Design and Implementation of a Patient Education Center for the Childhood Asthma Management Program

Brief-interval telephone surveys of medication adherence and asthma symptoms in the Childhood Asthma Management Program Continuation Study

BACKGROUND

Although it is known that most patients do not consistently take controller medications every day, the impact of nonadherence on asthma control is not well documented.

OBJECTIVE

To establish the relationship between medication adherence and symptom control in adolescents and young adults with asthma.

METHODS

A total of 756 adolescents and young adults diagnosed as having mild to moderate asthma on entry into the original study underwent 6 monthly telephone interviews as an ancillary project to the Childhood Asthma Management Program Continuation Study. Participants were queried about medication use and symptom control within each 1-month interview window. Strategies adopted to improve self-report accuracy included use of repeated interviews, confidential reporting to staff unknown to the participants, and use of questions focused on recent behavior.

RESULTS

Only participants who were consistently on inhaled corticosteroids (ICSs) for the entire 6-month study interval were included. Three groups of patients were contrasted: those not on ICSs (n = 420), those on ICSs with high adherence (> or = 75% of medication taken, n = 90), and those on ICSs with low/medium adherence (< 75% of medication taken, n = 148). Participants in the low/medium adherence group reported, on average, less symptom control and more variability in wheezing, awakening at night, missed activities, and beta2-agonist use during the 6-month period, although most in this group perceived their asthma to be under good control.

CONCLUSION

Despite extensive patient education and support, diminished ICS adherence was frequent and undermined symptom control in this group of adolescents and young adults with mild to moderate asthma.

Blood transfusion therapy is feasible in a clinical trial setting in children with sickle cell disease and silent cerebral infarcts

BACKGROUND

Silent cerebral infarcts are both morbid and progressive in children with sickle cell disease (SCD). While blood transfusion therapy is effective primary and secondary stroke prevention, the efficacy and acceptance of blood transfusion therapy for children with silent cerebral infarcts is unknown. The overall goals of this study were to determine the feasibility and short-term efficacy of blood transfusion therapy for silent cerebral infarcts.

PROCEDURE

We conducted a single-arm feasibility intervention study. Children with SCD and silent cerebral infarcts received blood transfusion therapy. Short-term efficacy was defined as no progression of MRI findings on repeat MRI.

RESULTS

Ten children enrolled in the study, and nine were evaluable. Five were male. The average age was 10.0 years (range 3.1-16.8). Seven of nine completed the transfusion therapy for over 2 years, with an average duration of therapy of 2.7 years (range 1-6). Twenty infarcts and four cases of Moya Moya were present on the initial MRI. Seven of nine subjects had repeat MRIs. Of these seven, there were a total of 18 infarcts. One infarct increased in size and one case of Moya Moya progressed on repeat MRI. All other lesions were stable or became smaller in diameter while on transfusion therapy during the time of follow up (mean 3.9 years, range 2.1-5.7).

CONCLUSIONS

Blood transfusion therapy is a feasible therapy for the prevention of progression of silent cerebral infarcts.

Childhood Asthma Management Program: lessons learned

The National Heart, Lung, and Blood Institute Childhood Asthma Management Program was initiated in 1991 and is now the largest and most comprehensive study of long-term intervention with anti-inflammatory therapy in children with mild to moderate asthma. The purpose of this perspective is to review key findings of the study and lessons learned in conducting research in more than 1000 children with persistent asthma for more than 10 years. A key lesson was absence of a continued effect of inhaled corticosteroid on lung growth during long-term follow-up even as symptoms and airway responsiveness remained improved.

Sequence, haplotype, and association analysis of ADRbeta2 in a multiethnic asthma case-control study

RATIONALE

The comprehensive evaluation of gene variation, haplotype structure, and linkage disequilibrium is important in understanding the function of beta2-adrenergic receptor gene (ADRbeta2) on disease susceptibility, pulmonary function, and therapeutic responses in different ethnic groups with asthma.

