Processes of Care for Individuals with Work Related Asthma: Treatment Characteristics and Impact of Asthma on Work

The prevalence of asthma among working adults continues to rise each year. The California Department of Health Services conducts surveillance of work related asthma (WRA) to classify each work related exposure using Doctor's First Reports of Occupational Illness and Injury (DFRs). Using a cross-sectional, descriptive, comparative design, additional interviews were conducted and medical records were reviewed to explore workers' and providers' perceptions of follow up care. Two cohorts were compared: workers with WRA who belonged to a large, single HMO (n = 79) and workers with WRA who underwent follow up outside this HMO (n = 76). The interview asked about providers seen, tests ordered, and the impact of asthma on work. The HMO clients were significantly more likely than the non-HMO clients to see occupational medicine specialists (p = .004) and have pulmonary function testing (p = .049) during initial treatment. Twenty-four percent of clients currently working reported missed workdays caused by asthma in the past 6 months. The findings indicate management of WRA varies by health care system in California.

Bangladeshi school-age children's experiences and perceptions on child maltreatment: A qualitative interview study

BACKGROUND

Child maltreatment (CM) is a public health problem and is recognized as a huge barrier for child development. Most of the research and definitions on CM are from the perspective of high-income western countries. Because no major studies have been conducted on CM in Bangladesh, the aim of the current study was to explore the experiences of and perceptions on CM in school-age children in rural and urban Bangladesh in order to understand maltreatment in a local context and from a child perspective.

METHODS

Semistructured individual interviews with 24 children (13 boys and 11 girls), between the ages of 9 and 13 years of which 11 were schoolgoing and 13 non-schoolgoing, were conducted during July 2013 and analysed according to qualitative content analysis.

RESULTS

CM was a common and painful experience with serious physical and emotional consequences but highly accepted by the society. Vulnerable groups were especially young children, girls, and poor children. The children's voices were not heard due to their low status and low position in their families, schools, and working places. The main theme that emerged in the analysis was children's subordination, which permeated the five categories: (a) perception of children's situation in society, (b) understanding children's development and needs, (c) CM associated to school achievement, (d) negative impact of CM, and (e) emotional responses.

CONCLUSIONS

Different kinds of abuse are obviously common in Bangladesh, and the schools do not follow the law from 2011 prohibiting corporal punishment at school. The society has to take further steps to live up to the UN Convention on the Rights of the Child, which was ratified already in 1990, to protect the Bangladeshi children from CM.

Huddle-coaching: a dynamic intervention for trainees and staff to support team-based care

Many outpatient clinics where health professionals train will transition to a team-based medical home model over the next several years. Therefore, training programs need innovative approaches to prepare and incorporate trainees into team-based delivery systems. To address this need, educators at the San Francisco Veterans Affairs (VA) Medical Center included trainees in preclinic team "huddles," or briefing meetings to facilitate care coordination, and developed an interprofessional huddle-coaching program for nurse practitioner students and internal medicine residents who function as primary providers for patient panels in VA outpatient primary care clinics. The program aimed to support trainees' partnerships with staff and full participation in the VA's Patient Aligned Care Teams. The huddle-coaching program focuses on structuring the huddle process via scheduling, checklists, and designated huddle coaches; building relationships among team members through team-building activities; and teaching core skills to support collaborative practice. A multifaceted evaluation of the program showed positive results. Participants rated training sessions and team-building activities favorably. In interviews, trainees valued their team members and identified improvements in efficiency and quality of patient care as a result of the team-based approach. Huddle checklists and scores on the Team Development Measure indicated progress in team processes and relationships as the year progressed. These findings suggest that the huddle-coaching program was a worthwhile investment in trainee development that also supported the clinic's larger mission to deliver team-based, patient-aligned care. As more training sites shift to team-based care, the huddle-coaching program offers a strategy for successfully incorporating trainees.

Exploring risk for abuse of children with chronic conditions or disabilities--parent's perceptions of stressors and the role of professionals

BACKGROUND

Children with chronic conditions or disabilities are at an increased risk for abuse. High level of parental stress has been identified as possible trigger for abuse, were a combination of several factors are of importance, as lack of social support and limited resources in the neighbourhood. Suggestions for preventive measures have merely focused on parenting strategies and targeted intervention programmes. So far, little attention has been paid on how the risk for abuse might relate to parent's perceptions of stressors and the role of professionals. The purpose of the current study was therefore to explore risk factors for abuse with focus on both parent-child and parent-professional relationships.

METHOD

Semi-structured in-depth interviews with 15 parents of children with chronic conditions or disability were collected and analysed according to qualitative content analysis.

FINDINGS

Three major themes were found that could be seen as risk factors for child abuse: (1) Emotional demands in precarious situations between parent and child. (2) Gradual shift in responsibility from professionals to parents concerning access to and co-ordination of service and support. (3) Emotionally closed environment between professionals and parents and taboo on talking about abuse. The gradual shift in responsibility had emotional implications, which could reinforce parental stress and thereby also indirect increase the risk of child abuse. The gradual shift in responsibility also seemed to generate an emotionally closed environment and reinforce the taboo on talking about abuse, which in turn hindered preventive measures.

CONCLUSIONS

In the light of parent's perceptions of stressors and the role of professionals the findings indicate that abuse against children with chronic conditions or disability is not only a family matter, but also depending on qualities in service, professional support and social norms. The result pinpoints three challenges for preventive measures, all with emotional implications, parental strategies, organizational efforts and cultural awareness.

