A Pragmatic Trial of Symptom-Based Inhaled Corticosteroid Use in African-American Children with Mild Asthma.

BACKGROUND: Symptom-based adjustment (SBA) of inhaled corticosteroids may be an alternative patient-centered approach in which day-to-day inhaled corticosteroid use is adjusted by symptoms and short-acting ß-agonist need. OBJECTIVE: To evaluate the effectiveness of SBA in the primary care setting. METHODS: We conducted a randomized, open-label, pragmatic equivalence trial in African-American children (6-17 years old) with mild asthma managed by 12 primary care providers (PCPs). A total of 206 participants were randomized to SBA (as-needed beclomethasone 80 µg with rescue short-acting ß-agonist) or provider-based guideline-directed adjustment (PBA): maintenance beclomethasone 80 µg/d (6-11 years old), 160 µg/d (12-17 years old), with subsequent guideline-based dose adjustment by PCPs. PCPs implemented both treatment assignments, with outcomes measured by blinded staff. All participants received symptom recognition and albuterol use education from peer educators. Primary outcome was change in asthma control (measured by Asthma Control Test [ACT]/childhood ACT [cACT]) over 12 months. RESULTS: Participants had adequately controlled asthma (mean ACT or cACT score = 21.6 ± 2.8) at baseline. After 1 year, there was no significant between-group difference in change in ACT scores (SBA - PBA): ACT: -0.88 (95% CI, -2.19 to 0.42), cACT: -0.73 (-2.09 to 0.62), or combined ACT and cACT (P = .10), and was within the predefined statistical clinical equivalence. The proportion with an exacerbation and measures of lung function were similar between groups. Compared with PBA, SBA led to less beclomethasone use (SBA: 526 µg/mo [95% CI, 412-639 µg] vs PBA: 1961 µg/mo [95% CI, 1681-2241]; P < .0001). More parents in the SBA arm felt they were managing their child's asthma. CONCLUSIONS: SBA in African-American children with mild asthma was similar to PBA in asthma control and events when implemented by PCPs with lower inhaled corticosteroid exposure.

The emergence of gender differences in physical aggression in the context of conflict between young peers.

It is well known that a gender difference in physical aggression emerges by the preschool years. We tested the hypothesis that the gender difference is partly due to changing tactics in peer interaction. Observations of girls' and boys' social initiatives and reactions to opportunities for conflict were made, using the Peer Interaction Coding System (PICS) in four independent samples of children between 9 and 36 months of age, which were aggregated to form a summary data set (N= 323), divided into two age bands (below or above 24 months of age). Linear mixed-model analyses revealed significant age by gender interactions in the use of bodily force in response to peers' initiatives and in the tendency to use bodily force at later stages of conflicts with peers. The gender difference in use of force was not explained by differences in the use of verbal tactics. These cross-sectional findings suggest that girls are initially more likely than boys to use reactive aggression, but then desist, whereas boys increase their use of force to defend their territory and possessions. The difference between older and younger girls likely reflects girls' abilities to regulate their behaviour in response to social challenges and the fact that girls are explicitly socialized to yield to peers' demands.