.5.
Environmental measures
Rationale: Environmental exposures to allergens, particularly those to which the individual

patient is sensitized, and irritants are know to affect the course of asthma. Careful collection of these
exposures over time will also allow studies of gene-by-environment. Data collection: A home
environmental questionnaire was administered at CAMP baseline and annually thereafter throughout
CAMP, CAMPCS, and CAMPCS/2. Questions from this form relating to household dust, heating
systems, and other environmental factors will be asked at each CAMPCS/3 visit. The interview will
also cover use of tobacco cigarettes, pipes or cigars by the patient and second hand exposure to
tobacco smoke.
4.4.6.
Atopy related phenotypes
Rationale: Atopy or allergy is a source of airway inflammation in asthma. Skin test reactivity
to aeroallergens is correlated cross-sectionally with serum total and allergen-specific IgE levels,
airway responsiveness, and asthma symptoms. In addition, it predicts subsequent decline in FEV 1 in
older adults (118). Various studies have demonstrated that serum total IgE is correlated with asthma
and airway responsiveness (119-121). Eosinophils may play a major role in the development of
airway inflammation and bronchial damage in asthmatic subjects (122). Peripheral blood
eosinophilia is known to be associated with increased airway responsiveness and higher serum total
IgE levels (122). Data collection: Presence of eczema will be queried at each visit as will presence
of upper airway disease. Questions to assess the frequency and severity of nasal symptoms are
derived from rhinitis and sinusitis quality of life and symptom questionnaires published by Juniper
and colleagues (124-126), Bousquet et al (127), Gliklich and Metson (128, 129), Benninger and
Senior (130), questionnaires used in the International Study of Asthma and Allergies in Childhood
(ISAAC) and the Health Survey for Pediatric Asthma Patients in NHANES IV).
4.4.7.
Pregnancy history
Rationale: Pregnancy can affect lung function and body mass index. Data collection: Since
information on pregnancy was not collected in prior phases of CAMP, each female participant will
be queried about past pregnancies (delivery dates) upon enrollment in CAMPCS/3. Participants will
be queried about delivery dates since the last contact at subsequent visits and will be queried about
current pregnancy at each spirometry session. Pregnancy is a contraindication for methacholine
challenge; female participants are also queried about pregnancy prior to initiation of the
methacholine challenge
4.5.
Patient retention
In informal discussions, patients have indicated that the bond with the study coordinators and
physicians is the most important reason for staying with CAMP, CAMPCS, and CAMPCS/2. We
plan to continue the $100 incentive per clinic visit for the participants in CAMPCS/3, as participants
M ethodsCS3
21
CAMPCS/3 Protocol
4. Methods
4.5. Patient retention
will be older, and many will be in college and/or have children of their own. Parents and the older
participants have responded enthusiastically to education and updating on new information on
asthma, particularly its treatment but also its pathophysiology. Education and information about
asthma will be provided during the CAMPCS/3 visits. Throughout CAMP, CAMPCS, and
CAMPCS/2, a few participants have required financial assistance to return for annual visits for data
collection after moves away from the CAMP clinic area.
4.6.
Data management for clinical data
A web based database management system patterned after the distributed database management
system used successfully in CAMP, CAMPCS, CAMPCS/2 will be used in CAMPCS/3. The
CAMP, CAMPCS, CAMPCS/2, and CAMPCS/3 databases will be maintained in separate but easily
combinable databases. The data system for CAMPCS/3 will continue to have 2 components: the
clinic data system and the clinic spirometry system. The major functions of the CAMPCS/3 data
system will be:
1.
2.
3.
4.
5.
6.
Patient registration into CAMPCS/3

Data entry of forms
Inventory of forms and visits keyed for each patient
Database backup (daily, weekly, monthly)
Generation of clinic management aids (labels, visit time windows guide, reminders of
upcoming and overdue visits)
Printing sets of blank case-report forms
The key features of the entry process include:

1.
2.
3.
4.
5.
6.
7.
8.
9.
Double entry of all data items

Checks on patient identifiers
Range checking on all items on entry
Within-form consistency and logic checks on entry
Data entry screens customized to the forms
100% electronic audit trail of all entries, changes, and deletions to the database
Additional monthly consistency checks (with follow-up) done centrally at the CC
Monthly audits a sample of forms and error-rate tracking over time for each clinic
Monthly performance reports by clinic sent to all clinics
A dedicated spirometry system will be used in CAMPCS/3. FEV 1, FVC, FEV 1/FVC ratio will
be recorded. A written report of the spirometry or methacholine challenge session is printed at the
close of the testing session.

M ethodsCS3
22
CAMPCS/3 Protocol
4.7.
4. Methods
Data management for genetic studies

4.7.1.
Bioinformatics management system (ORAGEN)
A bioinformatics management system (ORAGEN) has been developed b y the Genetics

Ancillary Study Group to handle their data for genetic studies. The ORAGEN application is
presently used to track genealogical and lab-management data for their ongoing genetic studies. This
application was written in Visual Basic, using the ORACLE database engine to manage relational
data items. By relying on a robust and relational data structure, the ORAGEN application can easily
manage and manipulate large quantities of phenotypic and genotypic data.
4.7.2.
Management of genotypic data
Under the CAMP Genetics Ancillary Study protocol, blood samples collected in the CAMP
cohort for DNA extraction were shipped to the Channing Laboratory where they were processed.
Once samples were logged into the ORAGEN system, the system printed labels with unique barcodes
assigned to each subject. Thus, processed specimens stored at the Channing Laboratory are not
identified by name and do not have any of the original identifiers. At the Channing Laboratory, only
authorized personnel are able to link these unique barcodes to a 12-digit ID number assigned to each
study participant. Only the Principal Investigator can link this 12-digit ID number to the original
identifier. After DNA was extracted, DNA aliquots were labeled with new unique barcodes and
stored prior to genotyping.
Genotypic data have been carefully checked for errors and inconsistencies. Genotypes were
assigned using semi-automated fluorescence scanning with the ABI GENESCAN/GENOTYPER
software (Perkin-Elmer, Inc.). A random sample of 5% of any candidate gene genotyping performed
at the Channing Laboratory will be redone at an independent laboratory to assure consistency and
quality. The Channing Laboratory averages 1% discordancy on their genotype data and has 91-95%
completeness for all the SNP's in their candidate genes.
4.7.3.
Management of phenotype data
The CAMP phenotypic data were incorporated into the GENERATIONS system via
intermediate ASCII data files. These data files can be read directly into statistical programs such as
SAS or exported in formats such as MLINK that are commonly used in statistical genetics. No
individual identifying information on CAMP subjects is available at the Channing Laboratory; only
the CAMP study identification number is used in the GENERATIONS system.
4.8.
Quality assurance
The quality assurance procedures used in CAMP, CAMPCS, CAMPCS/2 will be replicated in
CAMPCS/3. These are:
Certification of data collectors (e.g., clinic coordinator, pulmonary function technician, study
physician, data entry technician); requirements for certification include practice with the
procedure, completion of practice data collection forms, test of general knowledge of

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4. Methods
4.8. Quality assurance
CAMPCS/3 protocol, reading of study manuals, and signature of a statement agreeing to

abide by CAMPCS/3 protocol and acknowledging the need for accuracy and integrity in
completion of study tasks and for preserving the confidentiality of the study and patient
data.
Certification of clinics prior to initiation of data collection
Ongoing feedback on performance in the form of monthly reports and review of performance
at study meetings
Ongoing review of data collection forms by DCC staff and comparison of paper forms to
keyed data with feedback regarding and correction of discrepancies
Double entry of data collection forms
Range checking during data entry and periodic batch editing to cover more complex checks of
consistency and completeness of the keyed data
Periodic discussions at study meetings as to the importance of integrity in this or any other
research effort
System specific and appropriate quality control procedures
The data forms and data system will be designed to exclude transmission of name and other
personal identifiers to the DCC. Records will be identified by the CAMP ID number and code. Only
these identifiers will be used in edit messages and correspondence with clinics concerning individual
patients. Any forms received at the DCC (e.g., for quality control purposes) will be stored in a
secure monitored area, with access limited to DCC personnel.
Backup copies of the central master data file and program libraries will be generated at regular
intervals. These backup files will be stored in a secure location, remote from the DCC, to permit
regeneration of the master file, should it be destroyed by a computer malfunction, programmer error,
fire, or vandalism.
4.9.
Data monitoring
NHLBI will appoint an observational data and safety monitoring board for CAMPCS/3. The
board will meet annually to review the performance of CAMPCS/3 and any safety issues that may
arise. The board will review serious adverse events reported by the clinical centers.
Reports summarizing performance will be prepared at regular intervals by the DCC for
distribution to and review by clinic staff, the Steering Committee, and the data monitoring board.
The reports prepared will include a variety of tabulations which have been useful in CAMP,
CAMPCS, and CAMPCS/2. Analyses will be performed comparing the clinics regarding rate of
patient recruitment, completion of visits, and number of data collection deficiencies. Assessment of
changes in performance will be based on comparisons within clinic involving, for example a
comparison of the rate of data collection deficiencies in the most recent time period contrasted with
rates observed in earlier time periods. While an overemphasis on competition can lead to problems,
it has proven useful for investigators to know the standing of their centers, relative to others, with
respect to the quantity and quality of the data supplied. Besides improving data quality, these reports
also help maintain the sense of being part of a team with a common goal.