OBJECTIVES

To identify ADRbeta2 polymorphisms and haplotype structure in white and African American subjects and to test for genotype and haplotype association with asthma phenotypes.

METHODS

A 5.3-kb region of ADRbeta2 was resequenced in 669 individuals from 429 whites and 240 African Americans. A total of 12 polymorphisms, representing an optimal haplotype tagging set, were genotyped in whites (338 patients and 326 control subjects) and African Americans (222 patients and 299 control subjects).

RESULTS

A total of 49 polymorphisms were identified, 21 of which are novel; 31 polymorphisms (frequency > 0.03) were used to identify 24 haplotypes (frequency > 0.01) and assess linkage disequilibrium. Association with ratio (FEV1/FVC)2 for single-nucleotide polymorphism +79 (p < 0.05) was observed in African Americans. Significant haplotype association for (FEV1/FVC)2 was also observed in African Americans.

CONCLUSIONS

There are additional genetic variants besides +46 (Gly16Arg) that are important in determining asthma phenotypes. These data suggest that the length of a poly-C repeat (+1269) in the 3' untranslated region of ADRbeta2 may influence lung function, and may be important in delineating variation in beta-agonist responses, especially in African Americans.

Nedocromil sodium for chronic asthma in children

BACKGROUND

Currently inhaled corticosteroids are the main stay in the maintenance treatment of chronic asthma in children. Although inhaled corticosteroids play a crucial role in the management of childhood asthma, the long-term side effects of inhaled corticosteroids used in the management of chronic asthma in children are not clearly known.

OBJECTIVES

The objective of this review is to compare the safety and efficacy of inhaled nedocromil sodium with placebo in the treatment of chronic asthma in children.

SEARCH STRATEGY

We searched the Cochrane airway group trials register, Cochrane controlled trials register, Current contents, review articles, reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. We also searched abstracts of major respiratory society meetings. The last search was carried out in October 2004

SELECTION CRITERIA

Randomised placebo controlled trials comparing nedocromil sodium to placebo in the treatment of chronic asthma in children (0 to 18 years).

DATA COLLECTION AND ANALYSIS

Both authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Fifteen trials (twelve parallel group studies; three crossover trials recruiting 1422 children (837 males and 585 females)) were included. The studies were generally of good methodological quality. Two large long term studies used nedocromil for six months and four to six years and showed conflicting results in symptom free days. Short term studies (duration between 4 weeks to 12 weeks) showed that nedocromil sodium produced some improvement in a number of efficacy measures compared to placebo including FEV(1), FVC, FEV(1) % predicted, PC20 FEV(1), evening PEF and symptom scores. The parent's assessment of efficacy was in favour of nedocromil (odds ratio (OR) 0.5 (95% CI 0.3 to 0.8). Nedocromil sodium has a good safety profile. The only significant side effect observed was unpleasant taste. There was little evidence for a clinically dose response effect and only a few studies recruited participants with severe asthma.

AUTHORS' CONCLUSIONS

A limited number of small studies have shown that nedocromil is of benefit in improving lung function and some measures of symptoms, but the evidence with regard to the primary outcome of the review was conflicting. Two long-term trials did not show consistent effects on lung function outcomes, whereas several small short-term trials have shown benefit in these outcomes. Differing severities at baseline may explain this difference with milder participants experiencing less benefit, although the discrepancy between study findings may also reflect publication bias. Nedocromil sodium is associated with a very good safety profile with no significant short term or long- term adverse side effects. Although nedocromil may have advantages over inhaled corticosteroids in terms of side effects, there is a need for head to head trials of nedocromil and inhaled corticosteroids to establish whether asthma control is similar, especially in mild asthma. It is not yet clear where nedocromil should sit in relation to other therapies in the treatment of asthma in children.

