Assessment of acute asthma in children: do parents and healthcare providers speak the same language?

OBJECTIVE: Education and self-management plans enhance parents' self-efficacy in managing their child's asthma symptoms. By understanding how parents recognize and interpret acute asthma symptoms, we can compile patient information using terms that are familiar to parents. METHOD: Semi-structured interviews were carried out with 27 parents of children with asthma aged 2-12 years. The interviewees were selected from three groups: parents of children admitted for acute asthma, parents of children receiving outpatient asthma care, and parents who had access to a self-management plan. Parents were invited to report symptoms they would associate with acute asthma. Subsequently, parents were queried about their recognition of symptoms from a predefined list and asked to explain how they would assess these symptoms in case their child would experience an attack of acute asthma. RESULTS: The most frequently reported symptoms for acute asthma were shortness of breath (77.8%) and coughing (63%). Other signs such as retractions, nasal flaring, and wheezing were reported by less than 25% of the parents. All parents recognized shortness of breath, wheezing and gasping for breath from a predefined list of medical terms. Retractions and nasal flaring were recognized by 81.5% and 66.7% of the parents, respectively. Recognizing the medical terms did not necessarily translate into parents being able to explain how to assess these symptoms. CONCLUSION: Parents and healthcare professionals do not always speak the same language concerning symptoms of acute asthma. This may hamper timely recognition and adequate self-management, highlighting the necessity to adjust current medical information about acute asthma.

Education and self-management plans enhance parents' self-efficacy in managing their child's asthma symptoms.Parents may identify symptoms of acute asthma differently than healthcare providersInformation material about acute asthma should be adjusted to empower parents to decide when to commence treatment and when to seek medical attention.

Medical students' perception of general practice: a cross-sectional survey.

BACKGROUND: An increase in the demand for general practitioners is expected in many countries, but only a minority of medical students consider a career in general practice. More detailed and up-to-date knowledge about medical student's perception of general practice would be helpful for efforts to encourage medical students to consider a career in general practice. METHODS: We performed a cross-sectional single center survey among Dutch medical students to evaluate their perception of general practice at three different stages in their study: Ba1: first-year bachelor students; Ba3: third-year bachelor students; Ma3: third-year master students. The impact of different factors on their attitudes and perceptions was quantified. A multivariate logistic regression was performed with 'interest in general practice' as the outcome variable. RESULTS: The median age for Ba1 was 18 (IQR: 18-19) and 71.5% were female, for Ba3 the median age was 20 (IQR: 20-21) and 70.6% were female and for Ma3 the median age was 25 years (IQR: 24-26) and 73.3% were female. On average, 31.2% of the respondents had a migration background. The mean response rate for this study was 77.1%. Of the participating Ba1 students (n = 340) only 22.4% considered working as a GP after medical school; for Ba3 students (n = 231) this percentage was 33.8%, and for Ma3 students (n = 210) it was significantly higher at 70.5%; in the final multivariate model this corresponded to an odds ratio (OR) of 4.3 (95%-CI:2.6-6.9) compared to Ba1 students. The strongest predictor in the final model was the opinion that general practice provides a pleasant working environment (OR 9.5; 95%-CI: 6.2-14.5). CONCLUSION: This study showed that multiple factors are significantly related to medical students' interest in general practice. Although students believed that general practice does not have a high status within the medical profession, they acknowledged the social importance and the pleasant working environment of general practice. Knowledge obtained in this study can be used when designing a medical curriculum or a general practice course.

Occurrence of comorbidity following osteoarthritis diagnosis: a cohort study in the Netherlands.

