Mycoplasma pneumoniae and health outcomes in children with asthma.

BACKGROUND: Acute infections with Mycoplasma pneumoniae (Mp) have been associated with worsening asthma in children. Mp can be present in the respiratory tract for extended periods; it is unknown whether the long-term persistence of Mp in the respiratory tract affects long-term asthma control. OBJECTIVE: To determine the effect of Mp on asthma control. METHODS: We enrolled 31 pediatric subjects 3 to 10 years of age with persistent asthma who completed up to 8 visits over a 24-month period. We detected Mp by antigen capture and polymerase chain reaction. Primary outcome measurements included symptom scores, quality of life, medication scores, oral corticosteroid use, health care usage, school absences, and exhaled breath condensate pH. RESULTS: Low levels of Mp community-acquired respiratory distress syndrome toxin were detected in 20 subjects (64.5%) at enrollment. Subjects with Mp positivity at a given visit had a .579 probability of remaining Mp positive at the subsequent visit, whereas those with Mp negativity had a .348 probability of becoming Mp positive at the following visit. The incidence of Mp overall was higher in the spring and summer months. Overall, we found no significant relation between the detection of Mp and worse outcome measurements at the same visit or at subsequent visits. CONCLUSION: The long-term persistence of Mp in the respiratory tract is common in children with asthma. However, the detection of Mp was not associated significantly with worse asthma symptoms, quality of life, health care usage, school absences, or exhaled breath condensate pH in this pediatric asthma cohort.

Assessing proxy reports: agreement between children with asthma and their caregivers on quality of life.

BACKGROUND: Health-related quality of life (HRQOL) questionnaires are important tools to evaluate health status in children with asthma; however, children with asthma and their caregivers have shown only low to moderate agreement in their responses. OBJECTIVE: To analyze the agreement between children with asthma and their caregivers on HRQOL, specifically in the domains of activity limitation, emotional function, and overall quality of life (QOL). METHODS: We enrolled 79 pediatric patients (ages 5-17 years) with asthma (53 with acute asthma and 26 with refractory asthma) and their caregivers. Children completed the Pediatric Asthma Quality of Life Questionnaire, and caregivers completed the Pediatric Asthma Caregiver's Quality of Life Questionnaire (potential score, 1-7; higher scores indicate better QOL). We used paired t test to examine differences in child and caregiver responses, Pearson correlation to describe patterns of agreement, and multivariate analysis to evaluate the effect of sex, age, and ethnicity on differences in child and caregiver responses. RESULTS: Children with asthma and their caregivers reported similar scores and demonstrated moderate correlation in emotional function and overall QOL. Children reported a significantly better QOL than their caregivers in response to questions about activity limitation (mean score, 4.62 vs 3.49; P < .001). Male children were more likely to differ from their caregivers than females, especially in regard to activity limitation. CONCLUSION: Although caregivers of children with asthma can provide useful proxy information about QOL, their responses cannot be substituted for their children's reports regarding activity limitation. Clinicians and researchers should ask both children and their caregivers about asthma-specific QOL.

Mycoplasma pneumoniae in children with acute and refractory asthma.

BACKGROUND: The presence of Mycoplasma pneumoniae has been associated with worsening asthma in children. Sensitive assays have been developed to detect M pneumoniae-derived community-acquired respiratory distress syndrome (CARDS) toxin. OBJECTIVES: To identify the frequency and persistence of M pneumoniae detection in respiratory secretions of children with and without asthma and to evaluate antibody responses to M pneumoniae and the impact of M pneumoniae on biological markers, asthma control, and quality of life. METHODS: We enrolled 143 pediatric patients (53 patients with acute asthma, 26 patients with refractory asthma, and 64 healthy controls; age range, 5-17 years) during a 20-month period with 2 to 5 follow-up visits. We detected M pneumoniae using CARDS toxin antigen capture and polymerase chain reaction and P1 adhesin polymerase chain reaction. Immune responses to M pneumoniae were determined by IgG and IgM levels directed against CARDS toxin and P1 adhesin. pH was measured in exhaled breath condensates, and asthma control and quality of life were assessed using the Asthma Control Test and Pediatric Asthma Quality of Life Questionnaire. RESULTS: M pneumoniae was detected in 64% of patients with acute asthma, 65% with refractory asthma, and 56% of healthy controls. Children with asthma had lower antibody levels to M pneumoniae compared with healthy controls. Exhaled breath condensate pHs and asthma control and quality of life scores were lower in M pneumoniae-positive patients with asthma. CONCLUSION: The results suggest that M pneumoniae detection is common in children, M pneumoniae detection is associated with worsening asthma, and children with asthma may have poor humoral immune responses to M pneumoniae.