Nasal administration of albuterol: an alternative route of delivery

The use of metered-dose inhalers for the delivery of albuterol, a beta2-selective adrenergic agonist, is associated with drawbacks, especially in children and the elderly. This investigation was designed to assess the effectiveness of albuterol delivered intranasally and to compare this delivery route with intratracheal and intravenous delivery. Three parameters of pulmonary function (peak maximal expiratory flow, maximal expiratory flow at 50% vital capacity, and total lung capacity) in anaesthetized, artificially ventilated guinea pigs were used to determine the degree of protection produced by albuterol against bronchoconstrictor responses provoked by acetylcholine. The heart rate was also measured. Although intranasal albuterol induced a slower protective action during the very initial phase of absorption, the drug was shown to be equally effective when administered either intranasally or intratracheally. In contrast, despite a significant effect initially in the case of intravenous albuterol, its ability to influence pulmonary function faded rather rapidly. No statistically significant differences in heart rate could be detected among the different treatment groups. In conclusion, intranasal albuterol may offer an alternative to metered-dose inhalers for the treatment of acute bronchospasm and for prevention of exercise-induced asthma, especially for children and the elderly.

Randomized controlled trial of asthma education after discharge from an emergency department

OBJECTIVES

To test the hypothesis that reinforcement of the advice given at the time of discharge from the emergency department by telephone consultation would improve asthma outcomes.

METHODS

A randomized controlled trial of the parents of 310 children who had been discharged from the emergency department with asthma was undertaken. The parents were randomized to receive either standard care (155 children) or standard care plus education by telephone (155 children) from a trained asthma educator. Symptoms, parental asthma knowledge, parental quality of life and use of asthma action plans and preventer therapy were collected at baseline and 6 months later. The primary measure was days of wheeze in last 3 months; intermediate measures were regular use of preventer medications, possession and use of written asthma action plan, parental asthma knowledge scores and parental quality of life scores.

RESULTS

A total of 266 parents (136 intervention) completed the follow-up questionnaires after 6 months. Both groups showed similar symptoms and process measures at baseline, apart from more regular use of preventer medication in the control children. At follow up, the intervention group children were significantly more likely than controls to possess (87.5% vs 72.3%; P = 0.002) a written asthma action plan. Possession of action plans increased from baseline in the intervention group but tended to decrease in the control group. Use of action plans was greater in the intervention group but decreased from baseline in both groups. Both intervention and control groups showed significant decreases in asthma symptoms.

CONCLUSIONS

Reinforcement by telephone consultation did not improve the primary outcome of wheeze in the last 3 months. However, it increased the possession and regular use of written asthma action plans in the intervention group.

Minimizing attrition in a long-term clinical trial of pediatric asthma

BACKGROUND

Despite increased attention focused on the need to prevent patient attrition in long-term clinical trials, high dropout rates have threatened the success of numerous studies.

OBJECTIVE

To evaluate the disease, demographic, and psychological factors associated with missed visits and study dropout to help improve patient management in long-term clinical trials.

METHODS

Predictors of attrition were examined within the Childhood Asthma Management Program (CAMP), a large, multicenter clinical trial that followed up 1,041 children with asthma for 4 to 6 years.

RESULTS

Eighty-two percent of patients attended all study visits. The tendency to miss visits was increased among older children with milder asthma, lower intellectual and social competence, and more symptoms of behavioral problems and emotional distress. Forty-two patients who missed 3 or more visits in a row and did not attend the final visit were considered study dropouts; these patients at baseline had milder asthma; lower cognitive, academic, and social competence skills; and more family conflict and distress than found among participants who remained in the study. The 49 children who had erratic attendance but did not drop out also had lower intellectual and academic skills and less family social support.

CONCLUSIONS

The 4% dropout rate in CAMP was lower than reported in any previous long-term asthma trial. The findings of milder disease, decreased psychological resources, and increased distress in problem-attendance patients can assist in identifying patients who are at risk for missed visits or dropout during the trial either to block their entry into the trial or to focus efforts at maintaining their attendance once enrolled in the trial.