Molecular identification of hybrids of the invasive gibel carp Carassius auratus gibelio and crucian carp Carassius carassius in Swedish waters

Both mitochondrial DNA sequence and two nuclear microsatellite markers were used to confirm the identity of the first record of Carassius auratus gibelio in the western (Swedish) Baltic Sea region. A total of 49 fishes were analysed, where 22 were from three Swedish sites connected to the Baltic Sea. The D-loop mitochondrial DNA sequences showed that 16 of 22 Swedish fishes were related to C. a. gibelio. The phylogenetic analysis of these sequences showed that these fish are probably not native, but represent different lineages of C. a. gibelio from China, Japan and Russia. All except three of these 16 fishes had microsatellite alleles suggesting hybridization with Carassius carassius. These findings suggest that a cryptic invasion of C. a. gibelio might be in progress.

Governance and implementation of sports safety practices by municipal offices in Swedish communities

The objective of this study was to explore whether all-purpose health or safety promotion programmes and sports safety policies affect sports safety practices in local communities. Case study research methods were used to compare sports safety activities among offices in 73 Swedish municipalities; 28 with ongoing health or safety promotion programmes and 45 controls. The offices in municipalities with the WHO Healthy Cities (HC) or Safe Communities programmes were more likely to perform frequent inspections of sports facilities, and offices in the WHO HC programme were more likely to involve sports clubs in inspections. More than every second, property management office and environmental protection office conducted sports safety inspections compared with less than one in four planning offices and social welfare offices. It is concluded that all-purpose health and safety promotion programmes can reach out to have an effect on sports safety practices in local communities. These safety practices also reflect administrative work routines and managerial traditions.

Suicide mortality trends in young people aged 15 to 19 years in Lithuania

AIM

This paper considers the suicide mortality trends from 1990-2009 in young people aged 15 to 19 years in Lithuania.

METHODS

Suicide and injury mortality data, plus mortality data from all causes, were used to compare the trend lines.

RESULTS

Suicide mortality rate in young people aged 15-19 years and in all population showed a rising trend from 1990, and then a decreasing trend from 2002 year. This trend was significant exclusively in boys. When comparing suicide deaths as a percentage of injury deaths and of all deaths in the age group 15-19 years, rising trends for boys were evident, whilst in girls, there was no evidence of change.

CONCLUSIONS

In Lithuania, from early 1990s, the frequency of suicide increased amongst adults and young people aged 15-19 years. After 2002, a decrease in deaths by suicide was observed both for the whole population and for young people aged 15-19 years. The rise and fall was obvious for boys. The reasons for different trends may have been influenced by the political and socioeconomic instability in the 1990-2002 period, and the socioeconomic stability, together with active preventive measures, from 2002. Although the consumption of modern Selective serotonin reuptake inhibitors (SSRIs) increased during the same time, suicide mortality was again high during the economic crisis in 2008-2009.

PVC--as flooring material--and its association with incident asthma in a Swedish child cohort study

The Dampness in Buildings and Health study (DBH) started in the year 2000 in Värmland, Sweden, with a baseline questionnaire sent to all children (n = 14,077) aged 1-6. Five years later, a follow-up questionnaire was sent to the children who were 1-3 years at baseline. A total of 4779 children participated in both the baseline and the follow-up studies and constitute the study population in this cohort study. The aim of this study was to examine the association between exposure to PVC-flooring in the child's and parent's bedroom in homes of children aged 1-3 and the incidence of asthma, rhinitis, and eczema during the following 5-year period. Adjusted analyses showed that the incidence of asthma among children was associated with PVC-flooring in the child's bedroom (AOR 1.52; 95% CI 0.99-2.35) and in the parent's bedroom (1.46; 0.96-2.23). The found risks were on borderline of significance and should therefore be interpreted with caution. There was further a positive relationship between the number of rooms with PVC-flooring and the cumulative incidence of asthma. PVC-flooring was found to be a stronger risk factor for incident asthma in multifamily homes when compared with single-family houses and in smoking families compared with non-smoking families and in women.

PRACTICAL IMPLICATIONS

These longitudinal data from the DBH study found an association between the presence of PVC-flooring in the home and incident asthma in children. However, earlier results from the DBH study have shown that PVC-flooring is one important source for phthalates in indoor dust, and exposure to such phthalates was found to be associated with asthma and allergy among children. This emphasizes the need for prospective studies that focus on the importance of prenatal and neonatal exposure to phthalates in the development of asthma and allergy in children.

Summary of NIH Medical-Surgical Emergency Research Roundtable held on April 30 to May 1, 2009

STUDY OBJECTIVE

In 2003, the Institute of Medicine Committee on the Future of Emergency Care in the United States Health System convened and identified a crisis in emergency care in the United States, including a need to enhance the research base for emergency care. As a result, the National Institutes of Health (NIH) formed an NIH Task Force on Research in Emergency Medicine to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. The objectives of these discussions were to identify key research questions essential to advancing the scientific underpinnings of emergency care and to discuss the barriers and best means to advance research by exploring the role of research networks and collaboration between the NIH and the emergency care community.

