Factors associated with poor controller medication use in children with high asthma emergency department use.

BACKGROUND: Understanding health and social factors associated with controller medication use in children with high-risk asthma may inform disease management in the home and community. OBJECTIVE: To examine health and social factors associated with the Asthma Medication Ratio (AMR), a measure of guideline-based care and controller medication use, in children with persistent asthma and frequent emergency department (ED) use. METHODS: Study questionnaires, serum allergen sensitization, salivary cotinine, and pharmacy record data were collected for 222 children enrolled from August 2013 to February 2016 in a randomized clinical trial that tested the efficacy of an ED- and home-based intervention. Logistic regression was used to examine factors associated with an AMR greater than 0.50, reflecting appropriate controller medication use. RESULTS: Most children were male (64%), African American (93%), Medicaid insured (93%), and classified as having uncontrolled asthma (44%). Almost half (48%) received non-guideline-based care or low controller medication use based on an AMR less than 0.50. The final regression model predicting an AMR greater than 0.50 indicated that children receiving specialty care (odds ratio [OR], 4.87; 95% confidence interval [CI], 2.06-11.50), caregivers reporting minimal worry about medication adverse effects (OR, 0.50; 95% CI, 0.25-1.00), positive sensitization to ragweed allergen (OR, 3.82; 95% CI, 1.63-8.96), and negative specific IgE for dust mite (OR, 0.33; 95% CI, 0.15-0.76) were significantly associated with achieving an AMR greater than 0.50. CONCLUSION: Clinical decision making for high-risk children with asthma may be enhanced by identification of sensitization to environmental allergens, ascertaining caregiver's concerns about controller medication adverse effects and increased referral to specialty care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01981564.

Factors associated with high short-acting ß2-agonist use in urban children with asthma.

BACKGROUND: One goal of guideline-based asthma therapy is minimal use of short-acting ß2 agonist (SABA) medications. Inner-city children with asthma are known to have high SABA use. OBJECTIVE: To examine factors associated with high SABA use in inner-city children with asthma. METHODS: One hundred inner-city children with persistent asthma were enrolled into a randomized controlled trial of an emergency department (ED) and home intervention. All children underwent serologic allergen specific IgE and salivary cotinine testing at the ED enrollment visit. Pharmacy records for the past 12 months were obtained. Number of SABA fills during the past 12 months was categorized into low- to moderate- vs high-use groups. SABA groups were compared by the number of symptom days and nights, allergen sensitization, and exposures. Regression models were used to predict high SABA use. RESULTS: Mean number of SABA fills over 12 months was 3.12. Unadjusted bivariate analysis showed that high SABA users were more than 5 times more likely to have an asthma hospitalization, almost 3 times more likely to have an asthma intensive care unit admission, and more than 3 times more likely to have prior specialty asthma care or positive cockroach sensitization than low to moderate SABA users. In the final regression model, for every additional inhaled corticosteroid fill, a child was 1.4 times more likely and a child with positive cockroach sensitization was almost 7 times more likely to have high SABA use when controlling for prior intensive care unit admission, receipt of specialty care, child age, and income. CONCLUSION: Providers should closely monitor SABA and controller medication use, allergen sensitization, and exposures in children with persistent asthma. TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT01981564.

Children with poorly controlled asthma: Randomized controlled trial of a home-based environmental control intervention.

BACKGROUND: Few trials have tested targeted environmental control (EC) interventions based on biomarkers of second hand smoke (SHS) exposure and allergen sensitization in reducing asthma emergency department (ED) visits in children with poorly controlled asthma. METHODS: Overall, 222 children with poorly controlled asthma were randomized into a home-based EC intervention (INT) or control (CON) group and followed for ED visits over 12 months. All children received allergen-specific IgE serologic testing and SHS exposure biomarker testing to inform the EC intervention. Pharmacy data was examined for asthma medication fills. Cox proportional hazards and multivariate regression models were performed to examine factors associated with repeat ED visits. RESULTS: There was no difference in increased risk of >1 ED visit at 12 months between INT and CON groups. Most children (75%) had moderate/severe persistent asthma. Over half (56%) had SHS exposure and 83% tested positive for >1 allergen sensitization. Among children without SHS exposure, the median time to first recurrent ED visit differed by group (CON: 195; INT: >365 days) after adjusting for child age, allergic sensitization, medication fills prior to baseline, controller medication use, and the interaction between group status and SHS exposure. Children who had positive allergic sensitizations, younger, had increased controller medication use and randomized to the CON group and had no SHS exposure had increased risk for a repeat ED visit over 12 months. CONCLUSIONS: In this study, a home-based EC intervention was not successful in reducing asthma ED revisits in children with poorly controlled asthma with SHS exposure. Allergic sensitization, young age, and increased controller medication use were important predictors of asthma ED visits.

Very Poorly Controlled Asthma in Urban Minority Children: Lessons Learned.