Self-management approaches for people with chronic conditions: a review

The purpose of this paper is to provide an overview of self-management approaches for people with chronic conditions. The literature reviewed was assessed in terms of the nature of the self-management approach and the effectiveness. Findings are discussed under the headings of: chronic conditions targeted, country where intervention was based, type of approach (e.g. format, content, tutor, setting), outcomes and effectiveness. The last of these focused on reports of randomised controlled studies.

Predictors of protocol adherence in a pediatric asthma clinical trial

BACKGROUND

Declining protocol adherence can threaten the validity of a clinical trial.

OBJECTIVE

We sought to explore patient and family factors important for protocol adherence in the 133 patients followed at one of the 8 Childhood Asthma Management Program (CAMP) clinical centers. Difficulties with timely return of diary cards (diary card problem), with keeping or frequently rescheduling appointments (appointment problem), and with commitment to all aspects of the trial (commitment problem) were tracked prospectively during the treatment phase of CAMP, which ranged from 20 to 40 months at the time of the analysis.

METHODS

We performed a cross-sectional analysis.

RESULTS

During the course of this investigation, no St Louis CAMP patients dropped out of the study, although signs of eroding participation were observed in 44% of patients. For this cross-sectional analysis, the percentage of patients exhibiting protocol-adherence problems was greater the longer patients had been in the trial: 33.3% at 20 to 25 months, 39.5% at 26 to 30 months, 51.4% at 31 to 35 months, and 69.2% at 36 to 40 months (P <.01). The diary card problem was present in 22.2% of the patients enrolled in the trial for 20 to 25 months compared with 66.7% for patients enrolled for 36 to 40 months (P <.005). Appointment and commitment problems were present in smaller percentages of patients and did not change by time in the trial (P =.41 and.22, respectively). A logistic regression analysis of demographic characteristics indicated that age at randomization and time in the trial were significant factors: for every 2-year increase in age, a child was twice as likely to have a commitment problem (odds ratio [OR], 1.96; 95% CI, 1.50-2.57), and for each additional 5 months of participation in the study, a child was twice as likely to have a diary card problem (OR, 1.91; 95% CI, 1.76-2.07). There was no influence of family income, patient race, or patient sex on the occurrence of any of the 3 protocol-adherence problems. A similar analysis of psychologic characteristics of the child and family indicated (1) a 2-fold increase in the risk of a diary card problem with a 10% increase in the percentage of total commissions on the attention scale of the Gordon Diagnostic Study (OR, 2.18; 95% CI, 2.02-2.35), (2) a 2-fold decrease in the risk of an appointment problem with a 10-unit increase in the Child Manifest Anxiety Scale (OR, 0.46; 95% CI, 0.44-0.49), (3) a 2-fold decrease in risk of an appointment problem with a 10-unit increase in the cohesion subscale of the Family Environment Scale (OR, 0.58; 95% CI, 0.55-0.60), and (4) a 5-fold decrease in the risk of a commitment problem with a 10-unit increase in the Child Depression Index score (OR, 0.21; 95% CI, 0.18-0.24).

CONCLUSIONS

Adherence and retention problems commonly occur in longer clinical trials. CAMP patients and families were selected in part on the basis of likelihood of being able to participate in the trial to enhance the conclusions of the trial. Despite this selection process, adherence problems were noted. Problems increased with duration of participation, increasing child age, and the presence of less family cohesion or attention problems in the child. In contrast, the presence of mild emotional distress (anxiety and depression) in the child was associated with fewer protocol-adherence problems. Incorporating procedures that help anticipate and identify adherence problems early might improve continued participation in all aspects of a trial and even retention in long-term clinical trials.

Self-management approaches for people with chronic conditions: a review

The purpose of this paper is to provide an overview of self-management approaches for people with chronic conditions. The literature reviewed was assessed in terms of the nature of the self-management approach and the effectiveness. Findings are discussed under the headings of: chronic conditions targeted, country where intervention was based, type of approach (e.g. format, content, tutor, setting), outcomes and effectiveness. The last of these focused on reports of randomised controlled studies.

