Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis

[{"text": "\"BACKGROUND:\r\nInfantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies.\r\n\r\nMETHODS:\r\nAn American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations.\r\n\r\nRESULTS:\r\nThe pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing.\r\n\r\nCONCLUSIONS:\r\nAlthough infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.\"", "_i": "en"}]

Clinical, radiological and pathological features of ABCA3 mutations in children.

BACKGROUND: Mutations in the ABCA3 gene can result in fatal surfactant deficiency in term newborn infants and chronic interstitial lung disease in older children. Previous studies on ABCA3 mutations have focused primarily on the genetic abnormalities and reported limited clinical information about the resultant disease. A study was undertaken to analyse systematically the clinical presentation, pulmonary function, diagnostic imaging, pathological features and outcomes of children with ABCA3 mutations. METHODS: The records of nine children with ABCA3 mutations evaluated at Texas Children's Hospital between 1992 and 2005 were reviewed and their current clinical status updated. Previous diagnostic imaging studies and lung biopsy specimens were re-examined. The results of DNA analyses were confirmed. RESULTS: Age at symptom onset ranged from birth to 4 years. Cough, crackles, failure to thrive and clubbing were frequent findings. Mean lung function was low but tended to remain static. CT scans commonly revealed ground-glass opacification, septal thickening, parenchymal cysts and pectus excavatum. Histopathological patterns included pulmonary alveolar proteinosis, desquamative interstitial pneumonitis and non-specific interstitial pneumonitis, and varied with age. Dense abnormalities of lamellar bodies, characteristic of ABCA3 mutations, were seen by electron microscopy in all adequate specimens. Outcomes varied with the age at which the severity of lung disease warranted open lung biopsy, and some patients have had prolonged survival without lung transplantation. CONCLUSIONS: The presentation and course of interstitial lung disease due to ABCA3 mutations are variable, and open lung biopsy and genetic testing are warranted early in the evaluation of children with a consistent clinical picture.

Development of an expert system knowledge base: a novel approach to promote guideline congruent asthma care.

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

Comparison of high-frequency chest wall oscillation and oscillating positive expiratory pressure in the home management of cystic fibrosis: a pilot study.

Enhanced airway clearance is thought to result in better-maintained pulmonary function in cystic fibrosis (CF). Postural drainage, percussion, and vibration (PDPV) have been the primary airway clearance technique (ACT) employed in CF for over 40 years. Two new airway clearance modalities are high-frequency chest wall oscillation (HFCWO) and oscillating positive expiratory pressure (OPEP). This pilot study was undertaken to evaluate the efficacy of these techniques during home use, assess patient satisfaction with them as compared to PDPV, and assess the feasibility of performing a definitive comparative trial. The prospective, randomized, multicenter crossover trial was conducted at three urban academic CF Care Centers. Twenty-nine CF patients, 9-39 years of age, participated. Subjects performed 4 weeks each of HFCWO and OPEP following 2-week lead-in/washout periods. Spirometry, lung volumes, National Institutes of Health and Petty Scores, and a satisfaction survey were performed at baseline and after each treatment period. An ACT preference survey was completed at the conclusion of the study. Twenty-four subjects completed both therapies. There were no statistically significant differences between therapies for spirometry, lung volumes, or clinical scores. No significant safety issues arose during the study period. Compliance between therapies was similar. Significant differences among therapies existed in patient satisfaction. Given a choice of therapy, 50% of subjects chose HFCWO, 37% OPEP, and 13% PDPV. This study suggests that HFCWO and OPEP are safe and as effective as patients' routine therapies when used for airway clearance in a home setting. Patient satisfaction and preference differ among ACTs and should be considered when prescribing home therapy. A definitive, multi-center, comparative study evaluating long-term efficacy of these techniques is feasible.

Impact of a computer-assisted education program on factors related to asthma self-management behavior.

OBJECTIVE: To evaluate Watch, Discover, Think and Act (WDTA), a theory-based application of CD-ROM educational technology for pediatric asthma self-management education. DESIGN: A prospective pretest posttest randomized intervention trial was used to assess the motivational appeal of the computer-assisted instructional program and evaluate the impact of the program in eliciting change in knowledge, self-efficacy, and attributions of children with asthma. Subjects were recruited from large urban asthma clinics, community clinics, and schools. Seventy-six children 9 to 13 years old were recruited for the evaluation. RESULTS: Repeated-measures analysis of covariance showed that knowledge scores increased significantly for both groups, but no between-group differences were found (P: = 0.55); children using the program scored significantly higher (P: < 0.01) on questions about steps of self-regulation, prevention strategies, and treatment strategies. These children also demonstrated greater self-efficacy (P: < 0.05) and more efficacy building attribution classification of asthma self-management behaviors (P: < 0.05) than those children who did not use the program. CONCLUSION: The WDTA is an intrinsically motivating educational program that has the ability to effect determinants of asthma self-management behavior in 9- to 13-year-old children with asthma. This, coupled with its reported effectiveness in enhancing patient outcomes in clinical settings, indicates that this program has application in pediatric asthma education.