OBJECTIVE: To determine the risk of comorbidity following diagnosis of knee or hip osteoarthritis (OA). DESIGN: A cohort study was conducted using the Integrated Primary Care Information database, containing electronic health records of 2.5 million patients from the Netherlands. Adults at risk for OA were included. Diagnosis of knee or hip OA (=exposure) and 58 long-term comorbidities (=outcome) were defined by diagnostic codes following the International Classification of Primary Care coding system. Time between the start of follow-up and incident diagnosis of OA was defined as unexposed, and between diagnosis of OA and the end of follow-up as exposed. Age and sex adjusted hazard ratios (HRs) comparing comorbidity rates in exposed and unexposed patient time were estimated with 99.9% confidence intervals (CI). RESULTS: The study population consisted of 1,890,712 patients. For 30 of the 58 studied comorbidities, exposure to knee OA showed a HR larger than 1. Largest positive associations (HR with (99.9% CIs)) were found for obesity 2.55 (2.29-2.84) and fibromyalgia 2.06 (1.53-2.77). For two conditions a HR < 1 was found, other comorbidities showed no association with exposure to knee OA. For 26 comorbidities, exposure to hip OA showed a HR larger than 1. The largest were found for polymyalgia rheumatica 1.81 (1.41-2.32) and fibromyalgia 1.70 (1.10-2.63). All other comorbidities showed no associations with hip OA. CONCLUSION: This study showed that many comorbidities were diagnosed more often in patients with knee or hip OA. This suggests that the management of OA should consider the risk of other long-term-conditions.

Asthma control is not associated with physical activity level in children with asthma during regular follow-up.

OBJECTIVE: Engagement in physical activity (PA) is one of the important aims of long-term asthma treatment. The objective of this study is to evaluate whether improvement of asthma control is associated with enhanced PA during regular follow-up in children with asthma. METHODS: Children, 6-18 years, with asthma were eligible for inclusion when their asthma was uncontrolled at a regular follow-up visit. Participants completed a seven-day recall questionnaire to assess engagement in different physical activities (Physical Activity Questionnaires for Children) at baseline and at the time asthma control was achieved according to predefined criteria. They were also instructed to wear an accelerometer (ActigraphTM GT1M) for seven consecutive days at these timepoints. RESULTS: Thirty children (21 boys), aged 10.5 (2.9) years, with uncontrolled asthma were included. After a median (IQR) follow up time of 163 (94-253) days PA was assessed again. Accelerometer obtained moderate vigorous PA (median (IQR) 56 (43-66) versus 53 (35-63) minutes) as well as self-reported PA (median (IQR) PAQ score 7.4 (5.9-10.1) versus 7.2 (6.5-11.0)) were not significantly different at the time of uncontrolled and controlled asthma. Moderate vigorous PA increased in 46.2%, was comparable in 23.1%, and decreased in 30.7% of patients, respectively. Self-reported PA increased in 19.0%, was comparable in 52.4%, and decreased in 28.6% of patients, respectively. CONCLUSIONS: Based on the results of this study we conclude that asthma control is not associated with self-reported and accelerometer obtained level of physical activity during regular follow-up in children with asthma.

Practice variation among Dutch paediatricians in palivizumab prescription rates: the importance of parental counselling approach.

AIM: To investigate differences in palivizumab prescription rates between Dutch paediatricians, and the role of parent counselling in this practice variation. METHODS: A retrospective chart review of premature infants <32 weeks of gestation, aged less than six months at the start of the winter season, born between January 2012 and July 2014, in three secondary hospital-based paediatric practices in the Netherlands. RESULTS: We included 208 patients, 133 (64%) of whom received palivizumab. Prescription rates varied considerably between the three hospitals: 8% (6/64), 89% (32/36) and 99% (97/98). A noticeable difference in the way parents were counselled about palivizumab was the use of the number needed to treat (NNT). In the hospital with the lowest prescription rate (8%), an NNT of 20 to prevent one hospitalisation was explicitly discussed with parents. Bronchiolitis-related hospital admissions occurred in 11.3% of patients receiving palivizumab compared to 20.0% in nonimmunised infants (p = 0.086). CONCLUSION: Considerable practice variation exists among Dutch paediatricians regarding palivizumab prescription rates. The counselling method seems to play an important role. Presenting palivizumab prophylaxis as a preference-sensitive decision, combined with the explicit use and explanation of an NNT, leads many parents to refrain from respiratory syncytial virus immunisation.