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CAMPCS/3 Protocol
4.10.
4. Methods
Human subjects
4.10.1.
Characteristics of the proposed study population
The CAMP study population includes 1041 patients with mild to moderate asthma of whom
1035 survive. Patients were age 5-12 at initiation of screening for CAMP. As of 31 July 2007 (close
of CAMPCS/2 patient visits), patients were age 17-26. 60% of the trial participants are male and
40% are female. There are 13.1% African American participants, 9.5% Hispanic, 68.4% white, and
9.0% other.
We expect that 80-85% patients enrolled in CAMP will enroll in CAMPCS/3. All clinical
centers have plans to invite CAMPCS/2 enrollees as well as CAMP patients who did not enroll in
CAMPCS or CAMPCS/2 to enroll in CAMPCS/3.
4.10.2.
Sources of research material
Data collected in CAMPCS/3 will be obtained by questionnaire, pulmonary function testing, and
height and weight measurements.
4.10.3.
Protection of human subjects
Protections for human subjects will include the consent process, linkage of patient records by ID
number (name will be known only to clinic staff), and procedures for reporting and reviewing
adverse events.
Consent. Written consent will be obtained from the participant if the participant is considered
of an age to provide consent per the local institutions definitions; written consent will be obtained
from the parent and assent from the participant will be obtained if the participant is considered not of
an age to provide consent. The goal of the consent process will be to provide each person
approached with sufficient time and information to make informed decisions about participation in
CAMPCS/3. The cornerstone for research on human beings is voluntary consent based on accurate
information. The consent process is one of the more important patient-investigator activities
because, if done properly, it serves not only to inform but also as a bonding experience. The bonding
process is of particular importance in studies where participation extends over a period of years.
Adverse event monitoring. Although CAMPCS/3 will be an observational study with
treatment managed by the patient's personal asthma care provider, the study will have a policy and
procedure for reporting adverse events. The policy used in CAMPCS/2 is to report all serious
adverse experiences judged by a study physician to be associated or possibly associated with the
patient's prior treatment with CAMP study medication and all other serious, adverse events (e.g.,
death, intubation, life-threatening asthma exacerbation, or other life-threatening event). Events are
reported to the DCC via narrative and the adverse event data collection form. The reports are then
forwarded by the DCC to the clinics, the study chair, and the NHLBI project officer, with
instructions to the clinics to submit the reports to their IRB as required by their institution. The
reports are also forwarded to the data and safety monitoring board with a ballot asking each member

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CAMPCS/3 Protocol
4. Methods
4.10.3. Protection of human subjects
to vote whether the event should be discussed in an immediate conference call or deferred until the
next in person meeting of the board.
Confidentiality. Patients will be identified by ID number and code in the study database.
Name will be known only to the clinic. The CAMP, CAMPCS, and CAMPCS/2 databases do not
include patient identifiers except ID number and code; this policy will continue in CAMPCS/3.
Clinics will be required to keep patient forms and other records in locking file cabinets or in a locked
room used only by CAMPCS/3 staff.
4.11.
Data analysis
4.11.1.
General approach
Since the CAMPCS/3 data will come from continued, long-term observation of the original trial
cohort, generalized linear regression models for the analysis of longitudinal data with continuous,
binary, and event count response variables will be required to combine data across all phases of
follow-up to address the Specific Aims for CAMPCS/3 (95). The choice of response and
explanatory variables will vary depending on the Specific Aim; these choices are outlined below.
Other, specialized methods are required for Specific Aim 2, Hypothesis 3 (genetics) and are
discussed in section 4.11.5.
Spirometry measures for use in Specific Aims 1-3 will be maximally attained lung function
measured after bronchodilator administration. For Specific Aim 4, CAMP values before
bronchodilator will be used for comparison to the normal control values, as normal control values are
available only without bronchodilator reversibility.
Depending on the Specific Aim, the data from the approximately m= 874 CAMPCS/3
participants can be expressed as yij and xijk, where yij is the applicable response measure and x ijk is the
value for the kth of p explanatory variables (predictors) on the ith participant at the jth time of
measurement out of ni repeated measurements on the ith participant. We will assume that continuous
response measures, such as FEV 1, FVC, FEV 1/FVC ratio, maximally attained FEV 1 and FVC,
log(FEV1 PC20 ), height, and height velocity, follow a linear regression model:
yij = 0 + 1 xij1 + 2 xij2 + + p xijp + ij
where gij are normally distributed errors associated with the ith measure at the jth time. When ni $ 2,
the responses will be correlated due to repeated measures on the same participant, which requires
special regression methods to determine SEs and P-values accurately. We will use generalized
estimating equations with robust variance estimation (GEE) for this purpose. In some cases, e.g., for
response measures expressed as change from baseline to the last available measure in young
adulthood, ni =1 and the usual regression models may be used, although we will also use GEE in this
case, since it offers the advantage of robust variance estimation. These models are very flexible and
can be extended to include interaction terms needed to compare patterns of response between 2 or
more groups across age, using regression spline terms to model complex age effects on response.

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CAMPCS/3 Protocol
4. Methods
4.11. Data analysis
4.11.1. General approach
For responses such as counts of asthma exacerbations or for binary responses such as remission
of asthma or not, we assume a generalized linear model regression applies where the mean response
E(yij)=ij is related to the explanatory variables by:
h(ij) = 0 + 1 x ij1 + 2 xij2 + + p xijp ,
where h(.) is a link function such as log for counts or logit for binary responses. The GEE
methodology can also be used to account for correlated responses in generalized linear regression
models. Primary analyses will use all individuals with sufficient data on the variables used for a
particular analysis. We expect that 80-85% of the original cohort of 1041 patients will be available
for use in analyses. While this is a high rate of follow-up for a cohort followed since 1993, we will
conduct additional, confirmatory analyses to assess the effects of missing data on inferences from the
primary analyses. We will use the definitions and methods described in Pothoff et al (101) to
perform approximate tests of whether the data are missing completely at random (MCAR) or missing
at random (MAR). We do not expect the data to be MCAR, so we will conduct sensitivity analyses
using both mixed random effect models and multiple imputation, which are still valid when the data
are not MCAR, but are MAR. It is possible that some data may be missing and non-ignorable -- the
probability that the data item is missing is related to the value of the data item. There is no way to
test for this, since the missing data items are not available; however, it is possible to conduct
sensitivity analyses making plausible (but untestable) assumptions using methods such as those in
Robins et al (103). For all key publications, we will follow the recommendations for handling
missing data in clinical trials given by Shih (102): (1) report frequency and reasons for missing data
by treatment or other major comparison groups, (2) conduct sensitivity analyses as outlined above
and discuss the implications of any discrepancies, found, (3) minimize missing data by maximizing
patient retention, (4) make efforts to bring in patients with missing data for a final assessment at the
end of follow-up, and (5) develop logistic regression models for the probability of missing data in
analysis as a function of variables in the analysis and of baseline characteristics.
4.11.2.
Measurement of steroid treatment
The steroid treatment during the CAMP trial and its subsequent phases will be used to control
for the effects of steroid treatment (oral and inhaled) on patterns of change in pulmonary function
with age for the natural history analyses to address Specific Aim 1, Hypotheses 1-2. Since sicker
asthmatics get more steroid medication (confounding by indication), controlling for the effects of
steroid treatment will allow examination of the net relationship between symptoms, allergy measures,
peripheral blood eosinophilia, airways responsiveness, and smoking on the natural history of the
disease. Since all analyses are time dependent with the relevant exposure to ICS treatment during the
interval before collection of outcome data, this information is obtained in sufficient detail in CAMP,
CAMPCS, CAMPCS/2 and CAMPCS/3 to allow us to aggregate over these time periods to get a
composite picture of the effect of ICS treatment on patterns of growth and decline of lung function.
In Specific Aim 3, Hypothesis 4, the primary analysis will be an intention-to-treat comparison
between ICS (budesonide) and placebo on attained maximal height and no adjustments for postrandomization treatment are appropriate. However, to help interpret any differences in attained
height, the steroid treatments in the two groups will also be compared. We do not expect differential