Watch, Discover, Think, and Act: a model for patient education program development.

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.

Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children.

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

Validation of an instrument measuring patient satisfaction with chest physiotherapy techniques in cystic fibrosis.

OBJECTIVES: Chest physiotherapy (CPT) has been an important part of cystic fibrosis (CF) treatment regimens for > 40 years. Techniques with different perceived costs, benefits, and patient satisfaction exist. An instrument measuring patient satisfaction with CPT has not been reported. Our goal was to develop and validate such an instrument. DESIGN: A cross-sectional survey sent to 349 patients seen at a large, urban, academic CF care center. The two-page survey asked 17 questions related to CPT satisfaction (efficacy, convenience, comfort, overall satisfaction), followed by 4 general CF-care questions (disease severity, importance of therapies, prescribed vs missed therapies). A 5-point Likert-type scale was used for responses. Psychometric analysis included itemetric performance, confirmatory factor analysis, test-retest reliability, and evaluation of subject's responses to the general CF-care questions. RESULTS: One hundred twenty-nine individuals returned completed surveys (39%; 66 males and 63 females; age range, 2 months to 47 years). FEV(1)values were 21 to 155% predicted (mean, 76%; n = 82). Disease severity was as follows: 60 mild, 47 moderate, and 14 severe. Seventy-nine subjects used postural drainage, percussion, and vibration (PDPV), 21 used a flutter device, and 14 used high-frequency chest wall oscillation (HFCWO). Five subjects used more than one technique. Internal consistency analysis found an overall coefficient alpha of 0.87 (range, 0.74 to 0.89 for four domains). Factor analysis demonstrated domains for efficacy, convenience, comfort, and overall satisfaction. Mean total satisfaction scores differed significantly among therapies (R(2) = 0. 118; F[ 2,111] = 7.56; p = 0.0008): PDPV, 3.8 (SD = 0.6); Flutter, 4. 3 (SD = 0.5); and HFCWO, 4.1 (SD = 0.5). Therapies also differed significantly on all subscores. Perceived importance of CPT and compliance with CPT increased linearly with disease severity. Overall satisfaction was positively correlated with CPT compliance. CONCLUSIONS: The CPT satisfaction survey has good reliability and content validity. Significant differences in patient satisfaction exist among therapies. Sicker patients recognize the importance of, and demonstrate better compliance with prescribed CPT. Increased satisfaction is associated with better compliance with therapy.

Asthma triggers in the elementary school environment: a pilot study.

Asthma, a major cause of school absenteeism, can be triggered by allergens and irritants in the child's environment. A new measurement tool, the Environmental Observation Checklist (EOC), was developed and piloted for qualitative assessment of indoor asthma triggers (allergens and irritants), adequacy of ventilation, and existing environmental control practices. Seventy-five classrooms in 20 schools from two large urban school districts in Texas were surveyed using the EOC. A Q-TRAK Air Quality Monitor was used to assess indoor carbon dioxide, temperature, and relative humidity, concurrently. The EOC appears to be a useful screening tool for identifying schools in need of intervention.

Pharmacokinetics of ibuprofen in patients with cystic fibrosis.

STUDY OBJECTIVES: To determine the pharmacokinetic disposition of high doses of ibuprofen in patients with cystic fibrosis (CF), and to evaluate the reliability of intrapatient dosage adjustments to achieve recommended peak ibuprofen plasma concentrations. DESIGN: First-order absorption, one-compartment model was fit to serial ibuprofen concentration-time data obtained from patients with CF and receiving high doses of ibuprofen 20-30 mg/kg. SETTING: Medical school-affiliated teaching hospital. PATIENTS: Ninety-eight patients with CF (53 males, 45 females; mean age 12.5 yrs). MEASUREMENTS AND MAIN RESULTS: The time to achieve apparent maximum ibuprofen concentration (Tmax) ranged from 1-3 hours, with maximum concentrations ranging from 21-150 microg/ml (mean 83 microg/ml). Apparent ibuprofen clearance (Cl/F) was significantly correlated with age (r2 = 0.43, p<0.0001) and measures of body size (body surface area [BSA] r2 = 0.50, p<0.0001). The Cl/F ranged from 21.1-114.7 ml/min/m2 (mean 45.5 ml/min/m2), a 5-fold difference. The Cl/F normalized to body weight decreased with increasing age (p=0.0009), but when normalized to BSA, there was no age-related change (p=0.65). Apparent volume of distribution was significantly correlated with age (r2 = 0.69, p<0.0001) and measures of body size (BSA r2 = 0.79, p<0.0001). Fourteen patients had ibuprofen dosage adjustments. The Cl/F was not different among doses; however, Tmax differed by an average of 1.25 hours (range 0-2 hrs). CONCLUSION: The substantial variability in ibuprofen disposition and clearance we report is greater than previously described. Individualized dosages and therapeutic drug monitoring may be required to ensure plasma concentrations considered necessary to prevent pulmonary deterioration in patients with CF.