[Treatment of asthma in children: revised international guidelines not suitable for use in the Netherlands]. / Behandeling van astma bij kinderen: herziene internationale richtlijnen niet geschikt voor gebruik in Nederland.

The most recent revision of the Global Initiative for Asthma (GINA) guidelines for the treatment of asthma propose to classify and monitor the disease based on asthma control. This concept is attractive but not evidence based. Based on methodological shortcomings the revised GINA guidelines fail to meet the standards for evidence-based guidelines. Inhaled corticosteroids are and remain the cornerstone of asthma management in children. Extensive explanation to children and their parents, intensive followup, and instruction of and adherence to a correct inhalation technique are key factors in effective treatment of asthma in children.

Impact of nurse-led outpatient management of children with asthma on healthcare resource utilisation and costs.

The high burden of asthma on healthcare utilisation and costs warrants economic appraisal of management approaches. The authors previously demonstrated that the efficacy of nurse-led outpatient management of childhood asthma was comparable to management by a paediatrician and now report on the healthcare utilisation and costs of both management approaches. A total of 74 newly referred children with asthma were randomly assigned to a 1-yr follow-up by paediatricians or asthma nurse. Healthcare utilisation was recorded and associated costs calculated for both management approaches. There were no significant differences in healthcare utilisation except for the total time spent on patient contact (136(n = 14) versus 187(n = 41) min, for patients followed-up by paediatrician and an asthma nurse repectively). Costs within the healthcare sector were reduced by 7.2% in favour of nurse-led care. The reduction in costs was solely attributable to a 17.5% reduction in the costs of outpatient visits. Nurse-led care appeared to be cost-saving even if the duration of follow-up visits would be twice that of doctor's visits. Overall healthcare costs (within and outside the healthcare sector) were 4.1% lower for nurse-led outpatient management compared to traditional medical care. Nurse-led outpatient management of childhood asthma can be provided at a lower cost than medical care by paediatricians.

Outpatient management of childhood asthma by paediatrician or asthma nurse: randomised controlled study with one year follow up.

BACKGROUND: Until now, care provided by asthma nurses has been additional to care provided by paediatricians. A study was undertaken to compare nurse led outpatient management of childhood asthma with follow up by a paediatrician. METHODS: Seventy four children referred because of insufficient control of persistent asthma were randomly allocated to 1 year follow up by a paediatrician or asthma nurse. The main outcome measure was the percentage of symptom-free days. Additional outcome measures were airway hyperresponsiveness, lung function, daily dose of inhaled corticosteroids (ICS), number of exacerbations, number of additional visits to the general practitioner, absence from school, functional health status, and disease specific quality of life. RESULTS: There were no significant differences at the end of the 1 year study period between the two treatment groups in percentage of symptom-free days (mean difference 2.5%; 95% CI -8.8 to 13.8), airway hyperresponsiveness (log10 PD20 0.06; -0.19 to 0.32), functional health status (10.1; -0.3 to 19.8), disease specific quality of life of patients (0.08; -0.9 to 0.7), and disease specific quality of life of caregivers (0.09; -0.2 to 0.3), nor in any other outcome parameters. Most outcome parameters improved considerably over the 1 year study period. These improvements were achieved although the daily dose of ICS was reduced by a mean of 26% compared with the dose received by children at referral. All parents were satisfied with the asthma care received. CONCLUSIONS: After initial assessment in a multidisciplinary clinic, childhood asthma can be successfully managed by an asthma nurse in close cooperation with a paediatrician. During close follow up by paediatrician or asthma nurse, asthma control improved despite a reduction in ICS dose.

Children with mild asthma: do they benefit from inhaled corticosteroids?

