The Impact of the Duration of Antibiotic Therapy in Patients With Community-Onset Pneumonia on Readmission Rates: A Retrospective Cohort Study.

BACKGROUND: Recent publications have confirmed that 70% of hospitalized adults with uncomplicated community-acquired pneumonia and health-care-associated pneumonia are prescribed a duration therapy that exceeds current guideline recommendations. OBJECTIVE: The primary objective is to evaluate the relationship between antibiotic duration and all-cause 30-day readmission rates. Secondary outcomes include pneumonia-specific 30-day readmission rate and identification of risk factors for readmission. METHODS: Patients aged ≥18 years with a primary diagnosis of pneumonia from January 1, 2016, to December 31, 2016, were included in this single-center, retrospective cohort study. Patients were categorized by antibiotic therapy duration of ≤7 days (n = 139) or >7 days (n = 286), and outcomes were analyzed in both bivariate and multivariate models. A multivariate logistic regression was used to assess the relationship between all-cause 30-day readmission and antibiotic days. RESULTS: Baseline characteristics were not significantly different between the 2 groups. All-cause 30-day readmission rates were 15.8% and 15.5% for patients who received ≤7 days versus >7 days of antibiotics, respectively (P = .95). Pneumonia-specific 30-day readmission occurred in 3.6% of patients who received antibiotics for ≤7 days compared to 3.5% of patients who received antibiotics for >7 days (P = .95). Multivariate logistic regression showed no statistically significant association between readmission rate and antibiotic duration of >7 days. Statistically significant risk factors for readmission identified by logistic regression include ≥3 hospital admissions within the previous year, a hematocrit <30% at discharge, a history of chronic obstructive pulmonary disorder (COPD), and weight. CONCLUSION: The use of prolonged antibiotic therapy for the treatment of community-onset pneumonia was not associated with a decrease in all-cause or pneumonia-specific 30-day readmission rates.

Analysis of the impact of secondary prophylaxis on Clostridioides difficile recurrence in critically ill adults.

INTRODUCTION: Clostridioides (formerly Clostridium) difficile infection recurrence in patients re-exposed to antibiotics for treatment of a non-Clostridioides difficile infection is high at approximately 33%. Low-dose per os vancomycin (e.g. 125 mg q12 h) or metronidazole (e.g. 500 mg intravenous/per osq8 h) may help prevent recurrences, but study of secondary prophylaxis in critically ill patients is needed. OBJECTIVES: To determine whether critically ill adults receiving low-dose per os vancomycin for secondary Clostridioides difficile infection prophylaxis have fewer recurrences of Clostridioides difficile infection in 90 days compared with patients receiving metronidazole for secondary Clostridioides difficile infection prophylaxis or control (no secondary prophylaxis). METHODS: This was a retrospective, two-center, observational study in a large academic medical center and affiliated community hospital. Included patients had a history of Clostridioides difficile infection within 1 year of receiving antibiotics for clinical care. We compared patients receiving secondary prophylaxis with vancomycin or metronidazole and control patients; in addition, an unplanned fourth group (vancomycin/metronidazole combination) was identified and analyzed. The primary outcome was Clostridioides difficile infection recurrence within 90 days of a course of broad-spectrum antibiotic therapy. Fisher's exact, analysis of variance, and Kruskal-Wallis tests were used to compare Clostridioides difficile infection recurrence with prophylaxis group and additional contributing factors. RESULTS: Eighty-two patients were included: 38 control (46.3%), 20 metronidazole (24.4%), 17 vancomycin (20.7%), and 7 combination (8.5%). Ten of 82 patients (12.2%) had at least one Clostridioides difficile infection recurrence; 8/38 patients in the control group (21.1%), 1/7 patients in the combination group (14.3%), 1/17 patients in the per os vancomycin group (5.9%), and 0/20 in the metronidazole group (0%; p = 0.073). As a post hoc secondary analysis, the three prophylaxis groups were coalesced into one group and compared with control (4.5% vs 21%; p = 0.039). Additional factors (e.g. age, obesity, immunosuppression, acid suppression) were not significantly associated with Clostridioides difficile infection recurrence or with prophylaxis group. CONCLUSION: There was no difference in Clostridioides difficile infection recurrence between prophylaxis groups, however, given the low recurrence rate, prospective evaluation with a larger sample of critically ill patients is necessary.

