Pictorial versus written asthma action plans for youth: initial impact on regimen knowledge, medication adherence, symptom control, and family satisfaction.

OBJECTIVE: Asthma action plans (AAP) are recommended to guide asthma management. Written AAPs (WAAPs) are under-utilized and can be difficult to understand. Our study designed and tested a simplified pictorial AAP (PAAP). We hypothesized that better outcomes would be obtained for youth with the PAAP. METHODS: One hundred and sixty-nine (169) youth (aged 8-17; AAP-naïve) were screened for this pilot, 2-arm randomized controlled trial. Feasibility, usability and preliminary efficacy of PAAP compared to a WAAP, for improving outcomes (inhaled corticosteroid (ICS) adherence, symptom control, AAP knowledge, AAP satisfaction) were assessed quantitatively. Youth received an AAP from their physician after completing baseline measures and completed measures at three additional time points (1-, 3-, and 6-month). RESULTS: Forty-five youth were recruited (PAAP = 22; WAAP = 23). Youth AAP knowledge was higher for the PAAP group compared to the WAAP group (p = .017). ICS adherence did not differ between groups, over time, or based on prescribed dosing; however, for WAAP participants, adherence was lower with a higher daily prescription (4 puffs) relative to a lower dose (p = .006). Symptom control improved with both AAPs, but the change was not statistically significant. Lung function did not change significantly by AAP type or time, and literacy variables were not related significantly to outcomes. Youth satisfaction with AAP improved significantly for the PAAP group compared to the WAAP group (p = .03). CONCLUSIONS: Higher AAP knowledge and satisfaction among youth in the PAAP group suggests that structured education from a physician using a PAAP is beneficial. Intervention and study design insights gained will guide future research.

Early evidence of pulmonary dysfunction in survivors of childhood Hodgkin lymphoma.

Survivors of childhood Hodgkin lymphoma (HL) are at risk for pulmonary late effects, but whether survivors also experience pulmonary dysfunction early off therapy is not well understood. We determined the incidence of pulmonary dysfunction in children/adolescents with HL at entry into survivorship, as well as risk factors related to this outcome. Survivors in clinical remission and with a pulmonary function test (PFT) obtained 2-6 years off therapy were included. Seventy-five of 118 subjects met eligibility criteria (mean age at diagnosis: 13 years, mean time off therapy: 40 months). Survivors of HL had a higher than expected incidence of pulmonary dysfunction at entry into survivorship (40/75 [53%] had an abnormal DLCO and/or a restrictive or obstructive impairment). Evidence for diffusion impairment was associated with female sex (odds ratio [OR] = 3.19, p = .04). Longitudinal follow-up studies are needed to determine if early evidence of pulmonary dysfunction predicts risk for later onset pulmonary outcomes.

Comparing Written Versus Pictorial Asthma Action Plans to Improve Asthma Management and Health Outcomes Among Children and Adolescents: Protocol of a Pilot and Feasibility Randomized Controlled Trial.

BACKGROUND: Asthma is an important focus for pediatric health research as management of asthma symptoms is a significant challenge, and morbidity and mortality among youths with asthma remain prevalent. Treatment guidelines for asthma recommend a written asthma action plan (WAAP) that summarizes individualized instructions for daily medication use. However, WAAPs are typically written at a seventh- to ninth-grade reading level, which can be a barrier to young people in understanding their treatment, having confidence in using a WAAP, and engaging with asthma education. OBJECTIVE: Utilizing a feasibility and pilot randomized controlled trial (RCT) design, the objective of the Take Action for Asthma Control study is to test a symptom-based, computer-generated pictorial asthma action plan (PAAP) in comparison with a standard WAAP and assess the feasibility and acceptability of the asthma action plan (AAP) intervention and study procedures. The study has 3 aims: (1) estimate the effect sizes of PAAPs compared with WAAPs on outcomes (eg, AAP knowledge and medication adherence), (2) evaluate feasibility and acceptability of AAP intervention and RCT procedures from the perspectives of key stakeholders, and (3) establish whether parent and youth literacy levels are associated with treatment outcomes. METHODS: This feasibility and pilot RCT is a block randomized, 2-arm, parallel-group clinical trial, lasting 6 months in duration. At baseline, participants will be randomly assigned to receive a PAAP or WAAP generated for them and reviewed with them by their asthma physician. Study procedures will take place over 4 separate time points: a baseline clinic appointment, 1-month telephone follow-up, and 3- and 6-month clinic-based follow-ups. At each time point, data will be collected related to the main outcomes: AAP knowledge, AAP satisfaction, asthma control, pulmonary function, and adherence to daily asthma medication. A sample size of up to 60 participants (aged 8-17 years) will be recruited. Feasibility and acceptability data will be collected via one-to-one qualitative interviews with providers involved in the study and a subgroup of families that participate in the study. RESULTS: Recruitment and data collection began in May 2017 and were completed in October 2018. CONCLUSIONS: This pilot and feasibility study will test the potential efficacy, feasibility, and acceptability of an AAP intervention and study procedures. The findings will inform the design and delivery of a future definitive trial to assess the efficacy of PAAPs versus WAAPs in supporting asthma self-management among children and adolescents. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11733.