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CAMPCS/3 Protocol
4. Methods
4.11. Data analysis
4.11.2. Measurement of steroid treatment
use of steroid treatment to be an issue, since we know that steroid use has been similar between the
ICS and placebo arms in CAMPCS and CAMPCS/2.
4.11.3.
Analyses for Specific Aim 1, Hypothesis 1
The primary analysis for this aim will use multiple linear regression models for responses (1)
maximally attained lung function (FEV1 and FVC) during CAMPCS/3 and (2) progression of
obstruction at the time of maximally attained lung function (FEV1/FVC) in relation to explanatory
variables measured prior to the beginning of CAMPCS/3 and during CAMPCS/3: log FEV1PC20,
bronchodilator response, skin test results, IgE (above/below median), peripheral blood eosinophil
count and smoking exposure (personal and passive), height (at maximal maximally attained lung
function),height2 , gender, and ethnicity. Secondary analyses for Hypothesis 1, aimed at clarifying the
natural history lung growth and the progression of childhood asthma into young adulthood, will use
three longitudinal linear regression analyses of the full set of repeated measures since the beginning
of CAMP on three response variables (FEV1 (L), FVC (L), and FEV1/FVC in relation to the
explanatory variables log FEV1PC20, IgE (above/below median), peripheral blood eosinophil count
and personal smoking exposure, controlling for age (using regression splines per year of age), height
and height2 (the log FEV1PC20 response will not be controlled for the height terms), gender, and
ethnicity, and on-going (i.e., time-dependent) asthma treatments (ICS vs. no ICS with indicators for
other modalities). Effects and statistical significance will be determined by the regression coefficient
of the appropriate explanatory variable. Since all the explanatory variables of interest are timedependent, we will need to explore the appropriate lag-interval for relating the explanatory measures
to the response variables.
4.11.4.
The primary analysis for Hypothesis 2(a) will use multiple linear regression models for
responses (1) maximally attained lung function (FEV1 and FVC) during CAMPCS/3 and (2)
progression of obstruction at the time of maximally attained lung function (FEV1/FVC) in relation to
measures related to lower respiratory symptoms (average cough/wheeze score during CAMPCS/3
prior to the attained maximally attained lung function), controlling for explanatory variables
measured prior to the beginning of CAMPCS/3 and during CAMPCS/3: log FEV1PC20,
bronchodilator response, skin test results, IgE (above/below median), peripheral blood eosinophil
count and smoking exposure (personal and passive), height (at maximal maximally attained lung
function), height2 , gender, and ethnicity. Secondary analyses similar to those described for
Hypothesis 1 above will be done, adding time dependent symptom scores to the longitudinal linear
regression models. The primary analysis for Hypothesis 2(b) of this aim will use a multiple logistic
regression model of the odds of persistent symptomatic asthma, (according to NAEPP guidelines) at
the end of CAMPCS/3 in relation to explanatory variables measured prior to the beginning of
CAMPCS/3 and during CAMPCS/3: log FEV1PC20, bronchodilator response, skin test results, IgE
(above/below median), peripheral blood eosinophil count and smoking exposure (personal and
passive), height (at maximal maximally attained lung function), height2 , gender, and ethnicity.
Effects and statistical significance will be determined by the regression coefficient of the appropriate
explanatory variable. The same issues related to lag-intervals for the secondary analyses for
Hypothesis 1 apply to the secondary analyses for Hypothesis 2(a).
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CAMPCS/3 Protocol
4.11.5.
4. Methods
Risch and Merikangas have shown that association studies can be a very powerful approach for
finding genetic determinants of a complex disorder (96). Since CAMP has more than 700 family
trios with DNA, the use of family-based controls obviates the potential for false-positive associations
related to population structure. The transmission/disequilibrium test (TDT), which typically employs
genotypic data from affected individuals and their parents, provides a test of linkage and association
without bias from population stratification or admixture (97, 98). For family-based association
analysis of FEV1 , FVC, and FEV1 /FVC in CAMP trios, the SNPs will be evaluated for their
conditional power based on the conditional mean model approach by Lange (99). The SNPs will
then be ranked as discussed in the algorithm by Van Steen (2005) (77, 100). In order to fully
maximize the statistical power to detect true associations in the first stage of the testing strategy, as
in Herbert et al. (81), we will use the FBAT-PC approach (82) with the CAMP pulmonary function
data (longitudinal for both FEV1 , FVC, and FEV1 /FVC are available for 12 consecutive time points).
Using the conditional mean model (99), the FBAT-PC approach estimates the genetic effect sizes for
all repeated measurements and constructs an overall phenotype with maximal heritability. The
overall phenotype is tested for association using the FBAT-statistic. As a rule of thumb (82), the
overall phenotype constructed by the FBAT-PC approach has a single-SNP heritability that is about
the sum of the estimated heritabilities for each repeated measurement that is included in the FBATPC approach (82). For the spirometric phenotypes in CAMP, single SNP heritabilities in the range of
0.5%-1% are realistic estimates (82), and the overall FBAT-PC phenotype can be expected to be in
the range of [6%-12%] = [0.5%-1%]*12 measurements. In Herbert et al (81), the FBAT-PC
approach was able to extract sufficient power from just 5 repeated BMI-measurements so that
genome-wide significance could be established within one sub-sample of the Framingham Heart
Study that contained only 200 families with 624 genotyped family members. We will then test our
significant SNPs from the 550,000 for our three phenotypes (post-bronchodilator FEV 1, FVC, and
FEV1 /FVC) first in the Sepracor/EMGB case control population then in the remaining 394 CAMP
trios and finally in 600 trios from the recently refunded Asthma in Costa Rica R01 HL 066289 (ST
Weiss PI). This three stage replication strategy takes maximal advantage of different study designs
and multiple ethnicities to enhance the power of replication.
4.11.6.
To determine the effects of 3.5 to 5.5 years of randomly assigned ICS therapy started in
childhood, the primary regression analysis will be of the change from baseline to the last available
post bronchodilator FEV1 % predicted in CAMPCS/3 in relation to indicator variables for assigned
treatment group (budesonide vs. placebo and nedocromil vs. placebo), and asthma severity (mild vs.
moderate) and duration at baseline. Secondary analyses will be carried out on other response
measures: change from baseline to last available corresponding measure in CAMPCS/3 in, post
bronchodilator FVC % predicted, post bronchodilator FEV1/FVC, log FEV1PC20, and height. The
explanatory variables will consist of two indicator variables for assigned treatment group
(budesonide vs. placebo and nedocromil vs. placebo); age, gender, ethnicity (except for the %
predicted responses which are, by definition, controlled for age, gender, ethnicity and height); and
asthma severity (mild vs. moderate) and duration at baseline. The primary effect associated with
each response will be determined by the size and statistical significance of the budesonide vs.
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4. Methods
4.11. Data analysis
4.11.6. Analyses for Specific Aim 3, Hypothesis 4
placebo indicator variable. Interpretation and analysis of the results of these intention-to-treat
comparisons are complicated by potential differential asthma treatment patterns over time after the
end of the CAMP trial phase; however, this does not appear to be an issue, since data on use of ICS
during CAMPCS ranges from 52-54% across the three groups (P=0.82) and ICS use as of the most
recent visit in CAMPCS/2 was nearly identical across treatment groups at 37% (P=0.96).
4.11.7.
Analysis for Specific Aim 4, Hypothesis 5
Hypothesis 5(a) requires classification of each subject into one of the 4 pre-defined patterns of
reduced lung function and decline using the methods outlined in section 4.14. Percent agreement and
kappa statistics will be calculated to establish the validity of the classifications. For Hypothesis 5(b),
linear discriminant function analysis for four groups will be carried out to identify clinical
characteristics, pulmonary function measures, and inflammatory markers available at the start of the
CAMP trial that discriminate among the groups. This analysis will be repeated using the same
measures available at the beginning of CAMPCS/3 as discriminators. In addition, polychotomous
(four category) multiple logistic regression models will also be used to cross check findings from the
linear discriminant analyses to mitigate issues with non-normality of the candidate discriminator
variables.
4.11.8.
Sample size considerations - all Specific Aims
The CAMP trial (104) was designed to recruit 960 patients to detect a 3.5% difference (between
each active treatment group vs. placebo in the change from baseline post-bronchodilator FEV1. The
calculation assumed a two-sided Type I error=0.01, power=0.90, within group SD=11% for the
change from baseline response, 10% lost to follow-up rate, and a 1:1:1.4 allocation ratio for
budesonide:nedocromil:placebo treatment groups. These rigorous design specifications proved to be
conservative, since recruitment totaled 1041 patients, and both the within group SD and loss to
follow-up rate were more optimistic than anticipated at 9.8% and 7% respectively. Allowing for a
higher loss to follow-up rate of 15%, with approximately 874 patients, CAMPCS/3 will have
power=0.96 to detect a 3.5% difference in the FEV1 change measure with a Type I error of 0.01 and
within group SD of 10%. With regard to other response measures, the sample size of 874 patients is
adequate to detect small effects (0.31SD) for other outcome measures across treatment groups with
power=0.90 and Type I error= 0.01. Comparisons between 2 groups (not necessarily treatment
groups) will be able to detect effect sizes from 0.26 to 0.44 SD units, assuming the proportion of the
total sample size in the smaller of the 2 groups ranges from 0.1 to 0.5 and assuming n=874,
power=0.90 and Type I error=0.01. For example, the estimated SD of maximally attained lung
function derived from the 44 CAMPCS/2 patients currently aged 23 or older is 0.69L, which implies
the ability to detect differences across groups with power=0.90 and Type I error=0.01 in mean
maximally attained lung function ranges from 0.18L to 0.30L. Since estimated SDs from regression
models will be smaller than total SD estimated from the 44 patients, effective detectable differences
in CAMPCS/3 will be smaller than the range just stated.

