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Mobile health technology offers promise for reducing disparities in pediatric asthma care and outcomes by helping parents more effectively communicate with their children's primary care providers and manage their children's asthma. This study tested the impact of a text messaging program on emergency department utilization and asthma morbidity.A randomized controlled trial enrolled 221 parents of Medicaid-insured children visiting the emergency departments of 2 urban children's hospitals in the Pacific Northwest for an asthma-related concern between September 2015 and February 2019. Standardized surveys were administered to parents at baseline and 12 months later to assess the primary outcomes of emergency department utilization and morbidity as well as primary care utilization, parent communication self-efficacy, and asthma self-management knowledge. The intervention group received brief in-person education on partnering with primary care providers, followed by 3 months of educational text messages.Participants were mostly female, English speakers, of minority race and ethnicity, and living below 200% of the federal poverty level. Negative binomial and linear regressions indicated no significant group differences in annual number of emergency department visits, morbidity, parent communication self-efficacy, or asthma self-management knowledge at 12 months' follow-up, adjusting for baseline covariates. Average annual rate of primary care visits for asthma was 35% higher in the intervention group compared to control group at follow-up (95% confidence interval 1.03-1.76, P = .03).This parent-focused text message intervention did not impact emergency department utilization or asthma morbidity; however, results suggest its potential for enhancing use of primary care for management of pediatric chronic conditions.

Respiratory rate (RR) measurement is critical to diagnosing pneumonia in resource-constrained settings, but accurate RR measurement is challenging. The acute lower respiratory illness treatment and evaluation (ALRITE) mobile phone application (app), designed to help healthcare workers (HCWs) manage pediatric respiratory illnesses, includes a semiautomated RR counter. This study aimed to evaluate the accuracy and usability of the ALRITE RR counter and a commercially available RR counter app, RRate, with a reference standard.This was a cross-sectional observational study of HCWs. Participants used both apps to measure the RR of pediatric patients from standardized videos. The reference standard was determined by consensus of a manual 1-min count by two providers. We assessed agreement using Spearman's rank correlation coefficient and constructed Bland-Altman plots to determine bias and limits of agreement. Participants completed a usability survey.Thirty-nine HCWs participated. The agreement between the apps and reference standard (Spearman's coefficient) was 0.83 (95% confidence interval [CI]: 0.78-0.87) for ALRITE and 0.62 (95% CI: 0.52-0.70) for RRate. ALRITE had a bias of -2 breaths/min (lower limit of agreement [LoA] -16 to +12) and RRate had a bias of -0.4 breaths/min (LoA -24 to +23) compared to the reference standard. Both apps had a poorer agreement at higher RRs. Based on usability survey responses, 95% found ALRITE easy to use.The ALRITE RR counter has acceptable accuracy for counting RR in infants with respiratory distress, appears to be more accurate than a commercially available option, and was user-friendly. The ALRITE RR counter is a promising tool for meriting evaluation in real-world settings.

The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality's (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.

OBJECTIVE. To evaluate communication training content fidelity included in a multifaceted intervention known to reduce antibiotic over-prescribing for pediatric acute respiratory illnesses (ARTIs), by examining the degree to which clinicians implemented the intended communication behavior changes. METHODS. Parents were surveyed regarding clinician communication behaviors immediately after attending 1,026 visits by children 6 months to < 11 years old diagnosed with ARTIs by 53 clinicians in 18 pediatric practices. Communication outcomes analyzed were whether clinicians: (A) provided both a combined (positive + negative) treatment recommendation and a contingency plan (full implementation); (B) provided either a combined treatment recommendation or a contingency plan (partial implementation); or (C) provided neither (no implementation). We used mixed effects multinomial logistic regression to determine whether these 3 communication outcomes changed between baseline and the time periods following each of 3 training modules. RESULTS. After completing the communication training, the adjusted probability of clinicians fully implementing the intended communication behavior changes increased by an absolute 8.1% compared to baseline (95% Confidence Interval [CI]: 2.4%, 13.8%, p=0.005). CONCLUSIONS. Our findings support the fidelity of the intervention’s communication training content. PRACTICAL IMPLICATIONS. Clinicians can be trained to implement communication behaviors that may aid in reducing antibiotic over-prescribing for ARTIs.

To effectively support asthma self-management among children most at risk for poor outcomes, it is important to examine potential disparities in parents' asthma-related knowledge. This study draws on baseline data collected from a randomized controlled trial to analyze how knowledge of asthma self-management varies by sociodemographic characteristics in a racially and economically diverse sample of Medicaid-insured children seeking emergency asthma care (N=221). Multivariable linear regression revealed that parent race/ethnicity, preferred language, and education were independently associated with scores on the Asthma Self Management Knowledge Questionnaire, and there was a significant interaction between parent race/ethnicity and education. In analyses stratified by parent education level, Latinx race/ethnicity was associated with lower-self-management knowledge among parents with higher education level, but not among those with a lower level of education. Our findings call for further research to understand and address the unique barriers to improving asthma self-management knowledge among Latinx parents and parents with limited English proficiency.