In children with mild asthma, who show hardly any abnormalities in pulmonary function, objective measurement of the effect of inhaled corticosteroids is difficult. The short term effect of fluticasone propionate (FP) in these children was evaluated, using both subjective and objective parameters. A total of 68 children (5-10 yrs old) were randomly assigned to either FP 250 microg or placebo twice daily as metered-dose inhaler via spacer during 12 weeks. Symptom scores, use of rescue medication, wheezing, parent global evaluation and pulmonary function tests including forced expiratory volume in one second (FEV1), peak expiratory flow (PEF) and bronchial responsiveness (provocation dose of methacholine causing a 20% fall in FEV1 (PD20)) were evaluated. FP-treated versus placebo-treated children showed significant changes in percentage symptom-free days, use of beta2-mimetics, morning and evening PEF, FEV1 % pred and wheezing. No significant improvements were found in parent global evaluation, absolute values of FEV1 nor PD20. These findings show that inhaled corticosteroids are effective in children with mild asthma. This effect can be assessed by both objective and subjective parameters. Early start of inhaled corticosteroids should be considered even when pulmonary function is normal.

The nitrate reductase and nitrite reductase operons and the narT gene of Staphylococcus carnosus are positively controlled by the novel two-component system NreBC.

In Staphylococcus carnosus, the nreABC (for nitrogen regulation) genes were identified and shown to link the nitrate reductase operon (narGHJI) and the putative nitrate transporter gene narT. An nreABC deletion mutant, m1, was dramatically affected in nitrate and nitrite reduction and growth. Transcription of narT, narGHJI, and the nitrite reductase (nir) operon was severely reduced even when cells were cultivated anaerobically without nitrate or nitrite. nreABC transcripts were detected when cells were grown aerobically or anaerobically with or without nitrate or nitrite. NreA is a GAF domain-containing protein of unknown function. In vivo and in vitro studies showed that NreC is phosphorylated by NreB and that phospho-NreC specifically binds to a GC-rich palindromic sequence to enhance transcription initiation. This binding motif was found at the narGHJI, nir, and narT promoters but not at the moeB promoter. NreB is a cytosolic protein with four N-terminal cysteine residues. The second cysteine residue was shown to be important for NreB function. In vitro autophosphorylation of NreB was not affected by nitrate, nitrite, or molybdate. The nir promoter activity was iron dependent. The data provide evidence for a global regulatory system important for aerobic and anaerobic metabolism, with NreB and NreC forming a classical two-component system and NreB acting as a sensor protein with oxygen as the effector molecule.

[The peak flow meter: limited role in the diagnosis and follow-up of children with asthma]. / De piekstroommeter: beperkte rol in de diagnostiek en follow-up bij kinderen met astma.

The peak flow meter is commonly used to diagnose and follow up asthma in children and adults. This practice, however, is not supported by evidence from the literature. The amount of overlap in peak flow level and variation between healthy and asthmatic subjects precludes the use of peak flow diaries as a reliable tool in diagnosing asthma. It has also become clear that the correlation between peak flow variation and other indices of asthma severity is inconsistent. Moreover, children and adults have been shown to be unreliable in keeping peak flow diaries: 20-40% of all recorded values in a peak flow diary are invented, and another 25% are recorded inaccurately. Finally, self-management programmes for asthma have been shown to be effective, whether they incorporate peak flow monitoring or not. Therefore, peak flow registration cannot be recommended for the routine diagnosis and follow-up of asthma. In isolated cases however, such as patients who poorly perceive a deterioration of their asthma, or when it is unclear what triggers asthmatic symptoms, the peak flow meter can be useful.

Determinants of correct inhalation technique in children attending a hospital-based asthma clinic.