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CAMPCS/3 Protocol
4. Methods
4.11. Data analysis
4.11.9.
Statistical power for multistage whole genome association analysis, Specific

Aim 2, Hypothesis 3
To assess the power of our multi-stage design, we used a mixture of simulations studies and
analytical power calculations. The power of the population-based case/control studies was estimated
based on simulation studies in R. The power of family-based studies was computed with using
PBAT. The power of the testing strategy by Van Steen was predicted based on simulation studies in
R using the R-interface with PBAT. Since the first 2 stages (screening and testing in the 400 trios
and testing in Sepracor/ENGB)) in Specific Aim 2 are analyzed jointly and the significance is
established based on the combined p-values of both stages, we used simulation studies in R to
estimate the overall power level of the first 2 stages in Project 1 of the PO1. The power to detect a
SNP with a true association in stages 1 & 2, and to push it forward to the 3rd stage (replication in the
other ethnic groups) is defined by the probability that both the SNP with true association achieves a
conditional power estimate in the first stage that is among the 3000/4=750 highest power estimates
for all 550,000 SNPs and that its combined p-value from the FBAT-statistic in stage 1 and the scoretest in stage 2 is significant at an adjusted alpha level of 5%/3000. We used simulation studies with
1000 replicates to estimate the power of this procedure. In the first step, we simulated 400 trios with
550,000 SNPs. For the SNPs that are not associated with the any of phenotypes, we simulate an
allele frequency from a beta-distribution that resembles the allele frequency distribution of the 500K
chip. The parental genotypes were then generated by assuming that Hardy-Weinberg equilibrium
holds and the offspring genotypes were constructed by Mendelian transmissions from the parents.
For a SNP that is associated with a quantitative trait, we simulate the phenotype and the genotype
configuration of the trio as described in (83). For the quantitative phenotypes, we measured the
genetic effect size in terms of heritability/standardized genetic effect size, i.e. the amount of
phenotypic variance that is explained by the single SNP, assuming that the phenotype is normally
distributed and the mode of inheritance is additive.
The combined power of stages 1&2 was assessed in the following way. For each phenotype ( the
3 selected quantitative traits FEV1, FVC and FEV1/FVC ratio), we estimated the conditional power
of the corresponding FBAT-statistic for all 550,000 SNPs, using the approach by VanSteen for the
quantitative traits. Then all 550,000 SNPs were ranked based on their power estimates and the
3072/4=768 SNPs with the highest power estimates were pushed forward to the 2nd stage of the
strategy (testing in Sepracor/EMGB). In the 2nd stage, we generated the genotype distribution for the
SNPs that are not associated with the selected phenotypes based on the Hardy-Weinberg assumption.
For the SNPs associated with one of the 3 quantitative phenotypes, we generated the genotype
distribution based on the Hardy-Weinberg assumption and simulated the phenotype as a normal
random variable with a heritability of 1/12th of the original heritability of the family sample. We will
apply the FBAT-PC approach to 12 repeated measurements in the CAMP study, but will have only 1
cross-sectional measurement available in the Sepracor/EMGB study. For each phenotype, we then
compute the score-test in the Sepracor/EMGB study and the FBAT/FBAT-PC test in the CAMP
study for all 3000 SNPs that are genotyped in stage 2. For each phenotype, we combine the p-values
from stage 1 and stage 2 using Fishers method (105). If a combination of SNP and phenotype had a
combined p-value that is less than 5%/3000, it is declared to be significant.

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CAMPCS/3 Protocol
4.12.
4. Methods
Study organization
The CAMPCS/3 Steering Committee will be comprised of the principal investigators from each
of the participating centers, the NHLBI project officer, and a representative from the clinic
coordinators. The Steering Committee will be responsible for the design and conduct of CAMPCS/3
and will meet monthly by conference call. The Publications Committee, a subcommittee of the
Steering Committee, will be responsible for organization and oversight of development of
manuscripts.
4.13.
Use of comparison populations to describe abnormal patterns of growth and

decline of lung function (Specific Aims 4, Hypothesis 5)
CAMP spirometry values will be compared to 3 sets of non-asthmatic comparison populations:

Vlagtwedde/Vlaardingen (4, 30, 41), NHANES III (73), and CARDIA (13):
1.Vlagtwedde/Vlaardingen: The Vlagtwedde/Vlaardingen cohort study is unique in having a 30-year
follow-up of individuals between the initial ages of 15-35 years in two Dutch towns. All individuals
in the two towns were surveyed every 3 years. The subjects are representative of the Dutch
population. Information is available on lung function (FEV1 and VC), airway responsiveness to
histamine, respiratory symptoms (including asthma diagnosis), cigarette smoking and allergy
(peripheral blood eosinophil counts, skin tests, and IgE). A total of 1818 male and 1732 female
subjects contributed at least one pulmonary function test value in the age range of 15-35 years, and
the total numbers of observations are 4378 for males and 3716 for females. We have extensive
experience working with these data and Dr. Weiss has written 17 papers on the data from this study.
2. NHANES III: The third National Health and Nutrition Examination Survey was conducted from
1988 to 1994, and it comprised a random sample of the U.S. population. Spirometry data were
collected in a standardized manner, with quality control conducted by National Institute of
Occupational Safety and Health. 20,627 individuals age 8 years or older participated. 7429 subjects
were asymptomatic, lifelong non-smoking subjects with at least 2 acceptable maneuvers and their
data allowed development of reference equations to describe normal pulmonary function for 3 major
race/ethnic groups: Caucasians, African-Americans, and Mexican-Americans. As can be seen from
our preliminary data, we have used non-asthmatic subjects as a comparison population for lung
growth analyses.
3. CARDIA: The Coronary Artery Risk Development in Young Adults Study examined 5115 black
and white men and women aged 18-30 at baseline in 1985-6, with re-examination 2, 5, and 10 years
later of 4624, 4352, and 3950 participants, respectively. Subjects were randomly sampled in
Birmingham, AL, Chicago, IL, Minneapolis, MN, and Oakland, CA. Questionnaires asked about
demographic characteristics, respiratory health, cigarette smoking, physical activity, and medical
history. Standard procedures of the ATS were followed for measurement of lung function using a
water sealed spirometer. We have obtained permission from the CARDIA group to use this data set
and we will use the available questionnaire data to identify non-asthmatic individuals within the
CARDIA population.