Is there a higher prevalence of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization in patients with antibiotic allergy labels?

BACKGROUND: A penicillin allergy label has been associated with significantly higher rates of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization, and correspondingly poorer clinical outcomes. However, there are limited data examining the association between any antibiotic label and colonization rates. We sought to evaluate if there is a relationship between patients with an antibiotic allergy label and prevalence of MRSA or VRE colonization. METHODS: We retrospectively reviewed all patients with an MRSA surveillance culture between December 15, 2014 and January 31, 2015, or a VRE surveillance culture between January 1, 2013 and January 31, 2015, at a tertiary community-based teaching hospital. Our primary objective was to evaluate the prevalence of MRSA or VRE colonization among patients with and without antibiotic allergies. Bivariate analyses included the χ² test and the Student t test to determine statistical significance for categorical and continuous variables, respectively. RESULTS: We included a total of 1,053 unique patients screened for MRSA, and 290 unique patients screened for VRE. The rate of MRSA and VRE colonization was 5.8% (62 of 1,053) and 32.4% (94 of 290), respectively, in our cohort. Antibiotic allergies were documented in approximately 1 out of 3 patients, 337 (32%) for the MRSA group and 94 (32%) for VRE group. There was a significant difference in MRSA colonization between patients with and without an antibiotic allergy, 28 of 337 (8.3%) versus 34 of 716 (4.7%) (P = .025), respectively. In contrast, there was no significant difference in antibiotic allergy rates with and without VRE colonization, 34 of 94 (36.2%) versus 92 of 196 (46.9%) (P = .10), respectively. CONCLUSIONS: An antibiotic allergy label was associated with significantly higher rates of MRSA colonization but no statistical difference with VRE colonization.

An Exploratory Study of Suboxone (Buprenorphine/Naloxone) Film Splitting: Cutting Methods, Content Uniformity, and Stability.

Suboxone films are U.S. Food and Drug Administration approved to treat opioid dependence. While the package insert states that films should not be cut, physicians often prescribe film fractions for treatment and tapering. There is no data to support this practice, and this study was initiated to evaluate cutting methods, content uniformity, and stability of split films. Suboxone 8-mg buprenorphine/2-mg naloxone films were split using four methods: 1) ruler/razor cut, 2) scissor cut, 3) fold/rip, and 4) fold/scissor cut. United States Pharmacopeia Chapter <905> was used to evaluate the weight variation and content uniformity of split films. The stability of split films stored in polybags was evaluated over 7 days. A stability-indicating high-performance liquid chromatography method was used for content uniformity and stability evaluation. The weight variation results were acceptable for the half films from all four cutting methods, but this was not true for the quarter films. The method of ruler/razor cut was determined most favorable and used for the content uniformity test. Based on the high-performance liquid chromatography results, the half films from the ruler/razor cut method met the passing criteria of United States Pharmacopeia Chapter <905> with acceptance values of 9.8 to 10.4 for buprenorphine and 8.4 to 11.5 for naloxone (=15 is considered passing). The stability results indicated that both actives retained >97.7% of initial strength. Four cutting methods were found to be acceptable for splitting Suboxone films into half but not quarter fractions. The half films from the ruler/razor cut method also passed United States Pharmacopeia Chapter <905> content uniformity test. Both actives remained stable for 7 days when the half films were stored in polybags at room temperature.

The relationship between pharmacy students' beliefs about medications and their academic achievement in a pharmacy practice counseling course.

INTRODUCTION: Pharmacists' beliefs about medications have been identified as a potential factor in how patients are counseled. However, no studies have assessed this relationship. METHODS: Third year pharmacy students were surveyed using previously validated questionnaires about medication beliefs, including the BMQ-General (General-Overuse and General-Harm subscales), Benefit, and Perceived Sensitivity to Medications (Sensitive Soma) scales; each is rated on a five-point Likert scale (higher scores represent stronger feelings). Belief profiles were created using two-step cluster analysis. Students also reported demographics and prior work in a pharmacy. Grades from simulated counseling sessions were collected via school records. Student t-test and multivariate linear regression were used to compare beliefs with grades. RESULTS: Among the 66 responders (84.5% response rate), 54.5% were female, 80.3% white, and 77.3% non-Hispanic; 84.8% reported prior work in a pharmacy. Overall mean (SD) belief scores were General-Overuse 3.12 (0.76), General-Harm 1.83 (0.53), Benefit 3.99 (0.55), and Sensitive Soma 2.37 (0.82). Cluster analyses revealed two beliefs profiles: negative profile (more feelings of overuse, harm, and sensitivity to medications) and positive profile (less feelings of overuse, harm, and sensitivity to medications). Students with positive belief profiles were graded higher by faculty compared to students with negative belief profiles (90.0 vs. 87.2, p = 0.014). Findings remained in a multivariate regression controlling for gender and prior work in a pharmacy. CONCLUSIONS: Findings from this study demonstrate the need for greater understanding about the relationship between pharmacists' beliefs about medications and patient counseling.