ObjectivesMobile health tools have potential to improve the diagnosis and management of acute lower respiratory illnesses (ALRI), a leading cause of paediatric mortality worldwide. The objectives were to evaluate health workers’ perceptions of acceptability, usability and feasibility of Acute Lower Respiratory Illness Treatment and Evaluation (ALRITE), a novel mobile health tool to help frontline health workers diagnose, treat and provide education about ALRI in children DesignA qualitative study including semistructured interviews with health facility administrators and focus groups with primary care health workers.SettingTwo federally funded Ugandan primary care health facilities, one peri-urban and one rural.ParticipantsWe enrolled 3 health administrators and 28 health workers (clinical officers and nurses).InterventionThe ALRITE smartphone application was developed to help frontline health workers adhere to ALRI guidelines and differentiate wheezing illnesses from pneumonia in children under 5 years of age. ALRITE contains a simple decision tree, a partially automated respiratory rate counter, educational videos and an adapted respiratory assessment score to determine bronchodilator responsiveness. We performed a demonstration of ALRITE for participants at the beginning of interviews and focus groups. No participant had used ALRITE prior.ResultsThemes impacting the potential implementation of ALRITE were organised using individual-level, clinic-level and health-system level determinants. Individual-level determinants were acceptability and perceived benefit, usability, provider needs and provider–patient relationship. Clinic-level determinants were limited resources and integration within the health centre. Systems-level determinants included medication shortages and stakeholder engagement.ConclusionsIncorporation of these themes will ready ALRITE for field testing. Early engagement of end users provides insights critical to the development of tailored mHealth decision support tools.

BACKGROUND: One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program’s effectiveness for reducing outpatient antibiotic prescribing for ARTI visits. METHODS: In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to RESULTS: Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90–0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50–0.87) and sinusitis (aRR 0.59; 95% CI, 0.44–0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83–1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51–0.70). CONCLUSIONS: This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.

[This corrects the article DOI: 10.1371/journal.pone.0221389.].

Background Respiratory disease and, specifically, pneumonia, is the major cause of mortality and morbidity in young children. Diagnosis of both pneumonia and asthma in primary care rests principally on clinical signs, history taking, and bronchodilator responsiveness. This study aimed to describe clinical practices in diverse global primary care settings concerning differential diagnosis of respiratory disease in young children, especially between pneumonia and asthma. Methods Health professionals in Greece, Kyrgyzstan, Vietnam, and Uganda were observed during consultations with children aged 2-59 months, presenting with cough and/or difficult breathing. Data were analyzed descriptively and included consultation duration, practices, diagnoses and availability/use of medications and equipment. The study is part of the European Horizon 2020 FRESH AIR project. Results In total, 771 consultations by 127 health professionals at 74 facilities in the four countries were observed. Consultations were shorter in Vietnam and Uganda (3 to 4 minutes) compared to Greece and Kyrgyzstan (15 to 20 minutes). History taking was most comprehensive in Greece. Clinical examination was more comprehensive in Vietnam and Kyrgyzstan and less in Uganda. Viral upper respiratory tract infections were the most common diagnoses (41.7% to 67%). Pneumonia was diagnosed frequently in Uganda (16.3% of children), and rarely in other countries (0.8% to 2.9%). Asthma diagnosis was rare (0% to 2.8%). Antibiotics were prescribed frequently in all countries (32% to 69%). Short acting β-agonist trials were seldom available and used during consultations in Kyrgyzstan (0%) and Uganda (1.8%), and often in Greece (38.9%) and Vietnam (12.6%). Conclusions Duration and comprehensiveness of clinical consultations observed in this study seemed insufficient to guide respiratory diagnosis in young children. Appropriate treatment options may further not be available in certain studied settings. Actions aiming at educating and raising professional awareness, along with developing easy-to-use tools to support diagnosis and a general strengthening of health systems are important goals.

BACKGROUND: The assessment of jaundice in outpatient neonates is problematic. Visual assessment is inaccurate, and more exact methodologies are cumbersome and/or expensive. Our goal in this study was to assess the accuracy of a technology based on the analysis of digital images of newborns obtained using a smartphone application called BiliCam. METHODS: Paired BiliCam images and total serum bilirubin (TSB) levels were obtained in a diverse sample of newborns ( RESULTS: Estimated bilirubin levels were calculated and compared with TSB levels in a diverse sample of 530 newborns (20.8% African American, 26.3% Hispanic, and 21.2% Asian American). The overall correlation was 0.91, and correlations among white, African American, Hispanic, and Asian American newborns were 0.92, 0.90, 0.91, and 0.88, respectively. The sensitivities of BiliCam in identifying newborns with high TSB levels were 84.6% and 100%, respectively, by using 2 decision rules; specificities were 75.1% and 76.4%, respectively. CONCLUSIONS: BiliCam provided accurate estimates of TSB values, demonstrating that an inexpensive technology that uses commodity smartphones could be used to effectively screen newborns for jaundice.

Purpose. Improving the quality of care provided to patients with pulmonary disorders is imperative, but properly performed and correctly interpreted spirometry is typically missing in primary care. There are increasing calls for widespread training efforts to mitigate this deficiency. This article describes why spirometry is needed in primary care and how it is performed and evaluated. Data Sources. The latest spirometry recommendations from the National Heart, Lung, and Blood Institute; the Global Initiative for Chronic Obstructive Lung Disease; the American Thoracic Society/European Respiratory Society; the American College of Physicians; the American College of Chest Physicians; and the US Preventive Services Task Force were consulted. Conclusions. Using spirometry to evaluate lung function is one of the simplest, most common pulmonary function tests. Nurse practitioners (NPs) will undoubtedly encounter these patients in their practice, and having comprehensive knowledge about spirometry will be a great asset to both their patients and health care team. NPs are often in a unique position with spirometry testing as they both perform and interpret the procedure. Implications for Practice. To better serve their patients, NPs need the knowledge to properly perform and correctly interpret spirometry.