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4. Methods
4.13. Use of comparison populations to describe abnormal patterns for growth

Since CAMP is a longitudinal follow-up of children starting in 1993, none of these sets of
normal subjects was examined concurrently with CAMP; however, these comparison populations
share a broad range of important characteristics, being national (NHANES and CARDIA) and
international (Vlagtwedde/Vlaardingen), longitudinal (CARDIA and Vlagtwedde/Vlaardingen) and a
cross-sectional representative sample of the US population (NHANES), with all 3 comparison groups
containing extensive data in the 20-30 year old age group in which CAMPCS/3 will focus. There is
good overlap of time of study with CAMP for Vlagtwedde/Vlaardingen, NHANES, and CARDIA.
Taken together these populations have the range of variables needed for comparison to CAMP
participants, and provide comparison groups that will allow us to define the magnitude and range of
abnormal patterns of maximal attained lung function and early lung function decline into young
adulthood in subjects with persistent childhood Most importantly, the effects of biases due to age,
period, and cohort effects can be minimized by seeking patterns of abnormality that are consistent in
comparisons to the two longitudinal populations and to the nationally representative cross-sectional
sample.
4.14.
Methods for defining patterns of reduced lung function growth and early decline
of lung function
Four patterns for classification have been identified in our Preliminary Data (C.4.8): normal
lung growth and no decline, reduced lung growth, normal lung growth then early decline, and
reduced lung growth then early decline. These patterns correspond to the patterns demonstrated by
individuals who acquire fixed airflow obstruction from asthma depicted in the schematic in 3.2.7.
We will not be able to reliably distinguish individuals in the schematic who exhibit rapid decline, as
this pattern typically emerges in the late 20s and will not become established sufficiently with the 2030 year age range at the end of CAMPCS/3.
Each CAMPCS/3 patient will be independently classified three times by each of two
pulmonologists (a total of six classifications) into one of the four lung growth patterns using
comparisons of locally weighted smoothed scatterplots (lowess smoothing) of all longitudinal post
bronchodilator measures on a patient plotted by age with superimposed and similarly smoothed age,
gender, and height adjusted expected curves from each of the three reference populations of nonasthmatics: NHANES III, Vlagtwedde/Vlaardingen, and CARDIA. Each graph will also have a
reference line consisting of the ratio of observed to expected with reference lines drawn a 0.9, 1.0,
and 1.1.
Assignment to a specific pattern will be made if four or more of the six classifications are to that
pattern. Otherwise, discrepant pattern assignments will adjudicated by a third pulmonologist at the
Data Coordinating Center. The graphs will be identified with a code # only to mask the
pulmonologists regarding patient and reference population. Duplicate readings will be made on a
random 10% sample of the graphs, which will be inserted randomly into the set of graphs to be read.
Inter- and intra-observer agreement kappa statistics will be calculated to assess the reliability of the
four category classification. These statistics will be generated periodically throughout the process.
After the first 100 patients have been read, the pulmonologists will meet to discuss discrepancies and
to refine the definitions below, if needed.

M ethodsCS3
33
CAMPCS/3 Protocol
4. Methods
4.14. Methods for defining patterns of reduced lung function growth
Following the clinical convention used for determining an exacerbation in chronic obstructive
pulmonary disease (1), a value of 10% below a non-asthmatic reference curve will be considered
lower than normal Working descriptions of the 4 patterns are as follows:
1.
2.
3.
4.
Normal lung growth, no decline: CAMP values are within 10% of normal throughout the
range.
Reduced lung growth: CAMP values are at least less than 90% of normal throughout the
range, but the values do not decrease further by more than 10% from the initial low value.
Normal lung growth then early decline: CAMP values are initially within 90% of normal and
then decline by more than 10% and stay below this value for the duration of the range.
Reduced lung growth, then early decline: CAMP values are initially less than 90% of normal
and then decline by more than 10% and stay below this value for the duration of the range.
It is likely that there will be patterns that do not fit one of the four descriptions above, although
we did not see this in the 44 patients evaluated to date. For instance, we may see decline followed by
increase to the previous baseline (present before the decline). If additional patterns occur, we will
include them in our analysis providing there are a sufficient number of subjects with the pattern.

M ethodsCS3
34
CAMPCS/3 Protocol
5. Appendices
5.1.
5.2.
Design summary.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Data collection schedule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Tables
35
CAMPCS/3 Protocol
5. Appendices
5.1.
Design summary
Name
Childhood Asthma Management Program Continuation Study/ Phase 3 (CAMPCS/3)
Objective
Extend follow-up study of the cohort established by the Childhood Asthma Management
Program (CAMP) for an additional 4 years to study the determinants of lung growth
and progression of obstruction due to persistent childhood asthma.
Type of study
Multicenter, long-term follow-up, cohort study

Population
830-880 participants in CAMP, aged 17-26 years, of whom 1/4 to 1/3 are minority
(anticipated)
Treatment
Prescribed by the patientss physician
Consultation of treatment provided by CAMPCS/3 physicians at the time of the annual

visit; advice provided will consider history of asthma symptoms, quality of life
(activity, school and work missed), medication use, and pulmonary function, and will
be based on the NAEPP Guidelines
Inclusion criteria
Participant in CAMP
Consent of the participant or consent of guardian and assent of minor child

Exclusion criteria
Refusal
Recruitment
As soon as IRB approval is obtained; at any time during CAMPCS/3

Duration of patient followup
4 years

Design
36
CAMPCS/3 Protocol
5. Appendices
5.1. Design summary
Outcomes
Rate of increase and maximal level of lung function (FVC, FEV1, FEV1/FVC)
Rate of increase in or maximal attained level of height
Airway responsiveness to methacholine
Occurrence, relapse, or remission of respiratory symptoms
Use of asthma medications
Use of health care services

Measures of independent and mediating variables
Treatment used by the patient
Environmental exposures
Manifestations of atopic status
Duration of asthma
Calendar period of patient visits
1 Jan 2008 through 31 Mar 2012

Visit schedule
Visit y1: any time from 01 Jan 08 - 31 Dec 08
Visit y4: any time from 01 Jan 11 - 31 Mar 12
Visit ym: any time from 01 Jul 08 - 31 Mar 12

Data collection schedule
Pre- and post-bronchodilator spirometry: yearly
Methacholine challenge: once
Height and weight: at every visit
Interim history (medication use, symptoms, health care utilization): at every visit
Environmental exposures: at every visit

Design
37
CAMPCS/3 Protocol
5.2.
5. Appendices
Data collection schedule

Visits
Y1
Y2
Y3
Y4
Ym
Pulmonary function
- Spirometry
- Methacholine challenge*
x
.
x
.
x
.
x
.
.
x
Physical growth and development

- Standing height
- Weight
x
x
x
x
x
x
x
x
x
x
Respiratory symptoms
Interim medical history
Treatments used
Environmental exposures
- Home characteristics
- Tobacco smoke
- Job exposures
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Atopic disease -- manifestations

- Eczema
- Upper airway symptoms
x
x
x
x
x
x
x
x
x
x
*ym may occur at any time between 01 Jul 2008 and 31 Mar 12

Data_sch
38
Literature cited
1.
Rosenfeld, M., J. Emerson, J. Williams-Warren, M. Pepe, A. Smith, and A. Montgomery. 2001.

Defining a pulmonary exacerbation in cystic fibrosis. J Pediatr 139:359-365.
2.
O'Connor, G., D. Sparrow, and S. Weiss. 1989. The role of allergy and nonspecific airway
hyperresponsiveness in the pathogenesis of chronic obstructive pulmonary disease. Am Rev
Respir Dis 140:225-252.
3.
Sparrow, D., and S. Weiss. 1989. Chapter 1: Background. In S. Weiss and D. Sparrow, editors.
Responsiveness and Atopy in the Development of Chronic Lung Disease. Raven Press,
New York. 1-19.
4.
Rijcken, B., X. Xu, J. P. Schouten, B. Rosner, and S. T. Weiss. 1995. Airway

hyperresponsiveness to histamine associated with accelerated decline in FEV1. Am J
Respir Crit Care Med 151:1377-82.
5.
Rijcken, B., and S. Weiss. 1996. Longitudinal analyses of airway responsiveness and pulmonary
function decline. Am J Resp Crit Care Med 154(6 Pt 2):S246-9.
6.
Hospers, J., D. Postma, B. Rijcken, S. Weiss, and J. Schouten. 2000. Histamine airway hyperresponsiveness and mortality from chronic obstructive pulmonary disease: a cohort study.
Lancet 356:1313-7.
7.
Burrows, B., M. Lebowitz, and R. Knudson. 1977. Epidemiologic evidence that childhood
problems predispose to airways disease in the adult (An association between adult and
pediatric respiratory diseases). Pediat Res 11:218-220.
8.
Burrows, B. 1987. The natural history of asthma. J Allergy Clin Immunol 80:373-77.
9.
Burrows, B. 1990. Airways Obstructive Diseases: Pathogenic mechanisms and natural histories
of the disorders. Med Clinics N Am 74(3):547-59.
10. Strunk, R., S. Weiss, K. Yates, J. Tonascia, R. Zeiger, and S. Szefler. 2006. Mild to Moderate
Asthma Affects Lung Growth in Children and Adolescents. J Allergy Clin Immunol
118:1040-1047.
11. Lange, P., J. Parner, J. Vestbo, P. Schnohr, and G. Jensen. 1998. A 15-Year Follow-Up Study of
Ventilatory Function in Adults with Asthma. N Engl J Med 339(17):1194-1200.
12. Burrows, B., R. Knudson, and M. Lebowitz. 1977. The relationship of childhood respiratory
illness to adult obstructive airway disease. Am Rev Resir Dis 115:751-760.