UNLABELLED: Many children with asthma use their inhaler device incorrectly even after comprehensive inhalation instruction. The aim of this study was to identify factors associated with correct inhalation technique. Two hundred children with asthma demonstrated their inhalation technique. Patient characteristics and the components of inhalation instructions they had received were compared for children demonstrating a correct or incorrect inhalation technique. In addition, the inhalation technique of 47 newly referred patients was followed-up prospectively after repeated comprehensive instruction sessions. Seventy-eight percent of all patients demonstrated a correct inhalation technique. Patients who had received repeated instruction sessions and patients who had previously been asked to demonstrate the use of their inhaler during an instruction session were more likely than other children to demonstrate a correct inhalation technique (p < 0.001 and p = 0.03, respectively). Multiple logistic regression analysis showed that repetition of instructions was significantly associated with a correct inhalation technique (odds ratio (OR) 8.2, 95% CI 3.2-21.5; p < 0.0001) irrespective of type of inhaler used. Demonstration of the inhaler use by the patient was significantly associated with a correct inhalation technique for patients using a metered dose inhaler plus spacer device (OR 3.5, 95% CI 1.0-12.6; p = 0.05). but not for patients using a dry powder inhaler (OR 1.6, 95% CI 0.4-6.4; p = 0.54). The number of newly referred patients demonstrating a correct inhalation technique improved from 57.4% to 97.9% after three comprehensive instruction sessions. CONCLUSION: Inhalation instruction should be given repeatedly to achieve and maintain correct inhalation technique in asthmatic children.

Effect of bacterial filters on spirometry measurements.

Lung function measurements with and without a disposable bacterial filter were compared in 60 children. Although statistically significant, the reduction of lung function measurements caused by using bacterial filters was small and clinically irrelevant (2-4% of predicted for forced expiratory volume in one second and vital capacity).

The feasibility of airways hyperresponsiveness as an inclusion criterion for studies on childhood asthma.

The feasibility of moderately severe airway hyperresponsiveness (AH) was examined as an inclusion criterion for clinical trials in asthmatic children. During the baseline period of a long-term clinical trial in asthmatic children, maintenance therapy with fluticasone (200 microg x day(-1)) was stopped for a maximum of 8 weeks and methacholine challenges were performed at 2-week intervals or earlier if the patients' condition deteriorated. Patients were eligible to continue the study if the provocative dose of methacholine causing a 20% fall in forced expired volume in one second (FEV1) (PD20) was <80 microg. Fifty-one per cent of the children did not develop a PD20 < 80 microg after withdrawal of fluticasone. Patients with or without a PD20 <80 microg did not differ in duration of asthma, duration of treatment, or peak flow variation. Patients with a PD20 <80 microg had higher levels of total and specific immunoglobulin-E, and lower levels of FEV1 and mean maximal expiratory flow than patients with a PD20 > or = 80 microg. Forty-four per cent of the patients with a PD20 > or = 80 microg did not have any symptoms during the wash-out period and 39% of these patients remained free from symptoms during one year follow-up. The results of this study suggest that recruiting asthmatic children for clinical trials may be difficult if airways hyperresponsiveness is used as the sole inclusion criterion.

Peak flow diaries in childhood asthma are unreliable.

BACKGROUND: A study was undertaken to investigate the compliance with and accuracy of peak flow diaries in childhood asthma. METHODS: Forty asthmatic children (5-16 years) were asked to perform peak flow measurements twice daily for 4 weeks by means of an electronic peak flow meter and to record values in a written diary. Patients and parents were unaware that the device stored the peak flow values on a microchip. In random order, half of the patients were only told that the device allowed for more accurate assessment of peak flow while the other half were told that accurate recording of peak flow was important because the results would be used in guiding adjustments to treatment. Data in the written diary (reported data) were compared with those from the electronic diary (actual data). RESULTS: In the entire study population the mean (SD) actual compliance (77.1 (20.5)%) was much lower than the mean reported compliance (95.7 (9.1)%) (95% CI for difference 12.7% to 24.4%) The percentage of correct peak flow entries decreased from 56% to <50% from the first to the last study week (p<0.04), mainly as a result of an increase in self-invented peak flow entries. Results were comparable for both groups. For incorrect peak flow entries the mean difference between written and electronically recorded entries ranged from -72 to 34 l/min per patient. CONCLUSIONS: Peak flow diaries kept by asthmatic children are unreliable. Electronic peak flow meters should be used if peak flow monitoring is required in children with asthma.