Background African-American and Latino patients are often difficult to recruit for asthma studies. This challenge is a barrier to improving asthma care and outcomes for these populations. Objectives We sought to examine the recruitment experiences of 8 asthma comparative effectiveness studies that specifically targeted African-American and Latino patients, and identify the solutions they developed to improve recruitment. Methods Case report methodology was used to gather and evaluate information on study design, recruitment procedures and outcomes from study protocols and annual reports, and in-depth interviews with each research team. Data were analyzed for themes, commonalities, and differences. Results There were 4 domains of recruitment challenges: individual participant, institutional, research team, and study intervention. Participants had competing demands for time and some did not believe they had asthma. Institutional challenges included organizational policies governing monetary incentives and staff hiring. Research team challenges included ongoing training needs of recruitment staff, and intervention designs often were unappealing to participants because of inconveniences. Teams identified a host of strategies to address these challenges, most importantly engagement of patients and other stakeholders in study design and troubleshooting, and flexibility in data collection and intervention application to meet the varied needs of patients. Conclusions Asthma researchers may have greater success with recruitment by addressing uncertainty among patients about asthma diagnosis, engaging stakeholders in all aspects of study design and implementation, and maximizing flexibility of study and intervention protocols. However, even with such efforts, engagement of African-American and Latino patients in asthma research may remain low. Greater investment in research on engaging these populations in asthma research may ultimately be needed to improve their asthma care and outcomes.

The Global Initiative for Asthma (GINA 2002), in its Practical Guide to Asthma Management provides an evidence-based management strategy that addresses severity assessment, pharmacotherapy, monitoring, environmental control and the patient-provider partnership (GINA 2002). Despite the existence of effective therapies, including inhaled anti-inflammatory and long-acting bronchodilators, current practice falls short of guidelines and consequently, inadequate asthma control continues to be the norm. Although evidence based guidelines have been established, there is significant variation among practitioners in treating this condition, indicating a significant gap between what we know is optimal care and current practice (Finkelstein 2000, Finkelstein 2002, Lozano 2003). We propose to undertake a review of interventions to improve the management of asthma in primary care. A variety of approaches have been taken to improve asthma care including; patient self-management support, provider directed education and behavior change, and organizational approaches. Considerable work has been done in reviewing patient self-management support interventions. For example, Gibson found that information only patient education programs did not appear to improve outcomes (Gibson 2001). Toelle found insufficient evidence about the effectiveness of written management plans for adults and children (Toelle 2001). Reviews of more complex self-management interventions have shown positive results: self-management support education for children directed at prevention and attack management showed demonstrably improved outcomes (Wolf 2002). Positive outcomes were found in studies of asthma education for adults that included self-monitoring of either peak flow or symptoms, when combined with regular medical review and a written action plan (Gibson 2002). Another review of multifaceted adult interventions showed equivalent effects for control of asthma management by regular medical review of inhaled corticosteroid use vs. control by self-adjustment using written self management plan (Powell 2002). To complement these reviews, we will focus our review on provider-directed interventions and organizational approaches, only including patient-oriented interventions when they are part of a multi-focus study. The objectives of this review are to determine the effectiveness of various interventions to improve the management of asthma in primary care settings.

AIM: To examine whether exposure to the Spirometry Fundamentals(™) CD-ROM results in improved quality of spirometry testing in primary care. METHODS: Spirometry tests performed in 20 intervention and 19 control practices were analysed using American Thoracic Society grades A and B for ‘passing’ and grades C, D and F for ‘failing’. Intervention effects on spirometry quality were assessed using random effects multivariate logistic regression. RESULTS: Adjusted analyses revealed no intervention effect. The likelihood of passing tests was higher in paediatrics-only practices (adjusted odds ratio (AOR) 2.60, 95% confidence interval (CI) 1.32 to 5.12; p=0.01). Hospital or university-based clinics had a lower performance than private or community-based practices in unadjusted analysis (7% vs. 22% passing tests; p=0.05). However, this relationship was not significant in adjusted analyses. CONCLUSIONS: Spirometry Fundamentals(™) is insufficient to improve the quality of spirometry in primary care, suggesting the need for more comprehensive multifaceted training resources.

Background Children with lifelong chronic conditions (LLCC) are costly, of low prevalence, and a high proportion of patients at children's hospitals. Few methods identify these patients. Objectives We sought to identify children with LLCC in hospital discharge data for care coordination by using clinical risk groups (CRGs), to evaluate the accuracy of this methodology compared with a chart review and to investigate accuracy according to condition groups. Methods CRG software identified LLCC children who receive care at a primary care clinic, Odessa Brown Children's Clinic, by using Seattle Children's Hospital discharge data. Results There were 5356 active Odessa Brown Children's Clinic patients with at least 1 clinic encounter in 2006–2007. Six hundred two (11.2%) patients were admitted to Seattle Children's Hospital, and 1703 (31.8%) were seen only in the emergency department over 7 years (2001–2007). One hundred sixty-four (7%) were identified to have a LLCC. In a blind review of 200 (33.2%) children with inpatient encounters, the specificity of the CRG designation to LLCC was 95.0% (95% confidence interval [CI], 90.0%–98.0%), sensitivity 76.3% (95% CI, 63.4%–86.4%). Mental health conditions formed the largest group that was chart-review positive and CRG negative (7 of 14). Children hospitalized before 13 months of age were the second largest group (3 of 14). Clinical review placed the 164 patients in these condition groups: sickle cell disease, 43 (26.2%), neurological, 37 (22.6%), mental health, 22 (13.4%), malignancies, 4 (2.4%), other 52 (31.7%), and no chronic condition 6 (3.7%). Conclusion This study demonstrates a unique way to identify children with LLCC for care coordination by using hospital administrative data.

