A Randomized Controlled Trial Using the School for Anti-inflammatory Therapy in Asthma

This study investigated the impact of providing low-dose inhaled corticosteroids (ICS) at school or at home to asthmatic inner city children over a 14-week period, compared with the existing community standard. Eight elementary schools in the Dallas Independent School District with a high incidence of asthma located in predominantly urban African-American communities were randomly assigned to one of four groups. The treatment arms were school-based delivery of inhaled steroids, home-based delivery of inhaled steroids, and home-based delivery of inhaled steroids with school-based asthma education, and the control group was no change in current therapy. Fifty students were objectively diagnosed with mild, persistent asthma and participated in the study. Students in the treatment arms received beclomethasone (42 mcg/puff) 4 puffs, twice a day, either at school or at home. Students in the control, “community standard of care” group received no additional medical intervention. Higher peak flows for the treatment groups were seen in the first week and maintained throughout the study (P = .047). By week 5 significant differences were found in frequency of bronchodilator use (P = .025), episodes of nocturnal awakening with asthma symptoms (P = .022), and visits to the primary health care provider (P = .022). Treatment groups rated their asthma as “better than the week before” more frequently than the control group (P = .001). Delivering ICS in school is associated with improved asthma control than when anti-inflammatory medication was delivered to children with asthma in a home-based setting, and both are superior when compared with a control, “community standard of care” group in which no additional medical intervention occurred.     

Improving Asthma Care for the Elderly: A Randomized Controlled Trial Using a Simple Telephone Intervention

Background. Several studies suggest that asthma is undertreated in the elderly population. Objective. To determine if the use of a simple telephone intervention can improve asthma care in the elderly. Methods. Fifty-two elderly subjects with asthma who required their rescue inhalers more than twice a week and had at least one emergency department or urgent care visit in the previous year were randomized to an intervention or control group. All subjects received two telephone calls over a 12-month period. The intervention group received an asthma-specific questionnaire and the control group received a general health questionnaire. Medication use and health care utilization were evaluated at the beginning and end of a 12-month period. Results. The study was completed by 23 control and 25 intervention subjects. Baseline data were similar in both groups. After 12 months, 72% (n = 18) of the intervention group were on an inhaled corticosteroid compared with 40% (n = 10) of the control group (p = 0.08). The intervention group had fewer emergency department visits when compared with the control group (p = 0.21). Sixty-four percent (n = 16) of the intervention group had an asthma action plan compared with 26% (n = 6) in the control group (p = 0.01). Conclusion. This study suggests that asthma care in the elderly can be improved using a simple telephone intervention. Clinical implications. Clinicians need to recognize that under treatment of asthma in the elderly still exists and to use alternative methods such as a simple telephone questionnaire to improve care in this population.     

Rural School Nurses' Asthma Education Needs

School nurses play an important role in identifying children with asthma and providing care during school hours. Educational programs designed to improve nurses' asthma knowledge and practices have concentrated on urban settings. The purpose of this investigation was to determine asthma-related practices and educational needs of rural school nurses. A survey about asthma was mailed to school nurses in all counties of the state of Maryland and in Washington, D.C. Responses were compared between rural Maryland counties and counties from the remainder of Maryland and Washington, D.C. The survey addressed attitudes and beliefs, function and roles, medication administration, and educational needs about asthma. We found that rural nurses used peak flow meters less often to assess and monitor asthma, requested fewer referrals for asthma, had fewer interactions with health room assistants, and had reduced access to asthma educational resources. Also, they provided less asthma education in the schools than other school nurses. These results suggest a need for comprehensive asthma educational programs in rural areas that are based on national guidelines, and that address the unique needs of rural school nurses. These programs should also emphasize the need for open communication between rural school nurses, health room assistants, primary care providers, and parents/caregivers.     

Rural School Nurses' Asthma Education Needs

School nurses play an important role in identifying children with asthma and providing care during school hours. Educational programs designed to improve nurses' asthma knowledge and practices have concentrated on urban settings. The purpose of this investigation was to determine asthma-related practices and educational needs of rural school nurses. A survey about asthma was mailed to school nurses in all counties of the state of Maryland and in Washington, D.C. Responses were compared between rural Maryland counties and counties from the remainder of Maryland and Washington, D.C. The survey addressed attitudes and beliefs, function and roles, medication administration, and educational needs about asthma. We found that rural nurses used peak flow meters less often to assess and monitor asthma, requested fewer referrals for asthma, had fewer interactions with health room assistants, and had reduced access to asthma educational resources. Also, they provided less asthma education in the schools than other school nurses. These results suggest a need for comprehensive asthma educational programs in rural areas that are based on national guidelines, and that address the unique needs of rural school nurses. These programs should also emphasize the need for open communication between rural school nurses, health room assistants, primary care providers, and parents/caregivers.     