Radiation pneumonitis in pediatric Hodgkin lymphoma patients receiving radiation therapy to the chest.

PURPOSE: The purpose of this study is to determine the incidence of radiation pneumonitis (RP) in children receiving radiation therapy (RT) for Hodgkin lymphoma (HL). METHODS AND PATIENTS: A retrospective chart review was conducted of pediatric HL patients who received multiagent chemotherapy followed by RT to any part of the chest. The National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.03, was used to determine the RP grade. Parameters analyzed included sex; age; bleomycin dose; and RT dosimetric variables such as mean lung dose (MLD), mean individual (i; right vs left) lung dose or iMLD, V5 to V25, and individual lung V5 to V25. RESULTS: From 2008 through 2016, 54 children with HL received RT to the chest and had follow-up and dosimetry information. All patients received induction chemotherapy; the most common regimen was Adriamycin, bleomycin, vincristine, etoposide, prednisone, and cyclophosphamide-based chemotherapy (n = 48). All received a prescribed dose of 21 Gy in 14 fractions. Median follow-up from completion of RT was 39.5 months. Three of 54 patients (5.6%) or 3 of 108 (2.8%) lungs developed RP; 2 lungs had grade 1, whereas 1 had grade 2 RP. RP was seen only in patients with MLD >12.4 Gy (P = .009), V5 >66% (P = .033), V10 >55% (P =.015), V15 >45% (P =.005), and V20 >32% (P =.007). Likewise, RP was only seen in lungs with iMLD >13.8 Gy, iV5 >75% (P =.02), iV10 >64% (P =.02), iV15 >47% (P < .005), and iV20 >34% (P =.003). CONCLUSIONS: RP in pediatric HL patients is an uncommon complication. MLD, iMLD, V5-V20, and iV5-iV20 correlated with RP.

Oral Corticosteroid Prescribing for Children With Asthma in a Medicaid Managed Care Program.

BACKGROUND AND OBJECTIVE: Short courses of oral corticosteroid (OCS) medication are recommended for treatment of moderate to severe asthma exacerbations. Concern has been raised about OCS overuse. Our objective is to describe rates of OCS dispensing among children with asthma and factors associated with variation in OCS dispensing. METHODS: Claims data for children 1 to <18 years of age with an asthma diagnosis between January 2011 and January 2016 were extracted from the computerized databases of Texas Children's Health Plan. RESULTS: In the years 2011 to 2015, 17.1% to 21.8% of children had an asthma diagnosis. In each of these years 42.1% to 44.2% of these children had ≥1 OCS dispensing. OCS dispensing rates were higher for the children 1 to 4 years of age compared with older children. Repeated OCS dispensing was common, and was most common for children 1 to 4 years of age. Most children with an OCS dispensing (81%-83%) did not have other utilization suggesting poor asthma control (excessive ß-agonist refills, emergency department visit, or hospitalization for asthma). OCSs were less commonly prescribed to patients whose primary care provider was a board-certified pediatrician compared with other types of primary care providers. There was large variation in OCS prescribing rates among pediatricians (15%-86%). There were minimal differences in asthma emergency department visits and no differences in hospitalization rates by the pediatrician's OCS dispensing rate quartile. CONCLUSIONS: The patterns of dispensing observed suggest substantial overprescribing of OCS for children with an asthma diagnosis.