Consistent with the public health approach to prevention, surveillance analyses are needed to fully understand a health problem. U.S. military eye injury rates have not been fully described using medical surveillance data.Medical visit data on active duty personnel, 1996-2005, and causes of eye injury hospitalizations (identified by Standard NATO Agreement injury cause codes) were obtained from the Defense Medical Surveillance System. Eye injury-related ICD-9-CM codes beyond the traditional 800-999 injury code set were included. Rates by age and gender are reported for 1996-2005, along with the frequency of causes of injury hospitalizations and leading eye injury diagnoses for 2005.Eye injury rates among active duty military personnel increased from 1996 to 2005 among both men and women (p0.001), with the highest rates in 2004 (26/1000 person-years and 21/1000 person-years, women and men, respectively). Women consistently had 7%-21% higher rates than men (rate ratios=1.07; 95% CI=1.04, 1.11) to 1.21 (95% CI= 1.17, 1.25). From 1996-2005, eye injury rates increased among all age groups (p0.001). From 2002-2005, rates were highest for those agedor =40 years compared to those aged 17-19 years (rate ratios=1.17 [95% CI=1.11, 1.24] to 1.24 [95% CI=1.18, 1.31]). Leading causes of eye injury hospitalizations were ordnance handling (16.9%), enemy action (13.1%), and fighting (11.9%).Medical surveillance data enable the assessment and monitoring of overall active duty eye injury rates, trends, and causes. Outpatient data could be improved with the addition of cause of injury codes and eye protection use. Current data suggest that continued use of eye protection during ordnance handling, combat, motor vehicle use, and sports could help reduce eye injury rates.

Purpose. To explore the effects of visual acuity on target discrimination and marksmanship. Methods. A randomized, single-blind, repeated measures study was conducted to evaluate the effect of visual acuity on target discrimination and marksmanship. Subjects were examined for inclusion criteria and equivalent plus lens over-refractions necessary to obtain the five test visual acuity ranges. Qualified subjects fired at randomized target presentations from 50 to 300 m while wearing customized spectacles to yield the visual acuity levels being evaluated. Subjects then rotated foxholes for target discrimination sequences. Randomized targets marked as friend or enemy were presented in like manner for each of the five visual acuity levels. Results. Subjects at acuities better than 0.2 LogMAR were significantly more likely to hit the target than those with acuities equal to or worse than 0.7 LogMAR. Target discrimination results show subjects with acuities between −0.2 and 0.6 LogMAR were significantly more likely to correctly identify the target than those with acuities equal to or worse than 0.7 LogMAR. In addition, those at acuities of 0.0 LogMAR or better performed significantly better than those with acuities between 0.3 and 0.6 LogMAR. Conclusions. Visual acuity significantly affects target discrimination and marksmanship performance. Results of this study closely mirror expected findings based on visual angles with acuities in the range 0.3 to 0.4 LogMAR (20/40–20/50) being the transition zone where performance begins to deteriorate. This performance-based evidence fully supports a vision classification system that mandates eyewear to maximize visual performance for deployable military members. Based on the results of this study, the current U.S. Army, U.S. Navy, and U.S. Marine Corps vision readiness standards of 20/40 or better uncorrected or corrected vision seems to be a valid choice because it is the transition point for performance in both target discrimination and marksmanship ability.

Background Exposure to indoor allergens contributes to increased asthma morbidity. The Inner-City Asthma Study, a randomized trial involving home environmental allergen and irritant remediation among children aged 6 through 11 years with moderate-to-severe asthma, successfully reduced asthma symptoms. A cost-effectiveness analysis can help stakeholders to evaluate the potential costs and benefits of adopting such a program. Objective We sought to assess the cost-effectiveness of the environmental intervention of the Inner-City Asthma Study. Methods Incremental cost-effectiveness ratios for a 2-year study period were calculated. Health outcome was measured as symptom-free days. Resource use measures included ambulatory visits, hospitalizations, and pharmaceutical use. CIs were obtained by using bootstrapping. Results The intervention, which cost $1469 per family, led to statistically significant reductions in symptom days, unscheduled clinic visits, and use of β-agonist inhalers. Over the year of the intervention and a year of follow-up, the intervention cost was $27.57 per additional symptom-free day (95% CI, $7.46-$67.42). Subgroup analysis showed that targeting the intervention to selected high-risk subgroups did not reduce the incremental cost-effectiveness ratio. Conclusions A targeted home-based environmental intervention improved health and reduced service use in inner-city children with moderate-to-severe asthma. The intervention is cost-effective when the aim is to reduce asthma symptom days and the associated costs.

Background Despite growing evidence of the importance of exposure to fungi as an environmental risk factor for asthma, few data have been reported on the exposure to airborne fungi of asthmatic children living in US inner cities. Objective We sought to examine the spectrum and concentration of fungi in the air inside and outside of the homes of mold-sensitive children with asthma living in US cities. We also analyzed the relationship of the concentration of fungi in indoor air to home characteristics. Methods We performed a home environmental survey and measured the concentrations of culturable airborne fungi inside and outside the homes of 414 mold-sensitive children with asthma in 7 urban communities. Results The airborne fungi encountered indoors generally paralleled those found outdoors, and the similarities between communities were more striking than the differences. Indoor fungal concentrations were correlated with outdoor concentrations measured on the same day, suggesting the need to adjust for the outdoor concentration in analyses by using the indoor concentration as an indicator of the relative moldiness of a home. The concentration of fungi in indoor air in excess of outdoor air—that is, the indoor-outdoor difference—was significantly related to home characteristics, including dampness, having a cat, and cockroach infestation. Conclusion Mold-sensitive children with asthma living in urban communities across the US are exposed to airborne fungi in indoor and outdoor air. The concentrations of fungi are higher in homes with dampness problems, cockroach infestation, and cats. The indoor-outdoor difference in the concentration of airborne fungi may provide a valuable metric for investigations of the role of fungal exposure as a risk factor for asthma.