METHODS

The Medical-Surgical Research Roundtable was convened on April 30 to May 1, 2009. Before the roundtable, the emergency care domains to be discussed were selected and experts in each of the fields were invited to participate in the roundtable. Domain experts were asked to identify research priorities and challenges and separate them into mechanistic, translational, and clinical categories. After the conference, the lists were circulated among the participants and revised to reach a consensus.

RESULTS

Emergency care research is characterized by focus on the timing, sequence, and time sensitivity of disease processes and treatment effects. Rapidly identifying the phenotype and genotype of patients manifesting a specific disease process and the mechanistic reasons for heterogeneity in outcome are important challenges in emergency care research. Other research priorities include the need to elucidate the timing, sequence, and duration of causal molecular and cellular events involved in time-critical illnesses and injuries, and the development of treatments capable of halting or reversing them; the need for novel animal models; and the need to understand why there are regional differences in outcome for the same disease processes. Important barriers to emergency care research include a limited number of trained investigators and experienced mentors, limited research infrastructure and support, and regulatory hurdles. The science of emergency care may be advanced by facilitating the following: (1) training emergency care investigators with research training programs; (2) developing emergency care clinical research networks; (3) integrating emergency care research into Clinical and Translational Science Awards; (4) developing emergency care-specific initiatives within the existing structure of NIH institutes and centers; (5) involving emergency specialists in grant review and research advisory processes; (6) supporting learn-phase or small, clinical trials; and (7) performing research to address ethical and regulatory issues.

CONCLUSION

Enhancing the research base supporting the care of medical and surgical emergencies will require progress in specific mechanistic, translational, and clinical domains; effective collaboration of academic investigators across traditional clinical and scientific boundaries; federal support of research in high-priority areas; and overcoming limitations in available infrastructure, research training, and access to patient populations.

Sever's injury: treatment with insoles provides effective pain relief

Sever's injury (apophysitis calcanei) is considered to be the dominant cause of heel pain among children between 8 and 15 years. The traditional advice is to reduce and modify the level of physical activity. Recommended treatment in general is the same as for adults with Achilles tendon pain. The purpose of the study was to find out if insoles, of two different types, were effective in relieving heel pain in a group of boys (n=38) attending a Sports Medicine Clinic for heel pain diagnosed as Sever's injury. The type of insole was randomized, and self-assessed pain during physical activity in the treatment phase with insoles was compared with pain in the corresponding pre- and post-treatment phases without insoles. There were no other treatments added and the recommendations were to stay on the same activity level. All patients maintained their high level of physical activity throughout the study period. Significant pain reduction during physical activity when using insoles was found. Application of two different types of insoles without any immobilization, other treatment, or modification of sport activities results in significant pain relief in boys with Sever's injury.

Does health service use in a diabetes management program contribute to health disparities at a facility level? Optimizing resources with demographic predictors

The objective of this study was to determine if demographic variation in the use of health service resources among type 2 diabetes patients contributes to health disparities. A prospective cohort design was used to analyze differences in health care utilization among 315 adults registered in primary care internal medicine clinics of an academic medical center. Patients were cared for by interdisciplinary teams of internal medicine residents, nurse practitioner students, and pharmacy students supervised by interdisciplinary faculty. A post hoc multivariate repeated measures analysis, using generalized estimating equation (GEE) statistical modeling, was used to determine if age, sex, race, ethnicity, marital status, primary language, and insurance predicted use of health care services (ie, primary care, acute care, emergency department [ED], hospitalization). Medicare/Medicaid-insured patients had an average of 2.49 primary care visits per month (P < .0001) and 75% more ED visits (P < .001) during the study than patients with other insurance types. ED visits for Hispanics grew by a factor of 3.3 compared to non-Hispanics (P < .0001). Females had 52% more hospitalizations than males (P < .05), and Hispanics had 44% fewer hospitalizations than non-Hispanics (P < .05). Analysis of selected health status indicators showed no significant differences for HbA1c, significantly greater likelihood of blood pressure >130/80 with every 5-year increase in age, and significantly greater likelihood of low-density lipoprotein >100 among Medicare/Medicaid-insured patients. Sociodemographic characteristics are predictive of health care services use and suggest that, although equally available to all participants, the use of health care resources vary at the facility level and are independent of diabetes health status outcomes.

Low home ventilation rate in combination with moldy odor from the building structure increase the risk for allergic symptoms in children

There are consistent findings on associations between asthma and allergy symptoms and residential mold and moisture. However, definitions of 'dampness' in studies are diverse because of differences in climate and building construction. Few studies have estimated mold problems inside the building structure by odor assessments. In a nested case-control study of 400 Swedish children, observations and measurements were performed in their homes by inspectors, and the children were examined by physicians for diagnoses of asthma, eczema, and rhinitis. In conclusion, we found an association between moldy odor along the skirting board and allergic symptoms among children, mainly rhinitis. No associations with any of the allergic symptoms were found for discoloured stains, 'floor dampness' or a general mold odor in the room. A moldy odor along the skirting board can be a proxy for hidden moisture problem inside the outer wall construction or in the foundation construction. There are indications that such dampness problems increase the risk for sensitization but the interpretation of data in respect of sensitization is difficult as about 80% of the children with rhinitis were sensitized. Furthermore, low ventilation rate in combination with moldy odor along the skirting board further increased the risk for three out of four studied outcomes, indicating that the ventilation rate is an effect modifier for indoor pollutants.

