Pregnancy outcomes in urban teenagers.

OBJECTIVES: To compare pregnancy outcomes for teenagers with those for older gravidas. METHODS: A retrospective case control study was undertaken to compare teenagers who delivered between January 1996 and October 1999 at a public urban hospital with a group of older gravidas. RESULTS: Young pregnant teenagers were more likely to be nulliparous. They weighed less and gained less in pregnancy. More teen pregnancies occurred among Hispanics than other ethnic groups. The younger the teenager, the more likely for her infant to be of low or very low birth weight or growth restricted. There were fewer postmature deliveries, macrosomic fetuses and cesarean deliveries in young gravidas. Perinatal mortality was unaffected by maternal age. CONCLUSIONS: This investigation demonstrates that, while pregnancy outcomes in teenagers have improved in recent years relative to historical patterns, teenagers face continuing problems requiring special attention by care givers.

Asthma treatment and noncompliance.

RATIONALE: Noncompliance with asthma treatments is a common cause of hospitalization. Currently, physicians in the emergency department can only diagnose noncompliance with asthma therapy by asking patients if they have taken their medication (i.e., the HONOR SYSTEM). Patients frequently "overstate" their compliance and subsequently receive unnecessary supplemental medication (p.o. corticosteroid) as well as hospitalization. However, because their noncompliant behavior goes unrecognized, these individuals are at risk for recurrent emergency care and death. It is for these reasons that drug monitoring to identify compliance status should be available in the emergency department and in specialty clinics that care for chronic asthmatics. RECOMMENDATIONS FOR ACTION: 1) Develop drug monitoring systems and make them available. There are two electronic medication-monitoring devices with microprocessor technology available for metered-dose inhalers. These devices need further improvement in design, at a lower cost. Assays have been developed for oral and injectable medications recently approved by the FDA. These assays need to become commercially available. 2) Train health care providers to improve patient compliance. As noncompliance becomes more recognized, as a result of drug monitoring, educational and behavioral programs to improve compliance with treatment will need to be developed and disseminated.

When should your asthmatic patients refill their MDI propelled with chlorofluorocarbons?

BACKGROUND: The United States Food and Drug Administration has changed its policy regarding product labeling of asthma MDIs. All asthma MDIs propelled by CFCs should be discarded at the discard point labeled on the canister and box. This policy is in transition with inconsistent product information given to patients and physicians. Previously, patients had been educated to replace the canister by observing its floating pattern in water. Now FDA labeling asks users to count the number of actuations. OBJECTIVE: To compare the discard point of sample and prescription-size Serevent (6.5 g and 13 g) and Vanceril 84 DS (5.4 g and 12.2 g) canisters to their floating pattern and total number of actuations in the canisters. DESIGN: Seven canisters each of Serevent 6.5 g and 13 g as well as Vanceril 84 DS 5.4 g and 12.2 g were shaken vigorously prior to actuation. One minute separated each actuation. The floating pattern was observed beginning at 80 percent of the discard point. This was repeated to the last actuation of the canister. RESULTS: The floating pattern (tilt point) indicative to replace the Serevent 6.5 g and 13 g canisters as well as Vanceril 84 DS 5.4 g canister occurred after the discard point was reached. CONCLUSION: Floating patterns of the 6.5 g and 13 g Serevent inhaler as well as the 5.4 g Vanceril 84 DS do not assist the asthmatic patient in determining when to replace their canister. Because canisters have excess product and propellant beyond the labeled discard point, it may be possible for pharmaceutical companies to correlate the product's floating pattern to the drug concentration and particle size distribution up to and beyond the discard point. Through careful testing, floating patterns of MDIs may still be able to assist the asthmatic patient in determining when to discard the canister.

Maintaining theophylline compliance/adherence in severely asthmatic children: the role of psychologic functioning of the child and family.