To quantify the prevalence and impact of chronic respiratory symptoms among predominantly Alaska Native (AN)/American Indian (AI) middle school students.School-based prevalence assessment using the International Study of Asthma and Allergy in Children survey, with supplemental video material and added questions about productive cough, exposure to tobacco smoke, and the functional impact of symptoms.The Yukon-Kuskokwim delta region of western Alaska.A total of 466 children in the sixth to ninth grades, 81% of whom are AN/AI (377 children).No study intervention.Among the 377 AN/AI children, 40% reported one of the following three categories of chronic respiratory disease: physician-diagnosed asthma, 7.4%; asthma-like symptoms (ALS) without an asthma diagnosis, 11.4%; and chronic productive cough (CPC) without asthma diagnosis or symptoms, 21.5%. Symptom prevalence differed substantially between the largest town in the region and rural villages. After an adjustment for demographic factors, exposure to environmental tobacco smoke, active tobacco smoking, and self-report of atopy, village residents were 63% less likely to have ALS (p = 0.009), and had a twofold greater risk of CPC (p0.001) compared to children living in the town. Children with respiratory symptoms experienced sleep disturbances and accessed clinic visits for respiratory problems more often than did asymptomatic children.Chronic respiratory symptoms are very common among AN children. CPC is an important nonasthmatic respiratory condition in this population. The differing patterns of respiratory illness within this region may help to elucidate the specific risk factors for asthma and chronic bronchitis in children.

Objectives. We examined the association between exposure to violence and asthma among urban children. Methods. We obtained reports from caretakers (n = 851) of violence, negative life events, unwanted memories (rumination), caretaker-perceived stress, and caretaker behaviors (keeping children indoors, smoking, and medication adherence). Outcomes included caretaker-reported wheezing, sleep disruption, interference with play because of asthma, and effects on the caretaker (nights caretaker lost sleep because of child’s asthma). Results. Increased exposure to violence predicted higher number of symptom days (P = .0008) and more nights that caretakers lost sleep (P = .02) in a graded fashion after control for socioeconomic status, housing deterioration, and negative life events. Control for stress and behaviors partially attenuated this gradient, although these variables had little effect on the association between the highest level of exposure to morbidity, which suggests there are other mechanisms. Conclusions. Mechanisms linking violence and asthma morbidity need to be further explored.

Studies addressing the impact of eye injuries on U.S. Army readiness and the effectiveness of countermeasures are lacking. In 1989, the U.S. Army Environmental Hygiene Agency undertook a prospective, multicenter study of military units in the peacetime Army at selected installations to define the incidence of eye injuries, assess associated variables, and identify targets for intervention. During the first 5 months of 1989 at Fort Bragg, North Carolina, Fort Campbell, Kentucky, and Fort Lewis, Washington, health care providers saw 103 new eye injuries with an overall rate of 14.18 injuries per 1,000 personnel annually. Almost one-half of the injuries (48 cases, 46.60%) occurred during on-duty work and training. Most (93 cases, 90.29%) of the soldiers were not wearing eye protection when injured. This study identifies possible targets for intervention and provides a baseline against which the interventions of the last decade may be assessed for effectiveness.

Most published environmental remediation interventions have been directed at single allergens and have employed demanding strategies; few have been performed in the homes of inner-city children disproportionately burdened by asthma. Our objective was a) to describe the allergen sensitivities, environmental tobacco smoke (ETS) exposure, and home environmental characteristics of a national sample of inner-city children with moderate to severe asthma and b) to develop and implement a multifaceted, home-based comprehensive intervention to reduce home allergens and ETS, tailored to the specific sensitization and exposure profiles of those children. Allergen skin testing and a home evaluation were performed to determine the presence of ETS and factors known to be associated with increased indoor allergen levels. Based on published remediation techniques, a home environmental intervention, organized into modules, each addressing one of five specific allergen groups or ETS, was designed. Of 994 allergic children from seven U.S. urban communities, 937 successfully completed baseline interviews and home allergen surveys and were enrolled. More than 50% of children had positive skin tests to three or more allergen groups. Cockroaches were reported in 58% of homes, wall-to-wall carpeting in the child's bedroom in 55%, a smoker in 48%, mice or rats in 40%, and furry pets in 28%. More than 60% of enrolled families received four or more modules, and between 94% and 98% of all modules were completed. We conclude that most inner-city children with moderate to severe asthma are sensitized to multiple indoor allergens and that environmental factors known to be associated with asthma severity are commonly present in their homes. The intervention developed for the Inner-City Asthma Study employs accepted methods to address an array of allergens and ETS exposure while ensuring that the intervention is tailored to the specific sensitization profiles and home characteristics of these children.

Explanatory models (EMs) were collected from 20 African-American adult primary caregivers, in Seattle and New Orleans, who have children with asthma, to understand asthma from their perspective. Family EMs of asthma shed light on the meaning family members give to the illness, and how they make internally logical decisions related to their healthcare behavior. Study findings show that families have their own EMs of asthma. Families draw on their cultural context to understand asthma. They compare their lived experience with healthcare-provider explanations of asthma. Specifically, the African-American families in this study drew much of their information about asthma from other family members and from personal experience. Collecting EMs of asthma may help healthcare providers know the meaning of asthma as understood by specific families and may reduce unscheduled use of health services. Further research should include encounters which increase the healthcare provider's context for understanding patient and family EMs.

Health sensing through smartphones has received considerable attention in recent years because of the devices' ubiquity and promise to lower the barrier for tracking medical conditions. In this paper, we focus on using smartphones to monitor newborn jaundice, which manifests as a yellow discoloration of the skin. Although a degree of jaundice is common in healthy newborns, early detection of extreme jaundice is essential to prevent permanent brain damage or death. Current detection techniques, however, require clinical tests with blood samples or other specialized equipment. Consequently, newborns often depend on visual assessments of their skin color at home, which is known to be unreliable. To this end, we present BiliCam, a low-cost system that uses smartphone cameras to assess newborn jaundice. We evaluated BiliCam on 100 newborns, yielding a 0.85 rank order correlation with the gold standard blood test. We also discuss usability challenges and design solutions to make the system practical.