The Relationship Between Prior Experiences in Mathematics and Pharmacy School Success.

Objective. To assess students' pre-pharmacy math experiences, confidence in math ability, and relationship between experiences, confidence, and grades in math-based pharmacy courses. Methods. A cross-sectional survey of first year to third year pharmacy students was conducted. Students reported type of pre-pharmacy math courses taken, when they were taken [high school (HS) vs. college] and year of HS and college graduation. Students rated their confidence in math ability using the previously validated 11-item Fogerty Math Confidence Scale (Cronbach alpha=0.92). Math grade point average (GPA), Pharmacy College Admission Test quantitative (PCAT quant) scores, and grades (calculations and kinetics) were obtained from transcripts and school records. Spearman correlation and multivariate linear regression were used to compare math experiences, confidence, and grades. Results. There were 198 students who reported taking math courses 7.1 years since HS graduation and 2.9 years since their last schooling prior to pharmacy school. Students who took math courses with more time since HS/last schooling had lower calculations and kinetics grades. Students reporting having taken more HS math courses had better calculations grades. Students with higher math GPA, and PCAT quant scores also had higher calculations and kinetics grades. Greater confidence in math ability was associated with higher calculations grades. In multivariate regressions, PCAT quant scores and years since HS independently predicted calculations grades, and PCAT quant scores independently predicted kinetics grades. Conclusion. The number of pre-pharmacy math courses and time elapsed since they were taken are important factors to consider when predicting a pharmacy student's success in math-based pharmacy school courses.

Signal detection for bleeding associated with the use of direct oral anticoagulants.

PURPOSE: The potential link between serious or life-threatening bleeding and the use of direct oral anticoagulants (DOACs) was evaluated. METHODS: Qualitative and quantitative reviews of case reports of bleeding events involving dabigatran, rivaroxaban, apixaban, edoxaban, and warfarin through March 31, 2017, were performed. A disproportionality analysis was conducted for each DOAC using an empirical Bayesian approach based on the relative reporting rate. Subanalyses were performed to assess (1) bleeding events (including mortality and life-threatening events) associated with DOACs among all adverse-event reports and (2) warfarin-related bleeding events. These analyses were conducted based on clinical definitions from the Medical Dictionary for Regulatory Activities. RESULTS: During the Food and Drug Administration Adverse Event Reporting System (FAERS) review period, 35 adverse-event terms (in any system organ class) with a disproportionality score (EB05) of >7.5 for DOACs were identified; this accounted for 40,109 adverse-event reports. Adverse events with the highest disproportionality scores included atrial thrombosis, increased factor X level, dysfunctional uterine bleeding, high-frequency ablation, pericardial hemorrhage, and internal hemorrhage. Adverse events with the highest EB05 (>5) included internal hemorrhage, hemorrhage, and exsanguination; events with the greatest number of patient experiences included hemorrhage (6,881 events), internal hemorrhage (2,569 events), and hematoma (1,995 events). Warfarin-related events (including death or life-threatening events) were also assessed. A total of 8,729 adverse events were associated with warfarin use. The most common of these included hemorrhage (6,225 events), hematoma (2,199 events), and internal hemorrhage (270 events). CONCLUSION: The disproportionality analysis of the FAERS database suggests a quantitative signal between DOAC use and life-threatening or serious bleeding.

The Use of Telemedicine for Penicillin Allergy Skin Testing.