The use of anti-inflammatory medications in cystic fibrosis: trends and physician attitudes.

STUDY OBJECTIVES: In recent years, there has been considerable interest in the use of antiinflammatory medications to decrease airway inflammation and preserve pulmonary function in patients with cystic fibrosis (CF) lung disease. Long-term use of oral corticosteroids (OCS) and ibuprofen (IBU) has been proven efficacious in slowing the progression of CF. Inhaled corticosteroids (ICS) have not been adequately studied. Little is known regarding use trends and physician attitudes toward these drugs. DESIGN: Cross-sectional survey mailed to 111 directors of Cystic Fibrosis Centers in the United States accredited by the Cystic Fibrosis Foundation. The two-page written questionnaire included items regarding physicians' attitudes toward anti-inflammatories, center demographics, patients receiving therapy, and number of physicians prescribing therapy. RESULTS: Sixty-seven surveys were returned (60%). The responding centers represented 239 physicians and served 9,363 patients, 2,234 (24%) of whom were receiving routine antiinflammatory drugs. Complete data sets were available for 8,803 patients with 2,169 (25%) receiving anti-inflammatory therapy. Ninety-eight (41%) physicians prescribed long-term use of oral steroids for 413 (5%) patients, 103 (42%) prescribed inhaled steroids for 1,032 (12%) patients, and 108 (45%) prescribed high-dose IBU for 723 (8%) patients to control CF. The practitioners reported familiarity and efficacy as the primary reasons for prescribing OCS; concerns over side effects were the major reason for not prescribing. Regarding ICS, the primary reasons for prescribing were familiarity and safety, with lack of efficacy being cited as the major reason for not prescribing. For IBU, efficacy was ranked highest among reasons for prescribing, with concern over safety being the highest ranked reason for not prescribing. CONCLUSIONS: Anti-inflammatory medications appear to be an underutilized therapeutic modality in CF care. This is true for numbers of patients receiving these drugs as well as numbers of care providers prescribing them. Additional studies will be required to address physicians' concerns regarding the long-term efficacy and safety of anti-inflammatory drugs in treating CF.

Attitudes of respiratory care practitioners and students regarding pulmonary prevention.

STUDY OBJECTIVES: (1) To examine attitudes of respiratory care practitioners (RCPs) and RCP students toward pulmonary disease prevention behaviors and their role in promoting them. (2) To compare RCPs' attitudes regarding pulmonary prevention with existing medical student survey data. DESIGN: Cross-sectional survey. SETTING: Three sites (Valhalla, NY; Winston-Salem, NC; Houston, TX). PARTICIPANTS: One hundred ninety RCPs and 164 RCP students compared with 5,744 medical students. MEASUREMENT AND RESULTS: Subjects completed a 35-item RCP Preventive Pulmonary Attitude (PPA) Survey using a five-point scale (1 = strongly disagree to 5 = strongly agree). A higher score indicates a more positive attitude toward prevention. RCP total scores averaged 117.6 (SD, 15.7; range, 52 to 160). RCP student total scores were significantly higher than RCP practitioners. No significant differences were observed by gender or by type of patient served (pediatric vs adult). RCPs with a history of tobacco smoking had significantly lower scores than RCPs who had never smoked. Most, but not all, respondents acknowledged the importance of patients with chronic lung disease receiving a yearly influenza vaccination. Total PPA scores for medical students were significantly lower than scores for both RCPs and RCP students. Significant differences were noted for a number of individual items. CONCLUSIONS: In general, RCPs had positive attitudes regarding the importance of prevention counseling and their role in providing this to patients. This is important given their potential as a resource in pulmonary prevention efforts. More attention to inclusion of training and evaluation of RCP effectiveness in promoting respiratory health is needed.

Prenatal smoking cessation counseling by Texas obstetricians.