House dust mite allergen exposure is a postulated risk factor for allergic sensitization, asthma development, and asthma morbidity; however, practical and effective methods to mitigate these allergens from low-income, urban home environments remain elusive. The purpose of this study was to assess the feasibility and effectiveness of physical interventions to mitigate house dust mite allergens in this setting. Homes with high levels of house dust mite allergen (Der f 1 + Der p 1 > or = 10 microg/g dust by enzyme-linked immunosorbent assay) in the bed, bedroom carpet, and/or upholstered furniture were enrolled in the study. Carpets and upholstered furniture were subjected to a single treatment of either dry steam cleaning plus vacuuming (carpet only) or intensive vacuuming alone. Bed interventions consisted of complete encasement of the mattress, box spring, and pillows plus either weekly professional or in-home laundering of nonencased bedding. Dust samples were collected at baseline and again at 3 days (carpet and upholstery only) and 2, 4, and 8 weeks posttreatment. We compared pretreatment mean allergen concentrations and loads to posttreatment values and performed between-group analyses after adjusting for differences in the pretreatment means. Both dry steam cleaning plus vacuuming and vacuuming alone resulted in a significant reduction in carpet house dust mite allergen concentration and load (p < 0.05). Levels approached pretreatment values by 4 weeks posttreatment in the intensive vacuuming group, whereas steam cleaning plus vacuuming effected a decrease that persisted for up to 8 weeks. Significant decreases in bed house dust mite allergen concentration and load were obtained in response to encasement and either professional or in-home laundering (p < 0.001). Between-group analysis revealed significantly less postintervention house dust mite allergen load in professionally laundered compared to home-laundered beds (p < 0.05). Intensive vacuuming and dry steam cleaning both caused a significant reduction in allergen concentration and load in upholstered furniture samples (p < 0.005). Based on these data, we conclude that physical interventions offer practical, effective means of reducing house dust mite allergen levels in low-income, urban home environments.

OBJECTIVES: Although asthma is the most common chronic childhood illness in the United States, little is known about its prevalence among American Indian and Alaska Native (AI/AN) children. The authors used the latest available household survey data to estimate the prevalence of asthma in this population. METHODS: The authors analyzed data for children ages 1 through 17 years from the 1987 Survey of American Indians and Alaska Natives (SAIAN) and the 1987 National Medical Expenditure Survey (NMES). At least one member of each AI/AN household included in the SAIAN was eligible for services through the Indian Health Service. RESULTS: The weighted prevalence of parent-reported asthma was 7.06% among 2288 AI/AN children ages 1-17 (95% CI 5.08, 9.04), compared with a US estimate of 8.40% for children ages 1-17 based on the 1987 NMES (95% CI 7.65, 9.15). The AI/AN sample was too small to yield stable estimates for a comparison between AI/AN children and all US children when the data were stratified according to household income and metropolitan vs non-metropolitan residence. The unadjusted asthma prevalence rates were similar for AI/AN children and for children in the NMES sample. CONCLUSIONS: In 1987, the prevalence of parent-reported asthma was similar for AI/AN children in the SAIAN sample and for children in the NMES sample. More recent data are needed to better understand the current prevalence of asthma among AI/AN children.

This discussion paper describes a scoping exercise and literature review commissioned by the International Primary Care Respiratory Group (IPCRG) to inform their E-Quality programme which seeks to support small-scale educational projects to improve respiratory management in primary care. Our narrative review synthesises information from three sources: publications concerning the global context and health systems development; a literature search of Medline, CINAHL and Cochrane databases; and a series of eight interviews conducted with members of the IPCRG faculty. Educational interventions sit within complex healthcare, economic, and policy contexts. It is essential that any development project considers the local circumstances in terms of economic resources, political circumstances, organisation and administrative capacities, as well as the specific quality issue to be addressed. There is limited evidence (in terms of changed clinician behaviour and/or improved health outcomes) regarding the merits of different educational and quality improvement approaches. Features of educational interventions that were most likely to show some evidence of effectiveness included being carefully designed, multifaceted, engaged health professionals in their learning, provided ongoing support, were sensitive to local circumstances, and delivered in combination with other quality improvement strategies. To be effective, educational interventions must consider the complex healthcare systems within which they operate. The criteria for the IPCRG E-Quality awards thus require applicants not only to describe their proposed educational initiative but also to consider the practical and local barriers to successful implementation, and to propose a robust evaluation in terms of changed clinician behaviour or improved health outcomes., The IPCRG commissioned this work as part of the IPCRG e-Quality initiative. HP is supported by a Primary Care Research Career Award from the Chief Scientist's Office of the Scottish Government.

Contains fulltext : 97853.pdf (Publisher’s version ) (Open Access) PURPOSE: Spirometry has become an indispensable tool in primary care to exclude, diagnose, and monitor chronic respiratory conditions, but the quality of spirometry tests in family practices is a reason for concern. Aim of this study was to investigate whether a combination of e-learning and bimonthly performance feedback would improve spirometry test quality in family practices in the course of 1 year. METHODS: Our study was a cluster trial with 19 family practices allocated to intervention or control conditions through minimization. Intervention consisted of e-learning and bimonthly feedback reports to practice nurses. Control practices received only the joint baseline workshop. Spirometry quality was assessed by independent lung function technicians. Two outcomes were defined, with the difference between rates of tests with 2 acceptable and repeatable blows being the primary outcome and the difference between rates of tests with 2 acceptable blows being the secondary outcome. We used multilevel logistic regression analysis to calculate odds ratios (ORs) for an adequate test in intervention group practices. RESULTS: We analyzed 1,135 tests. Rate of adequate tests was 33% in intervention and 30% in control group practices (OR = 1.3; P=.605). Adequacy of tests did not differ between groups but tended to increase with time: OR = 2.2 (P = .057) after 3 and OR = 2.0 (P = .086) in intervention group practices after 4 feedback reports. When ignoring test repeatability, these differences between the groups were slightly more pronounced: OR = 2.4 (P = .033) after 3 and OR=2.2 (P = .051) after 4 feedback reports. CONCLUSIONS: In the course of 1 year, we observed a small and late effect of e-learning and repeated feedback on the quality of spirometry as performed by family practice nurses. This intervention does not seem to compensate the lack of rigorous training and experience in performing spirometry tests in most practices. 6 p.