Refs.Pg
39
CAMPCS/3 Protocol
Literature cited
13. Apostol, G. G., D. R. Jacobs, Jr., A. W. Tsai, R. S. Crow, O. D. Williams, M. C. Townsend, and
W. S. Beckett. 2002. Early life factors contribute to the decrease in lung function between
ages 18 and 40: the Coronary Artery Risk Development in Young Adults study. Am J
Respir Crit Care Med 166(2):166-72.
14. Berhane, K., R. McConnell, F. Gilliland, T. Islam, W. Gauderman, E. Avol, S. London, E.
Rappaport, H. Margolis, and J. Peters. 2000. Sex-specific effects of asthma on pulmonary
function in children. Am J Resp Crit Care Med 162:1723-1730.
15. Weiss, S. 1992. The effect of asthma on lung growth in children: A longitudinal study of malefemale differences. Am Rev Respir Dis 145:58.
16. Lebowitz, M., C. Holberg, R. Knudson, and B. Burrows. 1987. Longitudinal study of pulmonary
function development in childhood, adolescence, and early adulthood. Am Rev Respir Dis
136:69-75.
17. Martin, D., K. Landau, and P. Phelan. 1980. Lung function in young adults who had asthma in
childhood. Am Rev Respir Dis 122:609-616.
18. Kelly, W., I. Hudson, J. Raven, P. Phelan, M. Pain, and A. Olinsky. 1988. Childhood asthma
and adult lung function. Am Rev Respir Dis 138:26-30.
19. Oswald, H., P. D. Phelan, A. Lanigan, M. Hibbert, J. B. Carlin, G. Bowes, and A. Olinsky.
1997. Childhood asthma and lung function in mid-adult life. Pediatr Pulmonol 23(1):14-20.
20. Gold, D., D. Wypij, X. Wang, F. Speizer, M. Pugh, J. Ware, B. Ferris, and D. Dockery. 1994.
Gender- and race-specific effects of asthma and wheeze on level and growth of lung
function in children in sex U.S. cities. Am J Respir Crit Care Med 149:1198-1208.
21. Sears, M., J. Greene, A. Willan, E. Wiecek, D. Taylor, E. Flannery, J. Cowan, G. Herbison, P.
Silva, and R. Poulton. 2003. A longitudinal, population-based, cohort study of childhood
asthma followed to adulthood. N Engl J Med 349:1414-1422.
22. Morgan, W., D. Stern, D. Sherrill, S. Guerra, D. Holblerg, T. Guilbert, L. Taussig, A. Wright,
and F. Martinez. 2005. Outcome of asthma and wheezing in the first 6 years of life. Am J
Resp Crit Care Med 172:1253-1258.
23. Ulrik, C., and V. Backer. 1999. Markers of imparied growth of pulmonary function in children
and adolescents. Am J Resp Crit Care Med 160:40-44.

Refs.Pg
40
CAMPCS/3 Protocol
Literature cited
24. Ulrik, C., V. Backer, A. Dirksen, M. Pedersen, and C. Koch. 1995. Extrinsic and intrinsic
asthma from childhood to adult age: a 10-yr follow-up. Respir Med 89:547-554.
25. Roorda, R., J. Gerritsen, W. van Aalderen, J. Schouten, J. Veltman, S. Weiss, and K. Knol.
1994. Follow-up of asthma from childhood to adulthood: Influence of potential childhood
risk factors on the outcome of pulmonary function and bronchial responsievness in
adulthood. J Allergy Clin Immunol 93:575-584.
26. Limb, S., K. Brown, R. Wood, R. Wise, P. Eggleston, J. Tonascia, and N. Adkinson. 2005.
Irreversible lung function deficits in young adults with a history of childhood asthma. J
Allergy Clin Immunol 116:1213-1219.
27. Williams, H., and K. McNicol. 1969. Prevalence, natural history, and relationship of wheezy
bronchitis and asthma in children. An epidemiological study. Br Med J 4:321-325.
28. Grol, M. H., J. Gerritsen, J. M. Vonk, J. P. Schouten, G. H. Koeter, B. Rijcken, and D. S.
Postma. 1999. Risk factors for growth and decline of lung function in asthmatic individuals
up to age 42 years. A 30-year follow-up study. Am J Respir Crit Care Med 160(6):1830-7.
29. Xuan, W., J. K. Peat, B. G. Toelle, G. B. Marks, G. Berry, and A. J. Woolcock. 2000. Lung
function growth and its relation to airway hyperresponsiveness and recent wheeze. Results
from a longitudinal population study. Am J Respir Crit Care Med 161(6):1820-4.
30. Rijcken, B., J. P. Schouten, S. T. Weiss, B. Rosner, K. de Vries, and R. van der Lende. 1993.
Long-term variability of bronchial responsiveness to histamine in a random population
sample of adults. Am Rev Respir Dis 148:944-9.
31. Kelly, W., I. Hudson, P. Phelan, M. Pain, and A. Olinsky. 1987. Childhood asthma in adult life:
a further study at 28 years of age. Br Med J 294:1059-62.
32. Kerrebijn, K., A. Fioole, and R. van Bentveld. 1978. Lung function in asthmatic children after
year or more without symptoms or treatment. Br Med J 1:886-888.
33. Gruber, W., E. Eber, B. Steinbrugger, M. Modl, E. Weinhandl, and M. S. Zach. 1997. Atopy,
lung function and bronchial responsiveness in symptom-free paediatric asthma patients.
Eur Respir J 10(5):1041-5.
34. Canny, G., and H. Levison. 1988. Pulmonary function abnormalities during apparent clinical
remission in childhood asthma. J Allergy Clin Immunol 82(1):1-3.

Refs.Pg
41
CAMPCS/3 Protocol
Literature cited
35. Cooper, D., E. Cutz, and H. Levison. 1977. Occult pulmonary abnormalities in asymptomatic
asthmatic children. Chest 71(3):361-365.
36. Cade, J., and M. Pain. 1973. Pulmonary function during clinical remission of asthma: How
reversible is asthma? Aust N Z J Med 3:545-551.
37. van den Toorn, L. M., S. E. Overbeek, J. C. de Jongste, K. Leman, H. C. Hoogsteden, and J. B.
Prins. 2001. Airway inflammation is present during clinical remission of atopic asthma. Am
J Respir Crit Care Med 164(11):2107-13.
38. Warke, T., P. Fitch, V. Brown, R. Taylor, J. Lyons, M. Ennis, and M. Shields. 2002. Outgrown
asthma does not mean no airways inflammation. Eur Respir J 19:284-7.
39. Weiss, S., and F. Speizer. 1997. Epidemiology and natural history.
40. Fletcher, C. 1976. The natural history of chronic bronchitis and emphysema: An eight-year
study of early chronic obstructive lung disease in working men in London. Oxford
University Press, New York.
41. Rijcken, B., J. P. Schouten, T. T. Mensinga, S. T. Weiss, K. de Vries, and R. van der Lende.
1993. Factors associated with bronchial responsiveness to histamine in a population sample
of adults. Am Rev Respir Dis 147:1447-53.
42. Wang, X., T. Mensinga, J. Schouten, B. Rijcken, and S. Weiss. 2004. Determinants of
maximally attained level of pulmonary function. Am J Resp Crit Care Med 169:941-949.
43. Tager, I. 1998. Smoking and childhood asthma-where do we stand? Am J Respir Crit Care Med
158:349-51.
44. Tager, I., S. Weiss, A. Munoz, B. Rosner, and F. Speizer. 1983. Longitudinal study of the
effects of maternal smoking on pulmonary function in children. New Engl J Med 309:699703.
45. Tager, I., M. Segal, F. Speizer, and S. Weiss. 1988. The natural history of forced expiratory
volumes. Effect of cigarette smoking and respiratory symptoms. Am Rev Resir Dis
138:837-849.
46. van Arsdel, P. P., and A. G. Motulsky. 1959. Frequency and heritability of asthma and allergic
rhinitis in college students. Acta Genet Med Gemellol 9:101.