Psychosocial Functioning and Stress-Processing of Children with Asthma in the School Context: Differences and Similarities with Children without Asthma

Objective. To characterize children with asthma by their stress processing at school and their psychosocial functioning. To establish similarities and differences between children with and without asthma. Methods. Participants were 79 children with asthma and 359 children without asthma (ages 8-12). Children completed questionnaires on stress processing and their well-being at school. Parents filled in a questionnaire on behavior problems, and teachers provided data on school performance and absence rate. Results. Children with asthma had higher scores on absence rates, teacher-rated well-being, internalizing behavior problems, occurrence of “rejection by peers,” and use of aggression when coping with “problems with school work.” However, using discriminant analyses, the groups could not reliably be distinguished from one another by these variables. Conclusions. Children with asthma are similar to other children with regard to their stress processing at school and their psychosocial functioning. The value of conducting multivariate analysis over several univariate tests is underscored.     

Psychosocial Functioning and Stress-Processing of Children with Asthma in the School Context: Differences and Similarities with Children without Asthma

Objective.?To characterize children with asthma by their stress processing at school and their psychosocial functioning. To establish similarities and differences between children with and without asthma. Methods.?Participants were 79 children with asthma and 359 children without asthma (ages 8–12). Children completed questionnaires on stress processing and their well-being at school. Parents filled in a questionnaire on behavior problems, and teachers provided data on school performance and absence rate. Results.?Children with asthma had higher scores on absence rates, teacher-rated well-being, internalizing behavior problems, occurrence of “rejection by peers,” and use of aggression when coping with “problems with school work.” However, using discriminant analyses, the groups could not reliably be distinguished from one another by these variables. Conclusions.?Children with asthma are similar to other children with regard to their stress processing at school and their psychosocial functioning. The value of conducting multivariate analysis over several univariate tests is underscored.     

A Randomized Controlled Trial of an Interactive Voice Response Telephone System and Specialist Nurse Support for Childhood Asthma Management

Objectives. To evaluate the effects of an automated interactive voice response system (IVR) and Specialist Nurse Support to reduce health care utilization and improve health-related quality of life in children with asthma. Study Design. A randomized controlled trial in 121 children with doctor-diagnosed asthma and an acute presentation with asthma in the previous 12 months aged between 3 and 16 years. Children were randomized to one of three groups for a 6-month intervention receiving asthma education and management support from a Specialist Nurse by telephone or e-mail (N = 41), from IVR (N = 39), or receiving usual care (control group; N = 41). Outcomes included health care utilization and use of oral steroid rescue. Health-related quality of life (HRQOL) data using the Pediatric Asthma Quality of Life Questionnaire and Pediatric Quality of Life Inventory were collected at baseline and at the end of the study. Results: There was no statistically significant benefit identified for either the IVR or the Nurse Support interventions for health care utilization, use of oral steroid rescue, or HRQOL compared with controls. Relative to controls, the incremental costs were ?A$225.73 (95% confidence interval [CI]: ?A$840, A$391) per child for the Nurse Support intervention and ?A$451.45 (?A$1075, A$173) per child for IVR. The results were most sensitive to the frequency of admissions to hospital. Conclusion. This study suggested that both IVR and Nurse Support interventions may be cost-saving from a health system perspective, with IVR providing the greatest benefit and this pilot study provides a strong basis for developing larger trials with longer follow-up.     

The Impact of Severe Asthma on Schoolchildren

Episodic airway obstruction and hypoxia are potentially life-threatening to children with asthma and may account for neuropsychological impairment. Moreover, living with this chronic disease may severely disrupt children's emotional functioning. The general functioning of 25 children with severe asthma aged 10-13 years was tested by a comparison with 25 matched normal controls. Testing included variables with relevance to normal daily functioning: memory, concentration, school performance, physical condition, subjective symptoms after exercise, and negative emotions. The results showed that children with asthma did not significantly deviate from controls. They reported more dyspnea after physical exercise, which could not be attributed to lung function. Differences in school performance were not significant. It was concluded that children may generally adapt well to living with asthma.     

The Role of Gastroesophageal Reflux in Exercise-Triggered Asthma: A Randomized Controlled Trial

Background Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms. Aims To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients. Methods We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO_2max. Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO_2max. They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated. Results A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009). Conclusion Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression.     

A Randomized Controlled Trial to Evaluate the Effectiveness of a Distance Asthma Learning Program for Pediatricians

Objectives. To assess provider acceptability of a distance learning program for pediatric asthma and pilot test its effects on physician knowledge, attitudes and treatment practices. Design. Randomized controlled trial. Setting. Louisville and the surrounding central Kentucky region. Participants. Twenty-four pediatricians in clinical practice. Interventions. A distance learning program for pediatric asthma consisting of Web- or CD-ROM–based multimedia learning modules and two teleconference calls. Outcome Measures. Learner satisfaction and change in physician asthma knowledge, attitudes, and treatment behavior at 1 to 4 months (short term) and 6 to 8 months (long term). Results. Pediatricians had graduated from medical school a mean of 11.6 years before baseline (SD ±8.9); 56% were female. On all learner satisfaction items, the average score was a 4.0 or greater on a 5-point scale, indicating a favorable response from the participants. Participants in the education group reported increased familiarity with asthma guideline for prescribing daily-inhaled corticosteroids compared to control physicians (p = .03) at short-term follow-up. Participants also expressed increased confidence in selecting a medicine for patients requiring a low-dose inhaled steroid (p = .03). However, these differences were not seen at long-term follow-up. Compared to the control group, there was no significant increase in the proportion of patients receiving inhaled steroids for persistent asthma at short- or long-term follow-up. Conclusions. Pediatricians utilizing an asthma distance learning program expressed a high degree of learner satisfaction. The program was associated with a temporary increase in familiarity and confidence in implementing components of the asthma guidelines.     