BACKGROUND: Noncompliance with asthma therapy by asthmatic children and their families is a common cause of treatment failure. Psychologic factors have been reported to influence adherence patterns. OBJECTIVE: To evaluate the relationship of psychologic function of severely asthmatic children and families with theophylline compliance during a 1-year follow-up period after inpatient asthma rehabilitation. METHOD: Thirty-seven severely asthmatic children with a median age of 9 years (range, 2 to 17 years) were treated in an inpatient rehabilitation program (median, 15 days). Established clinical rating scales of psychologic adjustment were used for children (Child Global Assessment Scale) and families (Family Global Assessment Scale) at the time of admission. Patients were defined as noncompliant if 30% or more of theophylline levels obtained during the 1-year follow-up period were less than 5 mg/L (mumol/L). RESULTS: Compliant children had higher scores on the Child Global Assessment Scale than noncompliant children (64 versus 48, P = .09). Families of compliant children had significantly higher scores on the Family Global Assessment Scale than did families with noncompliant children (63 versus 54, P < .05). There was no statistical relationship between compliance status and parent-reported behavior problems, demographic factors (age, race, sex, and number of parents at home), health insurance, specialty referral at admission, measures of medical morbidity (days hospitalized, number of emergency care visits, and number of corticosteroid bursts), or length of rehabilitation stay. Both compliant and noncompliant children had comparable reductions in morbidity (hospital and emergency care, number of corticosteroid bursts required). CONCLUSION: Psychologic functioning of the child and family may be related to theophylline compliance.

Caring for the severely asthmatic child and family. I. The rationale for family systems integrated medical/psychological treatment.

Comprehensive care for the severely asthmatic child includes psychological as well as medical treatment. Family therapy is a recognized modality of therapy. Investigations have examined the role of emotion and asthma as well as psychosomatic asthma. Pharmacological treatment of beta 2-agonist and cromolyn prior to disciplining the child prevents psychosomatic asthma secondary to crying or shouting. Adherence to multiple asthma therapeutic modalities is imperative, and a psychological and medical team can address these important clinical issues in a high-risk population.

An economic evaluation of short-term inpatient rehabilitation for children with severe asthma.

BACKGROUND: The cost of asthma care in the United States in 1990 has been estimated to be 6.2 billion dollars. The greatest proportion is due to hospital care. OBJECTIVE: We report changes in estimated medical charges of 59 children with severe asthma 1 year before inpatient rehabilitation and over a 4-year follow-up period. METHODS: Asthma resource use (e.g., hospital, physician, medication) was identified before and after inpatient rehabilitation. Estimated charges were assigned. This was done retrospectively for the 1-year period before rehabilitation, prospectively during rehabilitation, and over a 4-year follow-up period. Patients served as their own controls. There was no control group. RESULTS: When median asthma resource use 1 year before rehabilitation was compared with that during the first, second, third, and fourth years of follow-up, there was a reduction in median hospitalization and median emergency care. Compared with mean total medical charges the year before rehabilitation, reductions in mean total medical charges were 56.7% at the completion of the first year (excluding charges for rehabilitation), 70.5% at second year, 74.6% at third year, and 77.5% at fourth year. Over the 4-year postrehabilitation period, the discounted cumulative net savings was $29,605. The discounted cumulative net savings surpassed the mean rehabilitation charge during the early months of the fourth year of the postrehabilitation period. CONCLUSION: Inpatient rehabilitation was significantly associated with a reduction in estimated total medical charges over a 4-year follow-up period.

Clinical management strategies to maintain drug compliance in asthmatic children.

OBJECTIVE: Noncompliance with asthma medication is a common cause of treatment failure and may lead to unnecessary hospitalization and emergency care. This publication reviews factors associated with compliance with treatment regimens in general as well as with recommended asthma medications. General strategies (educational, organization, and behavioral) are reviewed with emphasis in behavioral strategies. These include reminders, tailoring, and contracting. STUDY SELECTION: A case report follows regarding a 9-year-old boy with severe asthma who was treated in a short-term inpatient asthma rehabilitation center and followed for 3 years as an outpatient. Specific clinical management strategies and techniques to maintain theophylline compliance are presented. CONCLUSION: A systematic approach emphasizing the use of behavioral strategies and drug monitoring can be helpful in promoting compliance with a therapeutic regimen. This may lead to a reduction in pulmonary morbidity and medical costs.

Outcome of short-term hospitalization for children with severe asthma.