Objectives To describe the prevalence of and risk factors for recent toothache among US children and to estimate frequency of contact between children with toothache and their pediatric primary care providers (PPCP). Design Cross-sectional analysis of nationally representative data. Setting The 2007 National Survey of Children's Health. Participants Population-based sample of parents/guardians of 86 730 children aged 1 through 17 years from 50 states and the District of Columbia. Outcome Measure Parent-reported toothache in the last 6 months. Results A total of 10.7% of US children and 14% of children aged 6 to 12 years experienced toothache in the last 6 months. Poor and low-income minority children and those with special needs were significantly more likely to have had a toothache on multivariable analysis. Most children with toothache in the last 6 months had their own physician (88.9%) and had a preventive medical visit in the last year (88.1%), pointing to opportunities for PPCP to identify and intervene with children who have untreated dental decay and toothache. Conclusions Toothache is not the universal experience it was before the advent of modern dentistry. Nevertheless, a substantial number of US children recently had a toothache, with noteworthy variability between states. There are opportunities for PPCP to address oral health prevention, assess for dental decay and toothache, and treat complications. We propose toothache as a potential quality indicator reflecting disparities in oral health for a population.

That pediatric resident trainees would demonstrate increased counseling skill following training in brief motivational interviewing (MI).Randomized controlled trial.University of Washington Pediatric Residency.Pediatric residents (N = 18), including residents in postgraduate years 1, 2, 3, and 4.Collaborative Management in Pediatrics, a 9-hour behavior change curriculum based on brief MI plus written feedback on communication skills (based on a 3-month Objective Standardized Clinical Evaluation [OSCE]).The percentage of MI-consistent behavior (%MICO), a summary score for MI skill, was assessed via OSCEs in which standardized patients portray parents of children with asthma in 3 clinical scenarios (stations). The OSCEs were conducted at baseline and 3 and 7 months. Blinded coders rated videotaped OSCEs using a validated tool to tally communication behaviors. Training effects were assessed using linear regression controlling for baseline %MICO. Global ratings of counseling style served as secondary outcome measures.Trained residents demonstrated a trend toward increased skill (%MICO score) at 3 months compared with control residents. At 7 months, %MICO scores increased 16% to 20% (P.02) across all OSCE stations after the combined intervention of Collaborative Management in Pediatrics training plus written feedback. The effect of training on global ratings supported the main findings.Pediatric trainees' skills in behavior change counseling improved following the combination of training in brief MI plus personalized feedback.

Background Despite increasing awareness of the National Asthma Education and Prevention Program guidelines, the relative contribution of symptom frequency or pulmonary function to the recommended asthma severity levels remains poorly understood. Objective To determine whether adding lung function measurements to clinical history substantially changes the asthma severity classification, thereby influencing treatment decisions. Design Baseline data were studied from children enrolled in 2 multicenter studies: phase 1 of the National Cooperative Inner-City Asthma Study (1992-1994) (cohort 1) and the Inner-City Asthma Study (1998-2001) (cohort 2). Setting Fifteen (8 for cohort 1 and 7 for cohort 2) major metropolitan inner-city areas in the United States. Participants Inner-city children aged 8 through 11 years with asthma. Main Outcome Measures Proportion of children reclassified from less severe asthma categories based on symptom frequency into more severe categories because of lung function. Results Of children with symptoms of mild intermittent asthma, 22.8% in cohort 1 and 27.7% in cohort 2 would be reclassified as having either moderate or severe persistent asthma. Of children with symptoms of mild persistent asthma, 31.2% in cohort 1 and 33.3% in cohort 2 would be similarly reclassified. Conclusions In 2 different studies of inner-city children with asthma, approximately one third of the participants were reclassified into higher National Asthma Education and Prevention Program asthma severity categories when pulmonary function was considered in addition to symptom frequency. This may have direct implications for the undertreatment of asthma.

CONTEXT. Barriers impede translating recommendations for asthma treatment into practice, particularly in inner cities where asthma morbidity is highest. METHODS. The purpose of this study was to test the effectiveness of timely patient feedback in the form of a letter providing recent patient-specific symptoms, medication, and health service use combined with guideline-based recommendations for changes in therapy on improving the quality of asthma care by inner-city primary care providers and on resultant asthma morbidity. This was a randomized, controlled clinical trial in 5- to 11-year-old children (n = 937) with moderate to severe asthma receiving health care in hospital- and community-based clinics and private practices in 7 inner-city urban areas. The caretaker of each child received a bimonthly telephone call to collect clinical information about the child's asthma. For a full year, the providers of intervention group children received bimonthly computer-generated letters based on these calls summarizing the child's asthma symptoms, health service use, and medication use with a corresponding recommendation to step up or step down medications. We measured the number and proportion of scheduled visits resulting in stepping up of medications, asthma symptoms (2-week recall), and health care use (2-month recall). RESULTS. In this population, only a modest proportion of children whose symptoms warranted a medication increase actually had a scheduled visit to reevaluate their asthma treatment. However, in the 2-month interval after receipt of a step-up letter, 17.1% of the letters were followed by scheduled visits in the intervention group compared with scheduled visits 12.3% of the time by the control children with comparable clinical symptoms. Asthma medications were stepped up when indicated after 46.0% of these visits in the intervention group compared with 35.6% in the control group, and when asthma symptoms warranted a step up in therapy, medication changes occurred earlier among the intervention children. Among children whose medications were stepped up at any time during the 12-month study period, those in the intervention group experienced 22.1% fewer symptom days and 37.9% fewer school days missed. The intention-to-treat analysis showed no difference over the intervention year in the number of symptom days, yet there was a trend toward fewer days of limited activity and a significant decrease in emergency department visits by the intervention group compared with controls. This 24% drop in emergency department visits resulted in an intervention that was cost saving in its first year. CONCLUSIONS. Patient-specific feedback to inner-city providers increased scheduled asthma visits, increased asthma visits in which medications were stepped up when clinically indicated, and reduced emergency department visits.