Ask Me 3: improving communication in a Hispanic pediatric outpatient practice.

OBJECTIVE: To implement Ask-Me-3, a program that encourages patients to ask questions of physicians, in a low-income, predominantly Hispanic pediatric practice. METHODS: We publicized Ask-Me-3 with posters/brochures in clinic. We interviewed parents before and 6 months after implementation to determine if they knew about and used the Ask-Me- 3 questions. RESULTS: No parents knew about Ask-Me-3 before implementation. Of 393 parents interviewed 6 months later, 42% knew about Ask-Me-3, and half of these used the questions. CONCLUSIONS: With a simple strategy for introducing Ask-Me-3, 20% of parents were using Ask-Me-3 six months later.

Feasibility of spirometry testing in preschool children.

RATIONALE: The primary purpose of this study was to evaluate the feasibility of obtaining acceptable and reproducible spirometry data in preschool aged children (3-5 years) by technicians without prior experience with spirometry. METHODS: Two technicians were trained to perform spirometry testing (ndd Easy on-PC) and to administer standardized questionnaires. Preschool aged children were enrolled from two Head Start centers and a local primary care clinic. Subjects were trained in proper spirometry technique and tested until at least two acceptable efforts were obtained or the subject no longer produced acceptable efforts. RESULTS: 200 subjects were enrolled: mean age 4.0 years (± 0.7 SD); age distribution: 51 (25.5%) 3 years old, 103 (51.5%) 4 years old, and 46 (23%) 5 years old. Fifty-six percent male and 75% Hispanic. One hundred thirty (65%) subjects produced at least one acceptable effort on their first visit: 23 (45%) for 3 years old, 67 (65%) for 4 years old, and 40 (87%) for 5 years old. The number of acceptable efforts correlated with age (r = 0.29, P < 0.001) but not gender. The mean number of acceptable efforts on the first visit was 2.66 (± 2.54 SD; range 0-10). One hundred twenty subjects (60%) had two acceptable efforts; 102 had FEV0.5 within 10% or 0.1 L and 104 had FVC within 10% or 0.1 L of best effort. The Asthma Health Screening Survey (AHSS) was 78% sensitive when compared to a specialist exam and 86% compared to a self-reported prior diagnosis of asthma. CONCLUSIONS: Technicians without prior experience were able to obtain acceptable and reproducible spirometry results from the preschool aged children; the number of acceptable efforts correlated significantly with age.

Assessing the value of disease management: impact of 2 disease management strategies in an underserved asthma population.

BACKGROUND: The goal of disease management (DM) is to improve health outcomes and reduce cost through decreasing health care utilization. Although some studies have shown that DM improves asthma outcomes, these interventions have not been examined in a large randomized controlled trial. OBJECTIVE: To compare the effectiveness of 2 previously successful DM programs with that of traditional care. METHODS: Nine hundred two individuals with asthma (429 adults; 473 children) were randomly assigned to telephonic DM, augmented DM (ADM; DM plus in-home visits by a respiratory therapist), or traditional care. Data were collected at enrollment and at 6 and 12 months. Primary outcomes were time to first asthma-related event, quality of life (QOL), and rates of asthma-related health care utilization. Secondary outcomes included rate of controller medication initiation, number of oral corticosteroid bursts, asthma symptom scores, and number of school days missed. RESULTS: There were no significant differences between groups in time to first asthma-related event or health care utilization. Adult participants in the ADM group had greater improvement in QOL (P = .04) and a decrease in asthma symptoms (P = .001) compared with other groups. Of children not receiving controller medications at enrollment (13%), those in the intervention groups were more likely to have controller medications initiated than the control group (P = .01). Otherwise, there were no differences in outcomes. CONCLUSIONS: Overall, participation in asthma DM did not result in significant differences in utilization or clinical outcomes. The only significant impact was a higher rate of controllermedication initiation in children and improvement in asthma symptoms and QOL in adults who received ADM.

Asthma risk factor assessment: what are the needs of inner-city families?