BACKGROUND: Penicillin skin testing (PST) is increasingly used as a tool to evaluate penicillin allergy in patients with a reported history. The limited availability of allergists, however, may be an impeding factor. OBJECTIVE: We sought to assess the clinical utility of telemedicine to facilitate PST. METHODS: Penicillin-allergic inpatients receiving systemic antibiotics were prospectively identified between April and August 2017. Qualifying patients underwent PST performed by a trained allergy/immunology physician assistant (PA). On completion of PST, a telemedicine consultation, through the use of real-time interactive video conferencing (Microsoft Lync 2013, Redmond, Wash), was performed remotely by an allergist. Patients were surveyed regarding their satisfaction with the telemedicine experience. RESULTS: Fifty patients consented to PST through a telemedicine consultation. The average total time to complete a consultation was 128 minutes (standard deviation [SD] ± 33). Of this, the average PA travel time was 46 minutes (36%) with the remaining time spent on clinical services (82 minutes, 64%). The average physician telemedicine time per patient was 5 minutes (SD ± 2). Patients rated their experience as an average of 4.5 on a scale of 1 (highly unsatisfied) to 5 (highly satisfied). Of the 46 PST-negative patients, 33 were transitioned to a ß-lactam antibiotic that reduced the use of vancomycin, metronidazole, aztreonam, aminoglycosides, and clindamycin (P < .05). More than $30,000 was saved throughout the study period. CONCLUSIONS: Telemedicine is an effective and novel approach to facilitate PST in the inpatient setting and carries a high degree of patient satisfaction. This method has the potential to optimize and improve access to allergy/immunology resources.

Evaluation of Over-the-Counter Medication Knowledge and Literacy in Adolescent Students.

OBJECTIVE: To 1) assess and compare knowledge and literacy of over-the-counter (OTC) medications among middle school (MS) and high school (HS) students, and 2) to assess student self-identified lack of knowledge regarding OTC medications. METHODS: A convenience sample of suburban adolescent students completed a 2-part survey about OTC medications: part 1 included demographics and baseline knowledge of OTCs, and part 2 included medication label interpretation (literacy). Descriptive statistics and chi-square test were used to summarize and compare responses among MS and HS students. RESULTS: Students (n = 309) were in MS (46.2%) and HS (53.8%), with a mean age of 14 ± 1.8 years, 61.4% male, 81.2% white, and 84.3% non-Hispanic. A majority of students (68.5%) agreed that they always speak with an adult before taking medication. Students responded correctly to 19% of brand versus generic knowledge questions; conversely, 65% selected "I don't know." Similar trends were seen for questions about medication indications (26% correct, 59% didn't know), side-effects (8% correct, 67% didn't know), and combining medications (21% correct, 63% didn't know). When students referenced a medication label, 55% answered label interpretation questions correctly and 30% reported "I don't know." HS students answered more questions correctly and were less likely to report "I don't know" to questions about common OTC medications (eg, ibuprofen, Tylenol, etc) compared with MS students (P < .05). DISCUSSION: Overall, baseline knowledge of OTC medications was low; however, students were better at interpretation of drug labels. MS students self-reported less knowledge about common OTC medications compared with HS students. This study provides an important foundation for future OTC medication educational programs for adolescents.

Enhanced Adherence in Patients Using an Automated Home Medication Dispenser.

BACKGROUND: Many factors contribute to medication nonadherence including psychological and memory disorders, aging, and pill burden. The Automated Home Medication Dispenser (AHMD) is a medication management system intended to help solve unintentional medication nonadherence. OBJECTIVE: The purpose of this study was to determine if use of the AHMD improved medication adherence. METHODS: We conducted a 6-month prospective, feasibility study assessing use of the AHMD in 21 patient-caregiver dyads. Patients were referred by their physician because of poor medication adherence and included if they resided in Rochester, NY and on at least two medications in pill form. Pill counts were performed at baseline to assess previous adherence. Prospective medication adherence was assessed using AHMD recorded dosing information. A paired t-test was used to compare previous and prospective adherence. RESULTS: The mean age of patients was 75.1 years. Fifteen patients (71.4%) and eight caregivers (38.1%) were women; half (47.6%) of caregivers lived with the patient. The most common patient comorbidities were hypertension (76.2%) and memory disorder (61.9%). Mean adherence increased from 49.0% at baseline to 96.8% after 6 months of AHMD use (p < .001). CONCLUSION: In a cohort of unintentionally nonadherent patients, use of the AHMD for 6 months significantly improved medication adherence.