This study presents results of a family-centered, short-term residential program in which medical, behavioral, and treatment assessments were provided to the child with severe asthma and the family. After a median stay of 15 days, forty-four consecutively admitted children with severe asthma achieved a 93% reduction in hospital days (median, 7 hospital days for the year before treatment versus median 0 hospital days per patient per year at 20 1/2-month follow-up; p less than 0.001) and an 81% reduction in emergency care (median, 4 visits for the year previously versus median, 0.4 visits per patient per year at follow-up; p less than 0.01). There was also a significant reduction in corticosteroid bursts and improvement in FEV1. Unique to this program was mandatory family participation focusing on the child's and family's adaptation to severe asthma and development of family-specific interventions to promote compliance with the treatment regimen. Child and family functioning was assessed at admission and follow-up. Hospital use at follow-up was greater for children from dysfunctional families. Families demonstrating difficulties in disciplining the child with asthma required more hospital days both before admission and at follow-up. Short-term hospitalization for children with severe asthma is associated with significant improvement in pulmonary morbidity when the family of the child is included in assessment and treatment.

Familial factors responsible for persistent crying-induced asthma: a case report.

Crying behavior of the asthmatic child may induce wheezing symptoms. This may be a clinical problem for families with asthmatic children who exhibit frequent and persistent crying behavior. This case report identifies behaviors by the child and parents that may be responsible for continual crying. Child factors include (1) "spoiled" personality, (2) poor self-image, (3) biologic sensitivity to foods, medication, and environmental allergens producing irritability. Parental factors include poor disciplinary practices secondary to (1) disrupted home life, (2) guilt, and (3) overprotective behavior. Identification of these factors may be helpful in establishing clinical management strategies to reduce crying-induced asthma.

Crying-induced bronchospasm in childhood asthma: response to nebulized metaproterenol 5% and sodium cromoglycate 1%.

Five asthmatic children (2 to 5 years) with persistent crying-induced bronchospasm refractory to concomitant oral theophylline and metaproterenol for 4 weeks were selected for an 8-week uncontrolled study with nebulized metaproterenol 5% and sodium cromoglycate 1%. All five patients had reduction in both crying and non-crying-related asthma. Three patients had reduction in crying behavior. Nebulized metaproterenol and sodium cromoglycate may be effective in treating crying-induced bronchospasm refractory to oral bronchodilators.

Sustained release theophylline for the forgetful asthmatic.

Several theophylline pharmacologic strategies were tested for the forgetful medication-dependent asthmatic who frequently initiates treatment from below the therapeutic range of 10 to 20 micrograms/mL. Theodur was found to give comparable if not higher levels (two, eight, and 24 hours) starting from 0 microgram/mL than Slophyllin Gyrocap during a multiple dose 28-hour study. In a single dose 12-hour study, Theodur 100-mg tablets gave higher levels during the first nine hours than Theodur 200-mg tablets. Theodur 100-mg tablets may be preferred for the forgetful asthmatic who can sustain pulmonary function despite greater fluctuation with theophylline levels.

Crying-induced bronchospasm in childhood asthma: response to medical management.

Crying-induced bronchospasm (CIB), cough and/or wheeze greater than or equal to 5 minutes during or after crying behavior, is a common feature of childhood asthma. Sixty CIB patients were evaluated during a 6-month clinical treatment study consisting of environmental and pharmacologic (xanthines, beta-agonist stimulants, and corticosteroids) interventions. Both CIB (P = .007) and non-CIB (P = .0005) symptoms were significantly reduced. CIB asthma had lesser reduction in wheezing than non-CIB (P less than .001), suggesting that nebulized medication and/or behavioral interventions may be of benefit to further reduce CIB symptoms.

Theophylline compliance in asthmatic children.

Thirty-nine chronic asthmatic children were enrolled in a 6-month outpatient theophylline compliance study. Seventy-two percent of these patients maintained mean theophylline levels greater than or equal to 5 mcg/ml, the definition of theophylline compliance. Both compliant and noncompliant patients showed significant reduction in wheezing symptoms (P less than .005). Demographic factors including age, race, sex, and number of parents at home were not correlated with drug compliance behavior. Specific behavioral interventions were implemented to promote drug compliance. Behavioral interventions that were most effective in achieving compliance were parental encouragement and increasing parental supervision of medication (compliance, asthma, theophylline, behavioral intervention).