Background Asthma-associated morbidity is rising, especially in inner city children. Objective We evaluated the allergen sensitivities, allergen exposures, and associated morbidity for participants in the Inner City Asthma Study. We also determined geographic variations of indoor allergen levels. Methods Nine hundred thirty-seven inner city children 5 to 11 years old with moderate to severe asthma underwent allergen skin testing. Bedroom dust samples were evaluated for Der p 1, Der f 1, Bla g 1, Fel d 1, and Can f 1. Results Skin test sensitivities to cockroach (69%), dust mites (62%), and molds (50%) predominated, with marked study site–specific differences. Cockroach sensitivity was highest in the Bronx, New York, and Dallas (81.2%, 78.7%, and 78.5%, respectively), and dust mite sensitivity was highest in Dallas and Seattle (83.7% and 78.0%, respectively). A majority of homes in Chicago, New York, and the Bronx had cockroach allergen levels greater than 2 U/g, and a majority of those in Dallas and Seattle had dust mite allergen levels greater than 2 μg/g. Levels of both of these allergens were influenced by housing type. Cockroach allergen levels were highest in high-rise apartments, whereas dust mite allergen levels were highest in detached homes. Children who were both sensitive and exposed to cockroach allergen had significantly more asthma symptom days, more caretaker interrupted sleep, and more school days missed than children who were not sensitive or exposed. Conclusion Geographic differences in allergen exposure and sensitivity exist among inner city children. Cockroach exposure and sensitivity predominate in the Northeast, whereas dust mite exposure and sensitivity are highest in the South and Northwest. Cockroach allergen appears to have a greater effect on asthma morbidity than dust mite or pet allergen in these children.

Studies addressing the impact of eye injuries on U.S. Army readiness and the effectiveness of countermeasures are lacking. In 1989, the U.S. Army Environmental Hygiene Agency undertook a prospective, multicenter study of military units in the peacetime Army at selected installations to define the incidence of eye injuries, assess associated variables, and identify targets for intervention. During the first 5 months of 1989 at Fort Bragg, North Carolina, Fort Campbell, Kentucky, and Fort Lewis, Washington, health care providers saw 103 new eye injuries with an overall rate of 14.18 injuries per 1,000 personnel annually. Almost one-half of the injuries (48 cases, 46.60%) occurred during on-duty work and training. Most (93 cases, 90.29%) of the soldiers were not wearing eye protection when injured. This study identifies possible targets for intervention and provides a baseline against which the interventions of the last decade may be assessed for effectiveness.

Background Continued high rates of smoking among socioeconomically disadvantaged women lead to increases in children's health problems associated with exposure to tobacco smoke. The pediatric clinic is a "teachable setting" in which to provide advice and assistance to parents who smoke. Objective To evaluate a smoking cessation intervention for women. Design Two-arm (usual care vs intervention) randomized trial. Setting Pediatric clinics serving an ethnically diverse population of low-income families in the greater Seattle, Wash, area. Intervention During the clinic visit, women received a motivational message from the child's clinician, a guide to quitting smoking, and a 10-minute motivational interview with a nurse or study interventionist. Women received as many as 3 outreach telephone counseling calls from the clinic nurse or interventionist in the 3 months following the visit. Participants Self-identified women smokers (n = 303) whose children received care at participating clinics. Main Outcome Measure Self-reported abstinence from smoking 12 months after enrollment in the study, defined as not smoking, even a puff, during the 7 days prior to assessment. Results Response rates at 3 and 12 months were 80% and 81%. At both follow-ups, abstinence rates were twice as great in the intervention group as in the control group (7.7% vs 3.4% and 13.5% vs 6.9%, respectively). The 12-month difference was statistically significant. Conclusions A pediatric clinic smoking cessation intervention has long-term effects in a socioeconomically disadvantaged sample of women smokers. The results encourage implementation of evidence-based clinical guidelines for smoking cessation in pediatric practice.

Reports of pediatric condition falsification (PCF) have noted, but not emphasized, exaggerated complaints of real and common illnesses. Among the most frequent chronic childhood illnesses are asthma, allergy, drug sensitivity, and ear and sinopulmonary infections. The most common pediatric surgery is the insertion of myringotomy tubes. A computer database of 104 PCF victims from 68 families spanning from 1974 to 1998 was searched for the frequency of these conditions. Outright falsification or extreme exaggeration of severity of asthma or allergies was noted in 52 children (50%), sinopulmonary infections in 50 (48%), and drug reactions or sensitivities in 30 (29%). Forty-five children (43%) had otolaryngologic surgery, including ear tubes. In all, 71 children (68%) had at least one of these conditions. Associated victimand perpetrator characteristics are described. Children with PCF are not only subjected to induced illnesses and excessive medical diagnostic and therapeutic efforts but also victimized by the consequences of false and exaggerated complaints of common pediatric diseases.