BACKGROUND: A complex array of risk factors contributes to sustained high levels of asthma morbidity in inner-city children. OBJECTIVE: To describe risk factors for asthma morbidity in a national sample of inner-city children with persistent asthma. METHODS: This study examined baseline questionnaire results from 1,772 children ages 5 to 11 years old with moderate to severe persistent asthma who enrolled in the Centers for Disease Control and Prevention-funded Inner-City Asthma Intervention between April 2001 and March 2004. Risk for asthma morbidity was assessed in 9 domains using the Child Asthma Risk Assessment Tool. The domains included environmental exposures, parental stress, medication adherence, pessimistic asthma beliefs, smoke exposure, aeroallergen exposure, child psychological well-being, responsibility for medication administration, and medical care. RESULTS: A total of 51% of families demonstrated high risk of asthma morbidity in 3 or more domains. High risk of asthma morbidity was suggested based on household environmental exposures (47.7%), high parental stress (38.5%), poor medication adherence (38.3%), pessimistic asthma beliefs (31.8%), environmental tobacco smoke (24.4%), sensitization to aeroallergens in the home (24.8%), child behavioral or emotional concerns (22.9%), child assigned responsibility for medication administration (21.2%), and poor medical care (20.7%). Allergy testing was completed for 40% of the participating children. Of these children, 61% were exposed to aeroallergens in their home to which they were sensitized. CONCLUSIONS: In this national sample of inner-city children, multiple risk factors for asthma morbidity were identified. Asthma programs that provide multilevel support and intervention are needed to reduce the burden of asthma on inner-city families.

The Inner-City Asthma Intervention: description of a community-based implementation of an evidence-based approach to asthma management.

BACKGROUND: In 2000, the Centers for Disease Control and Prevention funded a 4-year project to implement the Inner-City Asthma Intervention (ICAI)-an asthma treatment and management project based on the protocol developed for the National Cooperative Inner-City Asthma Study (NCICAS) funded by the National Institutes of Health, National Institute of Allergy and Infectious Disease. OBJECTIVE: To describe the ICAI's major components and implementation issues. METHODS: Information contained in this article is based on project activity and management reports, site client tracking and data collection reports, site visit and other program oversight activity, and general subject matter knowledge. The site client tracking data collection process varied among sites during the intervention. Common definitions and processes were developed and implemented as needed. RESULTS: Three of the 24 original sites discontinued participation. The remaining sites enrolled 4,174 children into the intervention. Although the project ended earlier than originally scheduled, 1,035 children completed the entire intervention. Of the 3,139 children who did not complete the entire protocol, 1,355 children and their families completed the core activities or the core activities plus one or more follow-up activities. CONCLUSION: The ICAI project demonstrated that although there were a number of implementation issues to overcome, it is possible to implement effectively a proven National Institutes of Health protocol in the community setting.

Welfare to work? Impact of maternal health on employment.

OBJECTIVES: This study investigated whether health problems among poor mothers of chronically ill children affect their ability to obtain and maintain employment. METHODS: Mothers of children with chronic illnesses were surveyed at clinical and welfare agency sites in San Antonio, Tex. RESULTS: There were distinct health differences according to mothers' TANF and employment status. Mothers without TANF experience reported better physical and mental health and less domestic violence and substance use than did those who had TANF experience. Those not currently working had higher rates of physical and mental health problems. CONCLUSIONS: Poor maternal health is associated with need for cash assistance and health insurance. Policymakers must recognize that social policies promoting employment will fail if they do not address the health needs of poor women and children.

Relationships between welfare status, health insurance status, and health and medical care among children with asthma.

OBJECTIVES: This study evaluated the relationships between health insurance and welfare status and the health and medical care of children with asthma. METHODS: Parents of children with asthma aged 2 to 12 years were interviewed at 6 urban clinical sites and 2 welfare offices. RESULTS: Children whose families had applied for but were denied welfare had more asthma symptoms than did children whose families had had no contact with the welfare system. Poorer mental health in parents was associated with more asthma symptoms and higher rates of health care use in their children. Parents of uninsured and transiently insured children identified more barriers to health care than did parents whose children were insured. CONCLUSIONS: Children whose families have applied for welfare and children who are uninsured are at high risk medically and may require additional services to improve health outcomes.

Employment barriers among welfare recipients and applicants with chronically ill children.

OBJECTIVES: This study evaluated the association of chronic child illness with parental employment among individuals who have had contact with the welfare system. METHODS: Parents of children with chronic illnesses were interviewed. RESULTS: Current and former welfare recipients and welfare applicants were more likely than those with no contact with the welfare system to report that their children's illnesses adversely affected their employment. Logistic regression analyses showed that current and former receipt of welfare, pending welfare application, and high rates of child health care use were predictors of unemployment. CONCLUSIONS: Welfare recipients and applicants with chronically ill children face substantial barriers to employment, including high child health care use rates and missed work. The welfare reform reauthorization scheduled to occur later in 2002 should address the implications of chronic child illness for parental employment.