Nocturnal awakening caused by asthma in children with mild-to-moderate asthma in the childhood asthma management program

BACKGROUND

Nocturnal symptoms of asthma are a cause of significant morbidity and are included as a central feature in the categorization of asthma severity.

OBJECTIVES

Data from the Childhood Asthma Management Program were used to estimate the prevalence of nocturnal awakenings in 1041 children with mild-to-moderate asthma and to investigate the relationships between awakenings and peak flows, severity of asthma, and allergen sensitivity and exposure.

METHODS

Daily diary care data were recorded during a 28-day interval in the Childhood Asthma Management Program screening process. The data on morning and evening peak flows, overall symptom codes, albuterol use for symptoms, and nocturnal awakenings for asthma symptoms were analyzed and compared with measures of personal characteristics, pulmonary function, and environmental characteristics of the patients.

RESULTS

Three hundred fifty-one (33.7%) children experienced 1 or more night awakenings caused by asthma during the 28-day screening period while not taking any maintenance medications. Greater risk of night awakening was associated with more severe asthma (greater responsiveness to bronchodilator, airway reactivity to methacholine, peak flow variability, and use of albuterol for symptoms, all P <.0001) and atopy (increased IgE and allergy skin test reactivity, both P =.0002). Those with a positive skin test response to dog and a high level of dog allergen in the home had a greater risk of night awakening caused by asthma (P =.01), as did those with a positive skin test response to cat and a high level of cat allergen in the home (P =.04). Mean daily symptom code and use of albuterol for asthma symptoms increased in the 3 days immediately before a single awakening compared with in the 4 to 6 days before the awakening (P =.02 and P =.01, respectively); however, both morning and evening peak flows as a percentage of personal best were similar in both intervals. Mean daily symptom code and daily use of albuterol were greater in the 3 days after an awakening than in the 3 days before (P <.0001 and P =.0002, respectively). Mean evening peak flow percentage of personal best the day after an episode of awakening was lower when a second consecutive awakening occurred than when there was only a single awakening (P =.01).

CONCLUSIONS

Nocturnal awakening occurred in one third of the children with mild-to-moderate asthma during a month of relative stability and appears to be an indicator of asthma that is becoming increasingly severe.

Risk factors for lack of asthma self-management knowledge among ED patients not on inhaled steroids

The study objective was to estimate the level of asthma knowledge and self-management skills among asthmatic patients who are not on inhaled corticosteroids and who present with acute asthma to the emergency department (ED). The design was to interview of patients by telephone at 90 to 100 days after enrollment in the Fourth Multicenter Airways Research Collaboration (MARC-4), a randomized trial comparing inhaled fluticasone versus placebo in addition to standard post-ED therapy. The setting was a multicenter trial involving 41 US urban EDs. Persons aged 12 to 54, not on inhaled steroids, who presented to the ED with acute asthma were studied. Of the 617 patients enrolled on MARC-4 405 (66%) were contacted. Mean (+/-SD) age was 30 (+/-11); 54% were women; acute asthma severity was 44% moderate and 56% severe; and 9% had prior intubation. Twenty percent (95% CI 16%-24%) responded that asthma could not be monitored and 40% (95% CI 35%-44%) scored low on a hypothetical acute asthma attack scenario. Predictors for lack of asthma knowledge and self-management skills were: less than a high school education; current smoking; lower median household income; and no history of steroid use. These data suggest that many ED patients with asthma have poor knowledge of asthma monitoring and poor self-management skills and that a "high risk" group is also identifiable. Efforts to design and implement an ED-based educational program should be tailored to better meet the needs of this high risk group.