PRACTICAL IMPLICATIONS

This study showed that mold odor at the skirting board level is strongly associated with allergic symptoms among children. Such odor at that specific place can be seen as a proxy for some kind of hidden moisture or mold problem in the building structure, such as the foundation or wooden ground beam. In houses with odor along the skirting board, dismantling of the structure is required for an investigation of possible moisture damage, measurements, and choice of actions. In homes with low ventilation in combination with mold odor along the skirting board, there was even a higher risk of health effects. This emphasizes the need for the appropriate remediation as this is an ever increasing problem in poorly ventilated houses that are damp.

Incidence rates of asthma, rhinitis and eczema symptoms and influential factors in young children in Sweden

AIM

To estimate the incidence rates for asthma, rhinitis and eczema symptoms and to investigate the importance of different influential factors for the incidence of these symptoms.

METHODS

The Dampness in Building and Health study commenced in the year 2000 in Värmland, Sweden with a parental questionnaire based on an ISAAC protocol to all children in the age of 1-6 years. Five years later a follow-up questionnaire was sent to the children that were 1-3 years at baseline. In total, 4779 children (response rate = 73%) participated in both surveys and constitute the study population in this cohort study.

RESULTS

The 5-year incidence of doctor-diagnosed asthma was 4.9% (95% CI 4.3-5.3), rhinitis was 5.7% (5.0-6.4) and eczema was 13.4% (12.3-14.5). However, incidence rates strongly depend on the health status of the baseline population. Risk factors for incident asthma were male gender and short period of breast-feeding. Allergic symptoms in parents were also a strong risk factor for incident asthma, as well as for rhinitis and eczema.

CONCLUSION

When comparing incident rates of asthma between different studies it is important to realize that different definitions of the healthy baseline population will give rise to different incident rates.

Rock climbing injury rates and associated risk factors in a general climbing population

The objective was to examine injury rates and associated risk factors in a representative sample of climbers. A random sample (n=606) of the Swedish Climbing Association members was sent a postal survey, with an effective response rate of 63%. Self-reported data regarding climbing history, safety practices and retrospective accounts of injury events (recall period 1.5 years) were obtained. Descriptive statistical methods were used to calculate injury incidences, and a two-step method including zero-inflated Poisson's regression analysis of re-injuries was used to determine the combination of risk factors that best explained individual injury rates. Overall, 4.2 injuries per 1000 climbing hours were reported, overuse injuries accounting for 93% of all injuries. Inflammatory tissue damages to fingers and wrists were the most common injury types. The multivariate analysis showed that overweight and practicing bouldering generally implied an increased primary injury risk, while there was a higher re-injury risk among male climbers and a lower risk among the older climbers. The high percentage of overuse injuries implies that climbing hours and loads should be gradually and systematically increased, and climbers regularly controlled for signs and symptoms of overuse. Further study of the association between body mass index and climbing injury is warranted.

Health behaviours, risk-taking and conceptual changes among schoolchildren aged 7 to 19 years in semi-rural Sweden

BACKGROUND

This study covers a broad age group (7-19 years) and includes a wide range of themes. The aim is to describe how various behaviours, complaints and conceptual changes come into play and to discuss the factors that might support or hamper the happiness and well-being of growing children and adolescents. We also discuss the implications of our findings for future prevention programmes.

METHODS

This cross-sectional study included all schoolchildren in a semi-rural district in Sweden (2181 pupils). A structured classroom questionnaire was used but the children were also given the opportunity to describe in their own words what was important for their happiness and well-being.

RESULTS

Mean response rate was 85%. Most changes in behaviour occurred between 11 and 14 years of age. Girls had a more rapid process of change than boys. Both girls and boys experienced stress in their relations with peers, parents and teachers. Gender differences in emotional support were prominent. Regardless of age and sex, all schoolchildren asked for a richer choice of leisure time activities, a place where they could meet with friends and caring teachers, parents and adults in the surrounding community.

CONCLUSIONS

Adolescence was perceived as a risky and problematic period not only by adults but also by the adolescents themselves. However, the perceived risks and the worries differed. While the adults mainly worried about the early onset of smoking and drug use, the schoolchildren worried about their social situation and their personal relationships. After decades of preventive programmes in Swedish schools, only modest results are seen. To be effective, future preventive programmes probably have to focus more on the conceptual world of the growing child.

Traffic injury mortality in children in transitional Lithuania--a longitudinal analysis from 1971 to 2005

AIM

Low- and middle-income countries bear far higher road traffic injury mortality rates than high-income countries. This paper considers the changing picture of child traffic injury mortality in Lithuania over a 35-year period.

METHODS

Road traffic injury mortality data, mortality data from other causes, and population data have been used to compare the trend lines of child road deaths with injury deaths and all deaths and calculate the road traffic mortality rates for children and young people aged 0-19 years.

RESULTS

This study revealed an inverted u-shaped trend, peaking in the 1980s and with a temporary elevated level in the early 1990s, in traffic mortality for the age group 0-19. However, unlike child death by all causes, road traffic injury has not declined significantly between the beginning and the end of the study period. Traffic deaths as a percentage of injury deaths and of all deaths showed a significantly rising trend.

CONCLUSION

Road traffic injury remains a serious public health problem in children and young people in Lithuania, which requires a high priority.

Adherence to a home-walking prescription in patients with chronic obstructive pulmonary disease

BACKGROUND

We know little about long-term exercise behavior and adherence in patients with chronic obstructive pulmonary disease (COPD).