Education, self-management and home peak flow monitoring in childhood asthma.

Current asthma guidelines focus on self-management by the patient, in which monitoring of peak flow plays an important role. To be able to participate in self-management, the patient must be educated rigorously on pathophysiological mechanisms of the disease, principles of treatment, correct inhalation technique, treatment goals and the action to take when symptoms or peak flow worsen. This is a time-consuming but important and worthwhile task. The pivotal role of home peak flow monitoring in asthma self-management is based on the assumptions that peak flow variation is a useful measure of disease activity and that peak flow diaries are kept reliably by patients. There is now evidence that neither of these assumptions are true. Self-management plans based on education alone are just as effective as those incorporating peak flow monitoring. Education, therefore, is the most important component of asthma self-management, and home peak flow monitoring is not needed in the majority of asthmatic children.

Poor inhalation technique, even after inhalation instructions, in children with asthma.

The aim of this study was to evaluate the effect of instructions to children with asthma (given by general practitioners or by pharmacy assistants) on how to inhale from metered dose inhalers with spacers (MDI/s) or dry powder inhalers (DPI). We scored inhalation technique of asthmatic children according to criteria defined by the Netherlands Asthma Foundation, and related the performance to the inhalation instructions given. For each inhaler, a number of steps were considered essential for reliable drug delivery. Patients newly referred for asthma were asked to demonstrate their inhalation technique and to fill out a questionnaire on the inhalation instruction received prior to referral. Children participating in a clinical trial, who had received repeated comprehensive inhalation instructions, served as a control group. Sixty-six newly referred patients (1-14 years of age, median age 5 years; 37 boys) and 29 control patients (5-10 years of age, median age 7 years; 21 boys) completed the study. Sixty patients (91%) had received inhalation instruction prior to referral. Only 29% of these patients, using a dry powder inhaler, performed all essential steps correctly, compared to 67% of children using a metered dose inhaler/spacer combination (P < 0.01). Children who had received comprehensive inhalation instructions with repeated checks of proper inhalation technique at the pharmacy or in the clinical trial setting were more likely to perform all essential steps correctly (79% and 93%, respectively) than children who had received a single instruction by a general practitioner (39%, P < 0.01). Many asthmatic children use their inhalers devices too poorly to result in reliable drug delivery, even after inhalation instruction. Comprehensive inhalation instruction and repeated check-ups are needed to assure reliable inhalation technique.

Role of macrophage colony-stimulating factor in the differentiation and expansion of monocytes and dendritic cells from CD34+ progenitor cells.

The present study focused on whether it is possible to expand monocytic cells from CD34+ progenitor cells by using macrophage colony-stimulating factor (M-CSF) in the absence and presence of mast cell growth factor (MGF) and IL-6. It was demonstrated that CD34+ cells differentiate without expansion to functional mature monocytic cells in the presence of M-CSF or combinations of M-CSF plus IL-6 and MGF. A different response pattern was observed for the number of clonogenic cells. The addition of IL-6 or both IL-6 and MGF to M-CSF containing cultures resulted in significant higher numbers of colony-forming unit-macrophage (CFU-M) as tested in clonogenic and 3H-thymidine assays. Furthermore, M-CSF plus both IL-6 and MGF appeared to be the most potent combination to preserve the monocytic precursor in cell suspension culture assays. These results indicate that IL-6 and MGF in conjunction with M-CSF affect CD34+ cells especially at precursor level without distinct effect on the more mature stages. Secondly we studied whether M-CSF is only critical for the monocytic lineage or also affects dendritic cell (DC) development. Indeed, we were able to culture CD83+ DC from CD34+ progenitor cells in the presence of M-CSF in conjunction with TNF-alpha, IL-4, and MGF although their absolute number is almost threefold lower than the number of CD83+ cells yielded from GM-CSF plus TNF-alpha, IL-4, and MGF stimulated CD34+ cells.