Challenges in assessing outcomes for pediatric asthma

Although progress has been made in understanding asthma, much remains unknown; as a result, diagnosis and treatment are not optimal. Information is still needed about the natural history of asthma to better understand which patients are at risk of inflammation and at what point during their disease that inflammation occurs. In the case of children, a greater understanding of the disease's natural history is needed to establish criteria for early diagnosis and to evaluate progressive aspects of the disease so that appropriate measures of progression can be defined. The safety of various medications used as long-term controllers must also be evaluated. The growing information about medication effects on asthma provides unique opportunities to design studies that will guide improvement in asthma care. A number of disease outcomes can be used as surrogate markers of clinically significant endpoints, and a number of adverse effects may serve as surrogate markers. The consequences of poor control of pediatric asthma can be observed in a variety of clinical markers, including clinical features of the disease that worsen as it progresses, pulmonary function deterioration, lung hyperexpansion, and inflammation increases. The Childhood Asthma Management Program is an ongoing clinical trial designed to improve the diagnosis and treatment of asthma in children. Its hypothesis is that anti-inflammatory treatment of childhood asthma will not only relieve morbidity but will also improve lung growth.

Long-term effects of budesonide or nedocromil in children with asthma

BACKGROUND

Antiinflammatory therapies, such as inhaled corticosteroids or nedocromil, are recommended for children with asthma, although there is limited information on their long-term use.

METHODS

We randomly assigned 1041 children from 5 through 12 years of age with mild-to-moderate asthma to receive 200 microg of budesonide (311 children), 8 mg of nedocromil (312 children), or placebo (418 children) twice daily. We treated the participants for four to six years. All children used albuterol for asthma symptoms.

RESULTS

There was no significant difference between either treatment and placebo in the primary outcome, the degree of change in the forced expiratory volume in one second (FEV1, expressed as a percentage of the predicted value) after the administration of a bronchodilator. As compared with the children assigned to placebo, the children assigned to receive budesonide had a significantly smaller decline in the ratio of FEV1 to forced vital capacity (FVC, expressed as a percentage) before the administration of a bronchodilator (decline in FEV1:FVC, 0.2 percent vs. 1.8 percent). The children given budesonide also had lower airway responsiveness to methacholine, fewer hospitalizations (2.5 vs. 4.4 per 100 person-years), fewer urgent visits to a caregiver (12 vs. 22 per 100 person-years), greater reduction in the need for albuterol for symptoms, fewer courses of prednisone, and a smaller percentage of days on which additional asthma medications were needed. As compared with placebo, nedocromil significantly reduced urgent care visits (16 vs. 22 per 100 person-years) and courses of prednisone. The mean increase in height in the budesonide group was 1.1 cm less than in the placebo group (22.7 vs. 23.8 cm, P=0.005); this difference was evident mostly within the first year. The height increase was similar in the nedocromil and placebo groups.

CONCLUSIONS

In children with mild-to-moderate asthma, neither budesonide nor nedocromil is better than placebo in terms of lung function, but inhaled budesonide improves airway responsiveness and provides better control of asthma than placebo or nedocromil. The side effects of budesonide are limited to a small, transient reduction in growth velocity.

Atopic diseases and upper respiratory infections

This article reviews information on the topics of asthma, atopic dermatitis, food allergy, and upper respiratory infections. The asthma section provides an in-depth look at sociodemographic factors contributing to asthma morbidity and the barriers to asthma control. New findings on the triggers and therapies of atopic dermatitis and new articles on formula allergy and peanut allergy are presented. Recent publications in the areas of sinusitis and upper respiratory infections are also reviewed.

The changing faces of asthma

Over the last 20 years, the understanding of the pathogenesis of asthma has changed dramatically. Asthma is now seen as a disease of chronic airway inflammation. Consequently, the paradigm of management has expanded from "as-needed bronchodilators" to include maintenance therapy with antiinflammatory medications and action plans. Health care professionals are assessing medications as potential disease-modifying drugs. To do this, they must understand the natural history of asthma and identify the markers of the disease that reflect long-term outcomes. This article reviews the way in which the concept of asthma has changed, the impact of this new knowledge on the basis of medication selection, and the options for evaluating the effect of medications on long-term outcomes. Reevaluating information will continue to expand our horizon of methods to improve asthma management.