BACKGROUND: Smoking during pregnancy causes 20 to 30 percent of low birthweight and 10 percent of infant mortality in the United States. Brief counseling can reduce rates of smoking. The study objectives were to describe Texas obstetricians' pregnancy smoking cessation counseling activity and to identify attributes associated with consistent, effective counseling. METHODS: A survey was mailed to a random sample of Texas obstetricians. RESULTS: A response rate of 44 percent (n = 204) was attained. A counseling coverage-effectiveness index was created based on the percentage of smokers counseled and use of specific techniques. Almost all respondents reported asking about smoking; fewer, however, reported counseling smokers. Physicians with low index scores, indicating inconsistent coverage, ineffective counseling, or both were dissatisfied with their current counseling, did not perceive counseling to decrease smoking, were not aware of the risks of smoking, and were unfamiliar with expert reports and recommendations for prenatal care. CONCLUSIONS: Obstetricians who are not reached by expert reports and guidelines from groups outside their specialty or who do not perceive the seriousness of maternal smoking are less likely to counsel consistently and to use the most effective techniques. Continuing medical education at local, state, and national levels should be directed toward increasing knowledge and skills about smoking cessation counseling of pregnant women.

Self-management of cystic fibrosis: short-term outcomes of the Cystic Fibrosis Family Education Program.

This study tested the efficacy of the Cystic Fibrosis Family Education Program, a cystic fibrosis self-management program, on improving participants' knowledge, self-efficacy, self-management behavior, health, and quality of life. A quasi-experimental pretest-posttest nonequivalent comparison group design was employed. Participants made up 104 patient-primary caregiver dyads from the intervention site cystic fibrosis center and 95 from the usual care comparison center. The intervention, a self-paced print curriculum based on social cognitive theory, targeted behavioral capability, self-efficacy, and outcome expectations and was implemented as an integral part of medical care. Parents, early childhood, middle childhood, and adolescents received separate materials on respiratory, nutrition and malabsorption, communication, and coping issues. Significant intervention effects were found on the knowledge scores for caregivers, adolescents, and children; caregiver and adolescent total self-management scores; Child Behavior Checklist total score; one parent coping scale score; the modified NIH score; NIH pulmonary factor 1; and the Brasfield total score. Significant interaction effects were evident in the self-efficacy scores for caregivers and children.

Severe necrotizing pneumonitis in a child with Mycoplasma pneumoniae infection.

Lower respiratory tract illness due to Mycoplasma pneumoniae is typically mild and self-limited. There are, however, numerous reports of serious and life-threatening cases of mycoplasma pneumonia in adults. We present a case involving a 4-year-old girl with severe mycoplasma infection and necrotizing pneumonitis requiring lobectomy. A detailed pathological report is provided.

The role of the pediatrician in smoking prevention.

Smoking prevention during childhood and adolescence is critical to the successful reduction of tobacco-related morbidity and mortality in the United States. The research literature is replete with surveys describing youth smoking acquisition and related factors. In addition to its direct harm, tobacco use may be a gateway to other substance abuse and a marker of other health-compromising behaviors. The pediatrician can play an important role in prevention by screening all patients and providing individual counseling. The pediatrician can also contribute as a consultant and advocate of school- and community-based smoking prevention efforts. Such a multicomponent approach provides the greatest likelihood of accelerating the decline in smoking and smokeless tobacco initiation.

Telephone-guided placement and removal of nicotine monitors for the assessment of passive exposure to environmental tobacco smoke.

The aim of this study was to determine the feasibility of telephone-guided placement of nicotine air sampling monitors in homes of women with infants. A monitor was mailed to homes in which the mother, her partner, or both were smokers, and a research assistant telephoned the woman and guided her through proper placement of the monitor according to a standard protocol. To assess the success of the guided placement, research assistants visited the homes of 50 women at the end of the two-week air-sampling period. The placement was determined to be correct if the monitor was positioned at least 1 ft from windows, more than 1 ft from the nearest corner of the room, and more than 2 ft from ashtrays. We had a 94% success rate for monitor placement in our study population, and our cost assessment showed that guided placement and removal cost approximately one-tenth the amount of methods requiring research assistants to conduct placements onsite. These results suggest that telephone-guided placement of monitors is an acceptable, inexpensive alternative to onsite placement by research assistants.

The respiratory effects of passive tobacco smoking.

Smokers not only increase their own risk of pulmonary disease, but contribute to the health risk of nonsmokers through the production of environmental tobacco smoke. Evidence continues to build regarding the positive association between passive smoking and increased risk of respiratory symptoms and lung diseases. Environmental tobacco smoke exposure has been implicated in both the development and worsening of airway hyperresponsiveness and wheezing. Pulmonary function reduction has been documented in children with both prenatal and postnatal exposure, but the presence of increased airway obstruction and its long-term significance is unclear in adults. There is growing concern about the risk of lung cancer, particularly among female never-smokers exposed to tobacco smoke in the home and workplace. Environmental tobacco smoke is a major component of indoor air pollution and a major public health threat. Most importantly, it is a preventable risk and efforts to control and eliminate exposure need to be encouraged.