Refs.Pg
42
CAMPCS/3 Protocol
Literature cited
47. Duffy, D. L., N. G. Martin, D. Battistutta, J. L. Hopper, and J. D. Mathews. 1990. Genetics of
asthma and hay fever in Australian twins. American Review of Respiratory Disease
142:1351-1358.
48. Edfors-Lubs, M. 1971. ALlergy in 7000 infants. Acta Allergologica 26:249-285.
49. Sibbald, B., M. E. Horn, E. A. Brain, and I. Gregg. 1980. Genetic factors in childhood asthma.
Thorax 35(671-674.).
50. Wjst, M., G. Fischer, T. Immervoll, M. Jung, K. Saar, F. Rueschendorf, A. Reis, M. Ulbrecht,
M. Gomolka, E. H. Weiss, L. Jaeger, R. Nickel, K. Richter, N. I. Kjellman, M. Griese, A.
von Berg, M. Gappa, F. Riedel, M. Boehle, S. van Koningsbrugen, P. Schoberth, R.
Szczepanski, W. Dorsch, M. Silbermann, and H. E. Wichmann. 1999. A genome-wide
search for linkage to asthma. German Asthma Genetics Group. Genomics 58:1-8.
51. Knapp, M. 1999. The transmission/disequilibrium test and parental-genotype reconstruction: the
reconstruction-combined transmission/disequilibrium test. Am J Hum Genet 64:861-70.
52. Dizier, M. H., C. Besse-Schmittler, M. Guilloud-Bataille, I. Annesi-Maesano, M. Boussaha, J.
Bousquest, D. Charpin, A. Degioanni, F. Gormand, A. Grimfeld, J. Hochez, G. Hyne, A.
Lockhart, L.-L. M, R. Matran, F. Meunier, F. Neukirch, Y. Pacheco, V. Parent, E. Paty, L.
Pin, C. Pison, P. Scheinmann, N. Thobie, D. Vervloet, F. Kauffman, F. Feingold, M.
Lathrop, and F. Demenais. 1999. Genome screen for asthma and related phenotypes in the
French EGEA Study. Am J Respir Crit Care Med 59:A649 (abstract).
53. Clayton, D., and H. Jones. 1999. Transmission/Disequilibrium Tests for Extended Marker
Haplotypes. Am J Hum Genet 65:1161-1169.
54. Bleecker, E. R., D. Postma, G. H. Koppelman, G. G. Meijer, J. Xu, O. C. Stine, and D. A.
Meyers. 1999. Genome screen for susceptibility loci in a genetically homogeneous Dutch
population. Am J Respir Crit Care Med 159:A645 (abstract).
55. Ober, C., N. J. Cox, M. Abney, A. Di Rienzo, E. S. Lander, B. Changyaleket, H. Gidley, B.
Kurtz, J. Lee, M. Nance, A. Pettersson, J. Prescott, A. Richardson, E. Schlenker, E.
Summerhill, S. Willadsen, and R. Parry. 1998. Genome-wide search for asthma
susceptibility loci in a founder population. Human Molecular Genetics 7:1393-1398.
56. Ober, C., and S. Hoffjean. 2006. Asthma genetics 2006: the long and winding road to gene
discovery. Review. Genes Immun 7:95-100.

Refs.Pg
43
CAMPCS/3 Protocol
Literature cited
57. Group, C. A. M. P. R. 2000. Long-term effects of budesonide or nedocromil in children with

asthma. New Eng J Med 343:1054-1063.
58. Auffarth, B., D. S. Postma, J. G. de Monchy, T. W. van der Mark, M. Boorsma, and G. H.
Koeter. 1991. Effects of inhaled budesonide on spirometric values, reversibility, airway
responsiveness, and cough threshold in smokers with chronic obstructive lung disease.
Thorax 46(5):372-7.
59. Kraan, J., G. Koeter, T. van der Mark, M. Boorsma, J. Kukler, H. Sluiter, and K. DeVries. 1988.
Dosage and time effects of inhaled budesonide on bronchial hyperreactivity. Am Rev Respir
Dis 137:44-48.
60. Szefler, S. J., R. J. Martin, T. S. King, H. A. Boushey, R. M. Cherniack, V. M. Chinchilli, T. J.
Craig, M. Dolovich, J. M. Drazen, J. K. Fagan, J. V. Fahy, J. E. Fish, J. G. Ford, E. Israel,
J. Kiley, M. Kraft, S. C. Lazarus, R. F. Lemanske, Jr., E. Mauger, S. P. Peters, and C. A.
Sorkness. 2002. Significant variability in response to inhaled corticosteroids for persistent
asthma. J Allergy Clin Immunol 109(3):410-418.
61. Hughes, I. 1987. Steroids and growth. Br Med J 295:683-84.
62. Francis, R. 1976. Long-term beclomethasone diproprionate aerosol therapy in juvenile asthma.
Thorax 31:309-314.
63. Bhan, G., C. Gwynn, and J. Smith. 1980. Growth and adrenal function of children on prolonged
beclomethasone diproprionate treatment. Lancet:96-97.
64. Godfrey, S., and P. Konig. 1974. Treatment of childhood asthma for 13 months and longer with
beclomethasone diproprionate aerosol. Arch Dis Child 49:591-96.
65. Balfour-Lynn, I. 1986. Growth and childhood asthma. Arch Dis Child 61:1049-1055.
66. Volovitz, B., J. Amir, H. Malik, A. Kauschansky, and I. Varsano. 1993. Growth and pituitaryAdrenal function in children with severe asthma treated with inhaled budesonide. N Engl J
Med 329:1703-8.
67. Tinkelman, D., C. Reed, H. Nelson, and K. Offord. 1993. Aerosol beclomethasone dipropionate
compared with theophylline as primary treatment of chronic, mild to moderately severe
asthma in children. Pediatrics 92:64-77.

Refs.Pg
44
CAMPCS/3 Protocol
Literature cited
68. Simons, F. 1997. A comparison of beclomethasone, salmeterol, and placebo in children with
asthma. New Engl J Med 337:1659-1665.
69. Doull, I., N. Freezer, and S. Holgate. 1995. Growth of prepubertal children with mild asthma
treated with inhaled beclomethasone dipropionate. Am J Respir Crit Care Med 151:17151719.
70. Verberne, A., C. Frost, R. Roorda, H. van der Laag, and K. Kerrebijn. 1997. One year treatment
with salmeterol compared with beclomethasone in children with asthma. Am J Respir Crit
Care Med 156:688-695.
71. Yunginger, J., C. Reed, E. O'Connell, L. I. Melton, W. O'Fallon, and M. Silverstein. 1992. A
community-based study of the epidemiology of asthma. Am Rev Respir Dis 146:888-894.
72. Agertoft, L., and S. Pedersen. 2000. Effect of long-term treatment with inhaled budesonide on
adult height in children with asthma. N Engl J Med 343(15):1064-9.
73. Hankinson, J., J. Odencrantz, and K. Fedan. 1999. Spirometric reference values from a sample
of the general U.S. population. Am J Resp Crit Care Med 159:179-187.
74. Childhood Asthma Management Program Research Group. 1994. Childhood Asthma
Management Program Spirometry Manual (version 3.0). National Technical Information
Service, Springfield, Virginia.
75. Childhood Asthma Management Program Research Group. 1994. Childhood Asthma
Management Program allergy and skin test manual, version 2.0. National Technical
Information Service, U.S. Department of Commerce, Springfield, Virginia.
76. Benuck, I., S. Gidding, and H. Binns. 2001. Identification of adolescent tobacco users in a
pediatric practice. Arch Pediatr Adolesc Med 155:32-35.
77. van Steen, K., and C. Lange. 2006. PBAT: A comprehensive software package for genome-wide
association analysis of complex family-based studies. Human Genomics In press.
78. Hochberg, Y., and Y. Benjamini. 1990. More powerful procedures for multiple significance
testing. Stat Med 9:811-818.
79. Benjamini, Y., D. Drai, G. K. Elmer, N, and I. Golani. 2001. Controlling the false discovery rate
in behavior genetics research. Behav Brain Res 125:279-284.