PURPOSE

The study's purpose was (1) to describe exercise behavior and adherence to a home-walking exercise prescription over 12 months in a sample of patients with COPD; and (2) to validate categories of exercise adherence over time in this population.

DESIGN

This was a secondary analysis of a randomized controlled trial.

SUBJECTS

A total of 103 participants with COPD who were randomly assigned to one of three versions of a dyspnea self-management program participated.

MEASURES

The components of exercise frequency, duration, and intensity were measured by exercise/dyspnea daily logs, and participants were classified into categories on the basis of their pattern of exercise adherence over the year.

RESULTS

Participants walked an average of 3 days per week initially, with a decline to 2.5 days per week over the year. On average, participants walked longer than the prescribed duration of 20 minutes per session. Dyspnea intensity at the end of the walk tended to remain stable at a mean level of 4 over the year. Classification by adherence category distinguished differences in 6-minute walk distance, endurance treadmill test time, Short Form-36 physical function, and Short Form-36 mental health, with endurance treadmill test time and physical function improvements mirroring increases in exercise adherence, and mental health highest among occasional lapse and lowest among relapser and recycle categories.

CONCLUSIONS

This investigation provides a description of long-term exercise behavior and adherence in a sample of patients with COPD. The categories suggest that physical benefits are related to consistent adherence, whereas mental health improvements are related to regular exercise with some flexibility in the schedule. Future research should test interventions to improve exercise adherence in patients with COPD and identify characteristics of patients who are most likely and least likely to adhere over time.

Using rare diseases as models for biobehavioral research: allergic bronchopulmonary aspergillosis

Biobehavioral science explores links between biological, psychosocial, and behavioral factors and health. Maintaining positive health outcomes over time and across a variety of populations and settings requires understanding interactions among biological, behavioral, and social risk factors as well as other variables that influence behavior. Some barriers to biobehavioral research are related to performing biobehavioral research along the natural history of an illness, limitations in existing methodologies to assess the biological impact of behavior, the unknowns relating to impact of behavior on biology, and lack of valid and reliable biobehavioral methods to assess outcomes. A rare disease, such as allergic bronchopulmonary aspergillosis (ABPA) can be used as a model of biobehavioral research. ABPA complicates asthma and cystic fibrosis. It is a hypersensitivity reaction to Aspergillus fumigatus in most cases. ABPA can be classified into five stages: acute, remission, exacerbation, steroid-dependent asthma, and fibrotic or end stage. Because of its rarity, there can be delays in diagnosis. Treatment has used oral corticosteroids and antifungal agents in addition to management of asthma or cystic fibrosis. The National Institute of Nursing Research held an invitational 2-day working group meeting on July 15-16, 2004 with biobehavioral, biological, and immunologic science experts to examine current knowledge of biobehavioral research and to provide recommendations for additional research. The focus was on biobehavioral methods of measurement and analysis with interdisciplinary/biobehavioral approaches. This article is an outcome of this meeting.

Impact of the home indoor environment on adult asthma and rhinitis

OBJECTIVE

We sought to study the combined effects of multiple home indoor environmental exposures in adult asthma and rhinitis.

METHODS

We studied 226 adults with asthma and rhinitis by structured interviews and home assessments. Environmental factors included dust allergen, endotoxin and glucan concentrations, and indoor air quality (IAQ) variables. Outcomes included forced expiratory volume in 1 second (FEV1) percent predicted, Severity of Asthma Score (SAS), Short-Form (SF)-12 Physical Component Scale (PCS), and asthma Quality of Life (QOL) score.

RESULTS

House dust-associated exposures together with limited IAQ variables were related to FEV1 % predicted (R = 0.24; P = 0.0001) and SAS (R = 0.18; P = 0.007). IAQ and limited dust variables were associated with SF-12 PCS (R = 0.15; P = 0.02), but not QOL (R = 0.13; P = 0.16).

CONCLUSIONS

The home environment is strongly linked to lung function, health status, and disease severity in adult asthma and rhinitis.

Group discussions with parents have long-term positive effects on the management of asthma with good cost-benefit

AIM

To investigate if an intervention with extra information and support in a group setting to parents of preschool children could improve adherence and clinical outcome.

METHODS

This is a controlled, prospective study where the parents of 60 newly diagnosed preschool asthmatic children aged 3 mo-6 y were randomized to either a control group or to an intervention that consisted of four group sessions in close connection with the diagnosis. The basic education on asthma and the written treatment plan were the same in both groups. The outcome measures were questionnaires to the parents and classification of the children according to symptoms and medication. The adherence rate and the burden of asthma were calculated with the help of diaries and weighing of the MDIs used between 12 and 18 mo after inclusion.

RESULTS

The follow-up rate was 85% after 18 mo. The parents' presence in the sessions was around 70%, with no gender difference. The parents' view on adherence issues improved significantly in the intervention group. In the control group, 30% had poor adherence compared to 8% in the intervention group (p=0.015). Both the parents and the paediatricians underestimated the number of children with poor adherence. The children in the intervention group had significantly fewer exacerbation days during the last 6 mo-2.1 compared to 3.9 d/child-although they had lower inhaled steroid doses after 18 mo. An economic calculation showed that the intervention was profitable.

CONCLUSION

This intervention resulted in an improvement in the parents' view on adherence, in the measured adherence rates and in the clinical outcome.