A Randomized Controlled Trial Examining the Efficacy of Motivational Counseling with Observed Therapy for Antiretroviral Therapy Adherence

This study determined whether motivational interviewing-based cognitive behavioral therapy (MI-CBT) adherence counseling combined with modified directly observed therapy (MI-CBT/mDOT) is more effective than MI-CBT counseling alone or standard care (SC) in increasing adherence over time. A three-armed randomized controlled 48-week trial with continuous electronic drug monitored adherence was conducted by randomly assigning 204 HIV-positive participants to either 10 sessions of MI-CBT counseling with mDOT for 24 weeks, 10 sessions of MI-CBT counseling alone, or SC. Poisson mixed effects regression models revealed significant interaction effects of intervention over time on non-adherence defined as percent of doses not-taken (IRR = 1.011, CI = 1.000–1.018) and percent of doses not-taken on time (IRR = 1.006, CI = 1.001–1.011) in the 30 days preceding each assessment. There were no significant differences between groups, but trends were observed for the MI-CBT/mDOT group to have greater 12 week on-time and worse 48 week adherence than the SC group. Findings of modest to null impact on adherence despite intensive interventions highlights the need for more effective interventions to maintain high adherence over time.     

Effectiveness of Educational Interventions on Asthma Self-Management in Punjabi and Chinese Asthma Patients: A Randomized Controlled Trial

Background. Asthma tends to be less well controlled among ethnic minority groups, and its prevalence in new immigrants increases significantly the longer they are in Canada; mainly due to their lack of familiarity with English and difficulty understanding information regarding the disease, health literacy, cultural issues, housing conditions, and lack of access to appropriate care services. Objective. To explore the effectiveness of different formats of culturally relevant information and its impact on asthma patients’ self-management within the Punjabi, Mandarin, and Cantonese communities. Methods. Using a participatory approach, we developed and tested knowledge and community educational videos (with similar information, but used a different approach, i.e., scientific vs. colloquial) and a pictorial pamphlet. A total of 92 physician-diagnosed adult asthma patients (47 Chinese and 45 Punjabi) were assigned at random to three experimental groups (watched one or both videos) and one comparison group (read pictorial pamphlet) and participated in three in-person interviews and one telephone interview within a 9-month period. Patients received education on asthma self-management via videos and pamphlet and outcomes, including their knowledge of asthma triggers (environmental-related and behavioral-related triggers) and symptoms; inhaler use skills and patient-reported medication adherence were measured. Results. Knowledge of asthma symptoms, inhaler use, and understanding of physician’s instructions improved significantly from pretest to 3 months post-intervention follow-up among all participants. Conclusions. Participants performed significantly better at follow-up than they did at baseline assessment, with the most notable improvements observed in the group that watched both community and knowledge videos. The results suggest that short, simple, culturally, and linguistically appropriate interventions can promote knowledge gain about asthma and improve inhaler use that can be sustained over the short term. Such interventions that provide authentic learning materials that draw on patients’ life experiences and sociocultural context can overcome certain limitations of conventional patient education approaches.     

Effectiveness of a Comprehensive Lifestyle Modification Program for Asthma Patients: A Randomized Controlled Pilot Trial

Objective. The aim of the study was to investigate the effectiveness and feasibility of conducting a complementary 8-week comprehensive lifestyle modification program (CLMP) compared to standard care in patients with bronchial asthma over a 6-month period. Methods. This was a randomized controlled pilot trial with two groups: intervention (N = 15) group and attention-placebo control (N = 14) group. The intervention group received an 8-week CLMP in addition to standard care. Quality of life, asthma control, lung function, reduction of rescue medication, perceived stress, and psychosocial and spiritual status were measured at the end of the intervention and at the 4-month follow-up. Results. In the intervention group, there was a statistically significant difference in the improvements of quality of life, asthma control, lung function, and the reduction of rescue medication intake at both the end of the intervention and at the 4-month follow-up, with no change being observed in the control group. Significant stress reduction and greater psychosocial and spiritual well-being were observed during the 8-week CLMP in the intervention group. At the end of the intervention, the measures of stress and psychological and spiritual well-being reached statistical significance. Conclusions. Preliminary findings suggest that adding a CLMP to standard care in patients with bronchial asthma offers greater clinical benefit than standard care alone and also suggest that conducting a large randomized clinical trial is feasible.