A survey of inpatient practitioner knowledge of penicillin allergy at 2 community teaching hospitals.

BACKGROUND: The negative effect of the penicillin allergy label on antibiotic use and patient outcomes has brought to light the need for thorough penicillin allergy assessments and heightened practitioner education. OBJECTIVE: To evaluate practitioner knowledge of penicillin allergy and the clinical approach to the patients with penicillin allergy. METHODS: An electronic survey was distributed to attending physicians, residents, pharmacists, nurse practitioners, and physician assistants practicing adult inpatient medicine at 2 community-based teaching hospitals from February to April 2016. RESULTS: A total of 276 (39%) of 716 practitioners completed surveys were analyzed. Most respondents were attending physicians (45%) with more than 10 years of experience (53%). Approximately half of the respondents indicated that they were unfamiliar with the rate of cross-reactivity between penicillin and cephalosporin (46%), carbapenem (42%), and monobactam (48%) antibiotics. When evaluating the role of penicillin skin testing and temporary induction of drug tolerance in the case vignettes, only 41% and 19% of respondents appropriately considered these options as the leading antibiotic management plan, respectively. Despite acknowledging the need for allergy/immunology consultation in clinical scenarios, 86% of respondents indicated that they never consult an allergist or immunologist or do so only once per year. Overall, pharmacists had a better understanding of the natural history of penicillin allergy and antibiotic cross-reactivity (P < .05). CONCLUSION: There is an overall limited understanding of the management of patients with a history of penicillin allergy in the hospital setting, where collaborative efforts between allergy and nonallergy health care practitioners are sparse. The expansion of a multidisciplinary approach may optimize antimicrobial prescribing in this subset of patients.

Medication adherence in patients with myotonic dystrophy and facioscapulohumeral muscular dystrophy.

Myotonic dystrophy (DM) and facioscapulohumeral muscular dystrophy (FSHD) are the two most common adult muscular dystrophies and have progressive and often disabling manifestations. Higher levels of medication adherence lead to better health outcomes, especially important to patients with DM and FSHD because of their multisystem manifestations and complexity of care. However, medication adherence has not previously been studied in a large cohort of DM type 1 (DM1), DM type 2 (DM2), and FSHD patients. The purpose of our study was to survey medication adherence and disease manifestations in patients enrolled in the NIH-supported National DM and FSHD Registry. The study was completed by 110 DM1, 49 DM2, and 193 FSHD patients. Notable comorbidities were hypertension in FSHD (44 %) and DM2 (37 %), gastroesophageal reflux disease in DM1 (24 %) and DM2 (31 %) and arrhythmias (29 %) and thyroid disease (20 %) in DM1. Each group reported high levels of adherence based on regimen complexity, medication costs, health literacy, side effect profile, and their beliefs about treatment. Only dysphagia in DM1 was reported to significantly impact medication adherence. Approximately 35 % of study patients reported polypharmacy (taking 6 or more medications). Of the patients with polypharmacy, the DM1 cohort was significantly younger (mean 55.0 years) compared to DM2 (59.0 years) and FSHD (63.2 years), and had shorter disease duration (mean 26 years) compared to FSHD (26.8 years) and DM2 (34.8 years). Future research is needed to assess techniques to ease pill swallowing in DM1 and to monitor polypharmacy and potential drug interactions in DM and FSHD.

Parent and Child Independent Report of Emotional Responses to Asthma-Specific Vignettes: The Relationship Between Emotional States, Self-Management Behaviors, and Symptoms.