'Dampness' at home and its association with airway, nose, and skin symptoms among 10,851 preschool children in Sweden: a cross-sectional study

There is convincing epidemiological evidence that 'dampness' in buildings is associated with respiratory effects. In order to identify health-relevant exposures in buildings with 'dampness', the study 'Dampness in Buildings and Health' (DBH) was initiated. In the first step of the study, cross-sectional data on home characteristics including 'dampness' problems, and symptoms in airway, nose, and skin among 10,851 children (1-6 years), were collected by means of a questionnaire to the parents. The prevalence of wheezing during the last 12 months was 18.9% and doctor-diagnosed asthma 5.4%. Rhinitis during the last 12 months was reported for 11.1% of the children and eczema during the last 12 months 18.7%. Gender, allergic symptoms among parents, and age of the child were associated with symptoms. Water leakage was reported in 17.8% of the buildings, condensation on windows in 14.3%, and detached flooring materials in 8.3%. Visible mould or damp spots were reported in only 1.5% of the buildings. The four 'dampness' indices were associated to higher prevalence of symptoms in both crude and adjusted analysis. Furthermore, it was found that the combination of water leakage in the home and PVC as flooring material in the child's or parent's bedroom was associated to higher prevalence of symptoms among children. However, the interpretation of this finding is unclear. The combination of water leakage and PVC may be a proxy, for example, reconstruction because of water damages.

PRACTICAL IMPLICATIONS

The study have showed that moisture-related problems in buildings are a risk factor for asthma and allergic symptoms among preschool children. The recommendation to the general public is to remediate damp buildings.

Quantitation of platelet aggregation and microaggregate formation in whole blood by flow cytometry

Platelet aggregation and microaggregate formation were measured in samples of stirred whole blood by flow cytometry. Blood samples were stirred in a multi-sample agitator with ADP, fixed and labelled with a platelet-specific CD42a-FITC fluorescent antibody. The blood was then diluted and applied directly to a flow cytometer. Platelets were identified using a gating procedure based on their expression of CD42a and then quantified. Aggregation was monitored as a fall in the number of single platelets. Both reversible and irreversible aggregation responses to ADP were determined and these were found to correlate directly with aggregation responses determined using a well-established single platelet counting technique using the Ultra-Flo 100 Whole Blood Platelet Counter. We found from flow cytometry that ADP-induced aggregation was coupled with a transient formation of platelet microaggregates over the initial 60 s following ADP addition. Assessment of single platelet loss by flow cytometry was found to be a reliable way of monitoring aggregation responses and provided new information on rapid microaggregate formation in ADP-stimulated blood.

A national survey of asthma knowledge and practices among specialists and primary care physicians

Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two-thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one-third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.

Processes of care for individuals with work related asthma: treatment characteristics and impact of asthma on work

The prevalence of asthma among working adults continues to rise each year. The California Department of Health Services conducts surveillance of work related asthma (WRA) to classify each work related exposure using Doctor's First Reports of Occupational Illness and Injury (DFRs). Using a cross-sectional, descriptive, comparative design, additional interviews were conducted and medical records were reviewed to explore workers' and providers' perceptions of follow up care. Two cohorts were compared: workers with WRA who belonged to a large, single HMO (n = 79) and workers with WRA who underwent follow up outside this HMO (n = 76). The interview asked about providers seen, tests ordered, and the impact of asthma on work. The HMO clients were significantly more likely than the non-HMO clients to see occupational medicine specialists (p = .004) and have pulmonary function testing (p = .049) during initial treatment. Twenty-four percent of clients currently working reported missed workdays caused by asthma in the past 6 months. The findings indicate management of WRA varies by health care system in California.

Pet-keeping in early childhood and airway, nose and skin symptoms later in life

BACKGROUND

It is discussed whether exposure to pets during childhood is a risk or a protective factor for sensitization and allergic symptoms. The aim of this study was to investigate the association between pet-keeping at time of birth and allergic symptoms in airways, nose and skin among young children in Sweden.

METHOD

A questionnaire was sent to the parents of 14 077 children (1-6 years), the focus being on allergic symptoms, home environment and other background factors including pet-keeping and avoidance behaviour. The response rate was 79%.

RESULTS

Almost one-tenth of the population had got rid of pets because of allergy in the family, and 27.3% reported "avoidance" behaviour towards pets. In a cross-sectional analysis current pet-keeping was "protective", but this may be due to the fact that people avoid exposing their child to something that they believe is a risk factor for allergies. Pet-keeping at the time of birth was associated with "wheezing", "asthma" and "rhinitis on pet-exposure" later in life for children from families with an "avoidance" behaviour, and was not "protective" for other children. There was also an indication of a dose-response relationship between the number of types of furred pets at time of birth and later symptoms in analyses adjusted for avoidance behaviour or current pet-keeping.

CONCLUSION

The distribution of pet-keeping in the population is largely explained by avoidance behaviour, meaning that those who have pets mainly are those who can stand them, indicating a "healthy pet-keeping effect".

The burden of asthma as reflected by the prevalence defined by doctor's diagnosis and the use of healthcare services by preschool children in a Swedish region

AIM

Epidemiological data and reports on the prevalence and burden of preschool asthma are mainly based on questionnaires and generally give a prevalence of above 6% in Sweden. In this study we used other ways of studying the prevalence, risk factors and the use of healthcare services in a defined region.