Refs.Pg
45
CAMPCS/3 Protocol
Literature cited
80. Benjamini, Y., and D. Yekutieli. 2005. Quantitative trait loci analysis using the false discover
rate. Genetics 171:783-790.
81. Herbert, A., N. Gerry, M. McQueen, I. Heid, A. Pfeufer, and I. T. 2006. A common genetic
variant 10kb upstream of INSIG2 is associated with adult and childhood obesity. Science In
press.
82. Lange, C., D. DeMeo, E. Silverman, S. Weiss, and N. Laird. 2003. Using the noninformative
families in family-based association tests: A powerful new testing strategy. Am J Hum
Genet 73:801-811.
83. Lange, C., H. Lyon, D. DeMeo, B. A. Raby, E. Silverman, and S. Weiss. 2003. A new powerful
non-parametric two-stage approach for testing multiple phenotypes in family-based
association studies. Hum Hered 56:10-17.
84. Laird, N., and C. Lange. 2006. Family-based designs in the age of large-scale gene-association
studies. Nature Reviews Genetics 7:385-394.
85. National Heart, Lung, and Blood Institute. 1997. National Asthma Education and Prevention
Program Expert Panel Report 2: Guidelines for the diagnosis and management of asthma.
National Institutes of Health, Bethesda, MD.
86. Leiria Pinto, P., M. Cordeiro, and R. Pinto. 1999. Adolescents and school asthma knowledge
and attitudes. Allergol Immunopathol 27:245-253.
87. Townsend, J., H. Wilkes, A. Haines, and M. Jarvis. 1991. Adolescent smokers seen in general
practice: Health, lifestyle, physical measurements, and response to antismoking advice.
BMJ 303:947-950.
88. Juniper, E., G. Guyatt, B. Andersson, and P. Ferris. 1993. Comparison of powder and
aerosolized budesonide in perennial rhinitis: Validation of rhinitis quality of life
questionnaire. Ann Allergy 70:225-230.
89. Juniper, E., and G. Guyatt. 1991. Development and testing of a new measure of health status for
clinical trials in rhinoconjunctivitis. Clin Exp Allergy 21:77-83.
90. Juniper, E., G. Guyatt, and J. Dolovich. 1994. Assessment of quality of life in adolescents with
allergic rhinoconjunctivitis: Development and testing of a questionnaire for clinical trials. J
Allergy Clin Immunol 93:413-423.

Refs.Pg
46
CAMPCS/3 Protocol
Literature cited
91. Bosquet, J., M. Bullinger, D. Fayol, P. Marquis, B. Valentin, and B. Burtin. 1994. Assessment
of quality of life in patients with perennial allergic rhinitis with the French version of SD36 Health Status Questionnaire. J Allergy Clin Immunol 94:182-188.
92. Gliklich, R., and R. Metson. 1997. Effect of sinus surgery on quality of life. Otolaryngol Head
Neck Surg 117:12-17.
93. Gleich, G., and R. Metson. 1995. Techniques for outcomes research in chronic sinusitis.
Laryngoscope 105:387-390.
94. Benniger, M., and B. Senior. 1997. The development of the rhinosinusitis disability index. Arch
Otolaryngol Head Neck Surg 123:1175-1179.
95. Diggle, P., P. Heagerty, K. Liang, and S. Zeger. 2002. Analysis of Longitudinal Data, 2nd ed.
Oxford University Press, New York, NY.
96. Risch, N., and K. R. Merikangas. 1996. The future of genetics studies of complex human
diseases. Science 273:1516-1517.
97. Spielman, R. S., and W. J. Ewens. 1996. The TDT and other family-based tests for linkage
disequilibrium and association. American Journal of Human Genetics 59:983-989.
98. Lazzeroni, L. C., and K. Lange. 1998. A conditional inference framework for extending the
transmission/disequilibrium test. Hum Hered 48:67-81.
99. Lange, C., K. van Steen, T. Andrew, H. Lyon, D. DeMeo, and B. Raby. 2004. A family-based
association test for repeatedly measured quantitative traits adjusting for unknown
environmental and/or polygenic effects. Stat Appl Genet Mol Biol 3:1-27.
100. van Steen, K., M. McQueen, A. Herbert, B. Raby, H. Lyon, and A. Murphy. 2005. Genomic
screening and replication in one data set in family based association testing. Nat Genet
37:683-691.
101. Cleveland, W. 1979. Robust locally weighted regression and smoothing scatterplots. J Am Stat
Assoc 74:829-836.
102. Press, W., B. Flannery, S. Teukolsky, and W. Vetterling. 1992. Maximization or Minimization
of Functions, Chapter 10. Numerical Recipes in Fortran 77. Cambridge University Press,
Cambridge.

Refs.Pg
47
CAMPCS/3 Protocol
Literature cited
103. Mansfield, J., G. Legge, and M. Bane. 1996. Psychophysics of Reading XV: Font Effects in
Normal and Low Vision. Investigative Ophthalmology & Visual Science 37:1492-1501.
104. Childhood Asthma Management Program Research Group. 1999. The Childhood Asthma
Management Program (CAMP): Design, Rationale, and Methods. Controlled Clinical
Trials 20:91-120.
105. Whitlock, M. 2005. Combining probability from independent tests: the weighted Z-method is
superior to Fisher's approach. J Evol Biol 18:1368-73.
106. Society, A. T. 2005. ATS Consesnus Statement: Research opportunities and challenges in
pediatric pulmonology. Am J Resp Crit Care Med 172:776-780.
107. Wenzel, S. 2005. Severe asthma in adults. Pulmonary perspective. Am J Resp Crit Care Med
172:149-160.

Refs.Pg
48

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Protocol

Childhood Asthma Management Program

CAMP Continuation Study/Phase 3 (CAMPCS/3) Protocol

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

4.4.7. Pregnancy history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

1. Objective and specific aims

CAMPCS/3 is an observational followup study of the children who participated in the

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

1. Objective and specific aims

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

Background for Specific Aim 1, Hypothesis 2

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

Background for Specific Aim 2, Hypothesis 3

Allergic asthma in childhood, as seen in the mild-to-moderate subjects enrolled in CAMP,

Background for Specific Aim 3, Hypothesis 4

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

In contrast to the transient-only benefit on post-bronchodilator FEV1, ICS treatment in CAMP

Background for Specific Aim 4, Hypothesis 5

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

Preliminary data from CAMP, CAMPCS, and CAMPCS/2

By the end of CAMPCS/2 in 2007,

Determination of lung function and airway responsiveness (Specific Aims 14)

Determination of inflammatory-related phenotypes (Specific Aims 1, 3, and

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

3.2. Preliminary Data from CAMP, CAMPCS, and CAMPCS/2

Personal smoking in CAMP participants (Specific Aim 1)

Asthma symptoms/morbidity and medication use (Specific Aim 1)

Patterns of growth and decline of lung function (Specific Aim 4,

Somatic Growth (Specific Aim 3)

Preliminary data on genetic polymorphisms and lung function (Specific

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

CAMPCS/3 is designed as an extension of CAMPCS/2, which was an extension of CAMPCS,

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

Consent and recruitment in CAMPCS/3

CAMPCS/3 participants may be as young as age 17 at enrollment. Consent and assent

Patient contact schedule and content of visits

Measurement and assessment methods

Pre- and post-BD FEV1 and FEV1 /FVC ratio

Rationale: FEV1 , a stable phenotype, is highly predictive of asthmatic attacks, is correlated

Symptoms/morbidity and medication use

Rationale: Environmental exposures to allergens, particularly those to which the individual

Atopy related phenotypes

Data management for clinical data

Patient registration into CAMPCS/3

The key features of the entry process include:

Double entry of all data items

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

Data management for genetic studies

Bioinformatics management system (ORAGEN)

A bioinformatics management system (ORAGEN) has been developed b y the Genetics

Management of genotypic data

Management of phenotype data

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

CAMPCS/3 protocol, reading of study manuals, and signature of a statement agreeing to

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6

Characteristics of the proposed study population

Sources of research material

Protection of human subjects

CAM PCS/CAM PCS3 Ntbs/Proto_CS3\M anall_6