UNLABELLED: Little is known about the emotional intelligence (EI) of parents and their children with asthma. Objectives of this study were to assess: 1) parent's and children's report of emotions in response to an asthma vignette (proxy for EI) and 2) the relationship between emotions, self-management behaviors, and symptoms. DESIGN AND METHODS: We conducted a descriptive, mixed methods study of children 7-12 years old with asthma. Parent-Child dyads (n=104) responded to an asthma vignette to gain insight into emotions, symptoms, and self-management behaviors. Additional questions assessed confidence and worry using a 5-point Likert scale. Thematic analyses and descriptive statistics were used to assess qualitative and quantitative outcomes. RESULTS: Children were predominantly male (58%), 7-9 (58%), and White (46%). The most common negative emotions reported by children were scared and sad. Children who sought help from an adult were less likely to report using medications compared to children who did not seek help (39.5% vs. 62.3%, p=.029). Children with low worry and high confidence had fewer symptoms compared to children reporting high worry and low confidence (symptoms: days 3.24 vs. 6.77, p=.012, nights 2.71 vs. 5.36, p=.004). CONCLUSIONS: Children provided appropriate emotional responses to the asthma vignette; emotions were related to self-management behaviors and symptoms. More studies are needed to specifically assess EI in this population. PRACTICE IMPLICATIONS: Parents and children with greater EI may be better able to understand their needs, engage in self-management behaviors, and communicate with their nurses, to improve their support network and ability to access services.

The relationship between helplessness and the child's asthma symptoms: the role of social support.

OBJECTIVE: Objectives of this study were to survey parents and children independently regarding feelings of helplessness specific to asthma and to examine the relationship between helplessness and the child's symptom-free days. METHODS: Parent-child dyads (children 7-12 years) from Rochester, NY were enrolled (November 2011-August 2012) from general pediatric clinics, pulmonary clinics, an Emergency Department, and area youth and asthma programs. Assessments included demographics, symptoms, ratings of helplessness related to asthma and parent social support. A multivariate linear regression was conducted to examine the relationship between feelings of helplessness and symptoms-free days: post hoc analysis assessed the moderating role of social support. RESULTS: Overall, 107 parent-child dyads enrolled (participation rate: 72%); 104 were included in analysis. Most children were male (58%), 7-9 years (58%) and White (46%). The child's feelings of helplessness scores were positively correlated with symptom-free days indicating less feelings of helplessness as symptom-free days increased (rs = 0.273, p = 0.01). In a stratified analysis, among parents who reported minimal social support (<1 sources of support), child's helplessness scores were positively correlated with symptom-free days (rs = 0.335, p = 0.02). Conversely, among parents reporting >2 supports, no relationship was found (rs = 0.195, p = 0.15). CONCLUSIONS: This study found less feelings of helplessness among children with asthma as symptom-free days increased. Social support appears to moderate this relationship; however further studies to confirm these findings are needed.

Health literacy and sources of health information for caregivers of urban children with asthma.

Little is known about the resources used by urban caregivers of children with asthma to obtain health information. The authors analyzed data for 304 families of children with persistent asthma to describe (1) sources of health information, (2) access and use of Internet resources, and (3) the association between the caregiver's health literacy (HL) and use of health information sources. Overall, 37% of caregivers had limited HL. Most families received health information from a health care professional (94%), written sources (51%), family/friends (42%), non-print media (34%), and the Internet (30%). Less than half of caregivers had access to the Internet at home, but 73% reported Internet use in the past year. Caregivers with adequate HL were more likely to obtain information from multiple sources and to use and have access to the Internet. The results suggest that HL is associated with where caregivers obtain health information from for their children and their use of the Internet.

Randomized controlled trial to improve care for urban children with asthma: results of the School-Based Asthma Therapy trial.

OBJECTIVE: To evaluate the impact of the School-Based Asthma Therapy trial on asthma symptoms among urban children with persistent asthma. DESIGN: Randomized trial, with children stratified by smoke exposure in the home and randomized to a school-based care group or a usual care control group. SETTING: Rochester, New York. PARTICIPANTS: Children aged 3 to 10 years with persistent asthma. INTERVENTIONS: Directly observed administration of daily preventive asthma medications by school nurses (with dose adjustments according to National Heart, Lung, and Blood Institute Expert Panel guidelines) and a home-based environmental tobacco smoke reduction program for smoke-exposed children, using motivational interviewing. MAIN OUTCOME MEASURE: Mean number of symptom-free days per 2 weeks during the peak winter season (November-February), assessed by blinded interviews. RESULTS: We enrolled 530 children (74% participation rate). During the peak winter season, children receiving preventive medications through school had significantly more symptom-free days compared with children in the control group (adjusted difference = 0.92 days per 2 weeks; 95% confidence interval, 0.50-1.33) and also had fewer nighttime symptoms, less rescue medication use, and fewer days with limited activity (all P < .01). Children in the treatment group also were less likely than those in the control group to have an exacerbation requiring treatment with prednisone (12% vs 18%, respectively; relative risk = 0.64; 95% confidence interval, 0.41-1.00). Stratified analyses showed positive intervention effects even for children with smoke exposure (n = 285; mean symptom-free days per 2 weeks: 11.6 for children in the treatment group vs 10.9 for those in the control group; difference = 0.96 days per 2 weeks; 95% confidence interval, 0.39-1.52). CONCLUSIONS: The School-Based Asthma Therapy intervention significantly improved symptoms among urban children with persistent asthma. This program could serve as a model for improved asthma care in urban communities.