METHODS

The catchment area included 9410 children aged 0-6 y. All outpatient clinics had computerized records of patients and visits to the outpatient clinic could be studied as well as admissions to hospital for asthma between 1988 and 1998.

RESULTS

According to patients' record data, the prevalence of doctor-diagnosed asthma was 4.5% in 1998. Seventy-nine percent of recorded patients are seen outside the hospital, thus the burden of asthma for the health system is mainly on the outpatient clinics. Admissions and especially readmissions to the hospital have decreased during the past decade. One-third of the children with newly diagnosed asthma had recurring exacerbations and risk for persistent asthma.

CONCLUSIONS

The prevalence of doctor-diagnosed asthma as measured by total mapping in a region is lower than that reported from questionnaire-based studies. Hospital admissions for preschool asthma have decreased possibly as a result of improved medical care in the paediatric outpatient clinics where asthma is a dominating diagnose. In one-third of identified new asthmatics, there is a high risk of developing persistent asthma.

Understanding how asthmatics perceive symptom distress during a methacholine challenge

The way, or ways, in which asthmatics recognize specific symptom(s) with varying degrees of their airway obstruction, or asthma severity, is poorly understood. Our purpose was to gain a better understanding of how asthma patients during acute episodes, based on their symptom perception, decide when to seek symptom relief. A cross-sectional design was used to study 32, 16 per group, African Americans and Caucasians with a mean age of 34.5 years. All had mild, stable asthma (FEV1 > or = 70%), were non-smokers, atopic, and had not used inhaled or oral steroids for 3 months. Their mean baseline FEV1 was 97.5% predicted; all were controlled with intermittent use of a beta agonist inhaler. All had a bronchoconstrictor challenge using a provocative concentration of methacholine to achieve a 30% fall (PC30) in their FEV1. After achieving a PC30 and before their first dose of a bronchodilator was given, all subjects were asked: "If you felt this way at home would you take your inhaler?" Subjects were blinded to the fact that the yes/no question was asked when their FEV1 was reduced by 30%. In both groups, 44% responded "no" that they would not use their inhaler at that point in time. This finding suggests that those subjects, the 44% who failed to associate a change in their symptoms with increased airflow obstruction, may be at risk for life-threatening episodes.

What nurses in primary care practices know about asthma care: results from a national survey

OBJECTIVES

The purpose of this study was to characterize what nurses working in primary care settings know about asthma care. Current views on the care of persons with asthma suggest the need for sound knowledge of guideline-based care and a health care team that includes both physicians, nurses, and other providers. While there are reports of physician-related asthma care practices in the United States, there are few, if any, reports of nursing knowledge, attitudes, or beliefs about asthma care.

METHODS

A national, randomly selected, representative sample of nurses working in ambulatory primary care settings was interviewed by telephone using a structured interview format.

RESULTS

Of a sample of 80 nurses, less than 10% identified inflammation of the airways as the underlying condition that causes asthma symptoms. Fifty-one percent believed the underlying condition could be treated, while 44% believed only the symptoms could be treated, and 5% didn't know. Only 35% said they were aware of the National Heart, Lung, and Blood (NHLBI) asthma guidelines.

CONCLUSIONS

Nurses working in ambulatory primary care settings may lack sufficient knowledge to effectively teach and participate in asthma care.

Where do leukotriene modifiers fit in asthma management?

Effective asthma treatment requires long-term inflammation control. Patient adherence to corticosteroid treatment regimens remains problematic. Leukotriene modifiers, a newer drug class, add to the pharmacologic approaches to asthma management. Here, we review the role of leukotrienes in asthma pathogenesis and appropriate uses for leukotriene modifiers in asthma management.

Relationship between airway inflammation, hyperresponsiveness, and obstruction in asthma

BACKGROUND

Although the role of eosinophils in airway inflammation in chronic asthma has been extensively studied, a role for neutrophils has not been well characterized. Furthermore, prior studies have not systematically sought or controlled for factors that might confound the relationship between cellular markers of inflammation and physiologic measures of airway function.

OBJECTIVE

The purpose of this study was to determine whether eosinophilic and neutrophilic inflammation independently contribute to abnormalities of airway function in asthma.

METHODS

Multivariate analysis of data collected during screening and enrollment of 205 asthmatic adults for clinical trials was conducted to examine the relationships between cellular inflammation in induced sputum and FEV(1) and methacholine responsiveness (PC(20)) while confounding factors were controlled for.

RESULTS

We found that age, sex, ethnicity, and use of inhaled corticosteroids were important confounding factors of the relationship between cellular inflammation and airway function. When these factors were controlled for, multivariate analysis showed that eosinophil percentage in induced sputum is independently associated with lower FEV(1) and lower PC(20) (P = .005 and P = .005, respectively). In the same models, increased sputum neutrophil percentage is independently associated with lower FEV(1) (P = .038) but not with PC(20) (P = .49).

CONCLUSIONS

These results suggest that both eosinophilic inflammation and neutrophilic inflammation independently contribute to abnormalities of FEV(1) in asthma. Therapies directed specifically at control of neutrophilic inflammation might be useful in improving airway caliber in patients with chronic asthma.