BACKGROUND: Very poorly controlled (VPC) asthma in children is associated with ongoing acute exacerbations but factors associated with VPC are understudied. OBJECTIVE: To examine the risk factors associated with VPC asthma in urban minority children. METHODS: This descriptive study examined asthma control levels (well-controlled [WC], not well-controlled [NWC], and VPC) at baseline and 6 months in children participating in an ongoing randomized controlled trial of an emergency department/home environmental control intervention. Data collection occurred during the index emergency department visit and included allergen-specific IgE and salivary cotinine testing and caregiver interview of sociodemographic and child health characteristics. Follow-up data were collected at 6 months. Unadjusted analyses examined the association of sociodemographic and health characteristics by level of asthma control. Multivariate analysis tested significant factors associated with VPC asthma at 6 months. RESULTS: At baseline most children were categorized with VPC asthma (WC, 0%; NWC, 47%; VPC, 53%) and rates of VPC minimally improved at 6 months (WC, 13%; NWC, 41%; VPC, 46%). Risk for VPC asthma was twice as likely in children with allergic rhinitis (odds ratio [OR], 2.42), having 2 or more primary care provider asthma visits within the past 3 months (OR, 2.77), or caregiver worry about medication side effects (OR, 2.13) and 3 to 4 times more likely when asthma control was assessed during the fall or spring season (OR: fall, 3.32; spring, 4.14). CONCLUSIONS: Improving asthma control in low-income, high-risk children with VPC asthma requires treatment of comorbidities, attention to caregiver medication beliefs, and adept use of stepwise therapy.

Acute onset rhythmic hiccup-like respirations secondary to oral baclofen toxicity.

OBJECTIVE: Baclofen toxicity has been associated with seizures, coma, apnea, autonomic disturbances, and cardiac conduction abnormalities. It has not been associated with rhythmic hiccup-like respirations. METHOD: We report a patient with suspected baclofen toxicity. RESULTS: Our patient is a 19-year-old girl with cerebral palsy secondary to prematurity and repaired tetralogy of Fallot who had started oral baclofen 8 months before to diminish spasticity. Her main concern was the acute onset of rhythmic, deep, continual, hiccup-like breaths every few seconds, increasing in frequency with exhaustion, and disappearing in sleep. The night after her evaluation, her symptoms significantly worsened. She presented at the Johns Hopkins pediatric emergency room where her symptoms were only somewhat responsive to a benzodiazepine; she was discharged without a clear etiology. After discussion the next day, her baclofen dose was reduced. Within 12 hours, her abnormal respirations disappeared without recurrence. CONCLUSIONS: Respiration involves glutamatergic excitatory synaptic input to medullary inspiratory γ-aminobutyric acid-mediated pacemaker neurons. Baclofen acts on presynaptic γ-aminobutyric acid B receptors on glutamate axons; derangement of this system may explain the irregular respirations in our patient in a dose-dependent fashion.

Adherence feedback to improve asthma outcomes among inner-city children: a randomized trial.

OBJECTIVE: We evaluated the longitudinal effects of home-based asthma education combined with medication adherence feedback (adherence monitoring with feedback [AMF]) and asthma education alone (asthma basic care [ABC]) on asthma outcomes, relative to a usual-care (UC) control group. METHODS: A total of 250 inner-city children with asthma (mean age: 7 years; 62% male; 98% black) were recruited from a pediatric emergency department (ED). Health-outcome measures included caregiver-frequency of asthma symptoms, ED visits, hospitalizations, and courses of oral corticosteroids at baseline and 6-, 12-, and 18-month assessments. Adherence measures included caregiver-reported adherence to inhaled corticosteroid (ICS) therapy and pharmacy records of ICS refills. Multilevel modeling was used to examine the differential effects of AMF and ABC compared with UC. RESULTS: ED visits decreased more rapidly for the AMF group than for the UC group, but no difference was found between the ABC and UC groups. The AMF intervention led to short-term improvements in ICS adherence during the active-intervention phase relative to UC, but this improvement decreased over time. Asthma symptoms and courses of corticosteroids decreased more rapidly for the ABC group than for the UC group. Hospitalization rates did not differ between either intervention group and the UC group. No differences were found between the ABC and AMF groups on any outcome. CONCLUSIONS: Asthma education led to improved adherence and decreased morbidity compared with UC. Home-based educational interventions may lead to modest short-term improvements in asthma outcomes among inner-city children. Adherence feedback did not improve outcomes over education alone.

Radiographic evaluation for suspected cerebrospinal fluid shunt obstruction.

OBJECTIVE: To measure the predictive value of plain radiographs (shunt series) and computed tomography (CT) scans in a group of children undergoing evaluation for suspected shunt obstruction in a tertiary care pediatric emergency department (ED). METHODS: Radiology reports were reviewed for all ED patients who underwent a shunt series over an 18-month period. Two investigators categorized all reports as normal, possibly abnormal (eg, kink in shunt tubing, no prior CT scan for comparison), or abnormal (with definite evidence of shunt dysfunction, such as shunt tubing disconnection and increase in ventricular size since prior CT scan). Studies for which there was disagreement were re-read independently by a pediatric radiologist. Medical records were reviewed to determine outcomes. RESULTS: A total of 233 patients had shunt series and CT scans ordered. Of these, 60 patients subsequently required surgery for shunt obstruction. The shunt series revealed abnormalities in 12 patients (sensitivity, 20%; negative predictive value, 22%), whereas CT scans showed definite or possible abnormalities in 50 patients (sensitivity, 83%; negative predictive value, 93%). Combined, the two tests detected 53 shunt obstructions (sensitivity, 88%; negative predictive value, 95%). Two obstructed patients had abnormalities on shunt series that would not have been suspected after physical examination or CT scan. CONCLUSIONS: Over one quarter of pediatric ED patients evaluated radiographically for suspected shunt obstruction required surgical management. One in eight obstructed patients had normal radiographic studies. Routine performance of shunt series had a low overall yield but on rare occasions detected abnormalities that were missed by CT. Prospective studies are needed to improve the use of radiographic tests for shunt evaluation and determine clinical indications for further workup when studies are normal.