Innovative delivery of newborn anticipatory guidance: a randomized, controlled trial incorporating media-based learning into primary care.

OBJECTIVE: Recent initiatives seek to incorporate efficient, evidence-based practices into primary care. This study tested the feasibility, impact, and acceptance of incorporating a DVD of newborn anticipatory guidance into routine well-child care. METHODS: This randomized trial tested a 15-minute educational DVD intervention versus control condition with paper handouts on newborn anticipatory guidance. We recruited parents of newborns ≤1 month old presenting for their first visit. Blinded research assistants conducted telephone follow-up 2 weeks later and medical chart reviews 2 months after enrollment. Clinic staff and providers completed semistructured surveys to rate the intervention. Primary outcomes included parent knowledge of infant development, self-efficacy with infant care skills, and problem-solving competence. RESULTS: We enrolled 137 subjects (response rate 82%). Scores on knowledge, self-efficacy, and problem solving were high at baseline for both groups and did not significantly change. More parents in the DVD group reported feeling prepared to care for their baby after the visit (94% vs 81%, P = .03), feeling high confidence bathing their baby (93% vs 78%, P = .01), and recognizing congestion (70% vs 52%, P = .03) compared to the control group. Those in the DVD group also had fewer additional office visits between birth and 2 months (P = .01). Staff and providers agreed the DVD was useful for patients (88%) and did not disrupt patient flow (93%). CONCLUSIONS: A DVD of newborn anticipatory guidance was feasible, well accepted, and had a positive impact in a pediatric practice. Video and other technologies represent an efficient, innovative way to reach parents as part of the office encounter.

Parent knowledge, attitudes, and household practices regarding SHS exposure: a case-control study of urban children with and without asthma.

Impoverished children suffer disproportionately from asthma and are more likely than other children to be exposed to secondhand smoke (SHS). We conducted a case-control study to describe and compare knowledge, attitudes, and household practices regarding SHS exposure among parents of young urban children with and without asthma (response rate, 76%). Overall, 39% of children lived with > or =1 smoker (cases, 36%; controls, 43%). The majority of parents (78%) felt that cigarette smoking is very dangerous and agreed that smoke harms the health of children (97%). Cases were more likely than controls to report that smoking in a car affects children's health (54% vs 42%) and that smoking in front of children is never allowed in their home (88% vs 79%). Additionally, more cases reported a home smoking ban (81% vs 70%). Our findings suggest that parents of children with asthma have somewhat better knowledge, attitudes, and practices regarding SHS; however, gaps remain, and many urban children continue to be exposed.

Motivation to quit smoking among parents of urban children with asthma.

OBJECTIVE: To identify factors associated with motivation to quit smoking among parents of urban children with asthma. METHODS: We analyzed data from parents who smoke and had a child enrolled in the School-Based Asthma Therapy (SBAT) trial. We assessed asthma symptoms, children's cotinine, and parent smoking behaviors. Motivation to quit smoking was assessed by a 10-point continuous measure (1, not at all motivated; 10, very motivated). RESULTS: 209 parents smoked (39% of sample), and children's mean cotinine was 2.48 ng/ml. Motivation to quit was on average 6.9, and 47% of parents scored >or=8 on the scale. Parents who believed their child's asthma was not under good control, and parents who strongly agreed their child's asthma symptoms would decrease if they stop smoking had higher motivation to quit compared to their counterparts (p<.05). In a multivariate analysis, parents who believed their child's asthma was not under control had more than twice the odds of reporting high motivation to quit. CONCLUSION: Parents' perception of the risks of smoking to their child with asthma is associated with motivation to quit. PRACTICE IMPLICATIONS: Raising awareness about the effect of smoking and quitting on children's asthma might increase motivation to quit among parents.