Alcohol, head injury, and pulmonary complications

The purpose of this study was to determine the difference in rates of pulmonary complications (e.g., aspiration, pneumonia) in head-injured patients with and without concomitant alcohol intoxication. The records of 98 consecutive patients admitted over a 1-year period to a Level I Trauma Center were reviewed. The patients were grouped into three subsets: acutely intoxicated (n = 26), acutely intoxicated with a diagnosis of chronic alcoholism (n = 14), and non-intoxicated (n = 58). Alcohol intoxication was defined as a blood alcohol level (BAL) > or = 0.08 mg/dl. Admission BALs and Glasgow Coma Scale (GCS) scores were tabulated at admission. Frequency of arterial blood gas (ABG) measurements, need for an artificial airway/mechanical ventilation, and length of stay (LOS) were analyzed by using one-way analysis of variance. Intergroup differences in breath sounds were compared by using the nonparametric Kruskall-Wallis technique. We found no statistical difference between groups in terms of pulmonary sequelae despite the remarkably high BALs observed in the study groups. Similarly, there was no statistically greater LOS in the groups with alcohol intoxication than in alcohol-free cohorts. Despite a great deal of BAL science research to support our hypothesis, we failed to demonstrate a significantly higher rate of pulmonary problems in inebriated individuals with head injuries. We found that our strict exclusion criteria (no concomitant chest, abdominal, or pelvic trauma) limited the sample to only those patients without significant intracranial bleeding, whereas most complications in blood alcohol neuroscience research have been associated with much larger mass lesions (e.g., epidural or subdural hematomas). In addition, we found the characterizations of patients as chronically alcoholic were cumbersome and inaccurate in many cases. Future research should allow for a greater range of concomitant injuries that might suggest a positive or negative relationship to acute intoxication.

Estimated prevalences of respiratory symptoms, asthma and chronic obstructive pulmonary disease related to detection rate in primary health care

OBJECTIVE

To assess the prevalence of respiratory symptoms, asthma and chronic obstructive pulmonary disease (COPD), and to relate it to an estimated detection rate in primary health care.

DESIGN

A two-staged study with a cross-sectional survey and a clinical validation.

SETTING

The adult population of Värmland, a county in Sweden.

SUBJECTS

4814 persons completed the survey and 206 the confirmative validation study.

MAIN OUTCOME MEASURES

Prevalence of respiratory symptoms, of asthma and COPD.

RESULTS

More than 40% reported respiratory symptoms. Wheeze was reported by 8.0%, shortness of breath by 11.4% and sputum production by 14.1%. Smoking was more common among women than among men. The prevalence of asthma was 8.2% and COPD 2.1%. Of persons with asthma, 33% were estimated to be undiagnosed, 67% used medication and nearly 60% attended primary health care services.

CONCLUSION

Respiratory symptoms as well as asthma were common in this study and equivalent to earlier findings. The difference between the epidemiologically estimated prevalence of asthma and the lower detection rate in primary health care can be explained by at least three factors: persons who did not seek any care, were underdiagnosed or attended other health care providers.

Advancing the science of symptom management

Since the publication of the original Symptom Management Model (Larson et al. 1994), faculty and students at the University of California, San Francisco (UCSF) School of Nursing Centre for System Management have tested this model in research studies and expanded the model through collegial discussions and seminars.

AIM

In this paper, we describe the evidence-based revised conceptual model, the three dimensions of the model, and the areas where further research is needed.

BACKGROUND/RATIONALE

The experience of symptoms, minor to severe, prompts millions of patients to visit their healthcare providers each year. Symptoms not only create distress, but also disrupt social functioning. The management of symptoms and their resulting outcomes often become the responsibility of the patient and his or her family members. Healthcare providers have difficulty developing symptom management strategies that can be applied across acute and home-care settings because few models of symptom management have been tested empirically. To date, the majority of research on symptoms was directed toward studying a single symptom, such as pain or fatigue, or toward evaluating associated symptoms, such as depression and sleep disturbance. While this approach has advanced our understanding of some symptoms, we offer a generic symptom management model to provide direction for selecting clinical interventions, informing research, and bridging an array of symptoms associated with a variety of diseases and conditions. Finally, a broadly-based symptom management model allows the integration of science from other fields.

Patients' perceptions of asthma control and impact on attitudes and self-management

The objective of this work was to describe the incidence of chronic breathing problems, particularly asthma-related breathing problems, in a cross-section of the United States population and to assess the perceived impact of these problems on daily living. An initial screening survey was used in a nationwide panel of 30,000 households; an in-depth follow-up questionnaire was sent to a random sample of respondents who reported a breathing problem. A sample (n = 2,685) of respondents who reported persistent cough, shortness of breath, or wheezing within the previous 2 years were sent a newly developed questionnaire. A subsample (n = 723) of respondents reported a primary diagnosis of asthma and of these, 59.4% were female and 90.2% were white. Their mean age was 37.4 years. Respondents (n = 723) characterized their level of perceived asthma control as completely controlled, well controlled, somewhat controlled, or poorly/not controlled. At least 31% of those with a perception of some control and 59% of those with a perception of poor/no control reported their breathing problems had increased in the last year. Those who perceived their asthma-related breathing problems as poorly controlled reported significantly greater symptom frequency, activity restriction, fears and concerns about their breathing difficulties, less helpful coping strategies, and less confidence in their doctor's ability to care for them. Responses to many of the questions indicated that the worst levels of disease control were associated with poorer quality of life and a more negative perception of the disease and its effects on daily living. A significant portion of the U.S. population appears to suffer from chronic breathing problems; this requires confirmation and further exploration to reduce the potential mortality and morbidity due to asthma in the United States.