Effects of a structured educational intervention on knowledge and emergency management in patients at risk for anaphylaxis.

BACKGROUND: Structured educational programmes for patients at risk for anaphylaxis have not yet been established. Patients and caregivers often lack adequate skills in managing the disease. METHODS: To investigate effects of structured patient education intervention on knowledge, emergency management skills and psychological parameters in patients with previous episodes of anaphylaxis and caregivers of affected children 95 caregivers (11 male, 84 female, mean age 37 years) of affected children and 98 patients (32 male, 66 female, mean age 47.5 years) were randomly assigned to an intervention (IG) or control group (CG) in a multicentre randomized controlled trial. The IG received two 3-h schooling modules of group education; the CG received standard auto-injector training only. Knowledge of anaphylaxis and emergency management competence in a validated training anaphylaxis situation as main outcome measures as well as secondary psychological parameters were assessed at baseline and 3 months after intervention. RESULTS: In comparison with controls, the intervention led to significant improvement of knowledge from baseline to 3-month follow-up (caregivers: IG 3.2/13.2 improvement/baseline vs CG 0.7/12.6; P < 0.001; patients: IG 3.9/10.8 vs 1.3/12.6; P < 0.001). Moreover, emergency management competence was increased after intervention as compared to controls (caregivers: IG 8.6/11.2 vs CG 1.2/10.8; P < 0.001; patients: 7.1/11.0 vs 1.1/11.1; P < 0.001). Intervention showed significant reduction of caregiver anxiety (-1.9/8.4 vs -0.7/7.5; P < 0.05). There were no significant changes in the depression scores. CONCLUSION: Structured patient education programmes may be beneficial in the management of anaphylaxis by increasing patients' empowerment to prevent and treat the disease.

Criteria for the differential indication of asthma education versus asthma instruction for families of preschoolers: results from the randomized DIAT2 study (Differential Indication of Asthma Trainings in Toddlers).

BACKGROUND: Asthma management of preschoolers is more improved by a family oriented psycho-educational program provided by a multi-professional team than by a short instruction alone. For some families however an instruction could be sufficient. Criteria to assign education or instruction to asthmatic schoolchildren (DIA) have been evaluated . This paper describes the use of those criteria in the Preschoolers' and parents' asthma education trial (P (2)AET) . PATIENTS: DIA at study entry were available of 233 children (aged 2-5 [mean 3.9] years) participating in the randomised controlled P (2)AET (education, instruction, waiting group). Children had been included after having at least 3 obstructive episodes in their life plus chronic or recurrent wheeze in the 6 months before the start of the study. 74 % were on inhaled corticosteroids. METHODS: Logistic regression procedures were used to assess the predictive value of DIA and possible confounders on the success of the interventions (education and instruction). RESULTS: Regarding the outcome "better in asthma management test" education is superior to instruction (OR 5.2; CI 1.7-16). DIA "quarrel about inhalation" indicates an even greater advantage of education (OR 19; CI 2-176). An equal high advantage was found, when there was NO "need for peer support" (OR 11; CI 2-64). CONCLUSION: Families with asthmatic preschoolers displaying dysfunctional interaction, which can only be corrected in an educational process, should be provided with the psycho-educational program promptly.

Preschoolers' and parents' asthma education trial (P2AET)--a randomized controlled study.

We aimed to evaluate a family-oriented psycho-educational asthma training program for the age group of 2-5 years, involving both parents and children. Children were included after having at least 3 obstructive episodes in their life plus chronic or recurrent wheeze in the 6 months before the start of the study. In the multicenter randomized trial we had (1) a waiting group (WG), (2) an instruction group (IG) trained in a structured way according to the national asthma guideline, and (3) an education group (EG), having a standardized multiprofessional psycho-educational program, according to the national licensed asthma education for the age group of 6-18 years. All were assessed after 6 months. A subgroup analysis was performed on those being on regular inhaled corticosteroids at study entry (74.3%). A total of 338 children were randomized, and 288 (85%) completed the study. In the asthma emergency management, test scores increased most in EG, less in IG, and not in WG. For emergency visits the risk ratio for EG was 0.68 compared to IG: Patients regularly inhaling corticosteroids (74.3%) had an increased risk for emergency visits when having only an instruction (OR 3.99 [1.89-8.40]) or had been waiting (OR 2.5 [1.16-5.37]) when compared to those having an asthma education. We conclude that in the German health system, the family oriented psycho-educational program provided in a standardized manner by a multiprofessional team is effective also in the age group of 2-5 years. It should be made accessible to each asthmatic child.

Changes in the use of analogue insulins in 37 206 children and adolescents with type 1 diabetes in 275 German and Austrian centers during the last twelve years.

AIMS: To describe changes in insulin treatment in children and adolescents in Germany/Austria regarding short acting (SA)- and long acting (LA) insulin analogues in different age groups over the last twelve years. METHODS: Use of different insulins and treatment regimens were analysed in 37 206 children and adolescents with the age of 0-20 years from 276 German and Austrian centers that were registered in the DPV-database (Dec. 2007). The group was subdivided into 4 age groups (A: 0-4 years; B:5-9 years;C:10-14 years,D:15-19 years). We further analysed the use of analogues from onset of diabetes. RESULTS: A significantly increasing percentage of pediatric patients in all age groups with Type 1 Diabetes use analogue insulins. In 2007, 48.5% used SA, 45.8% LA. 87.2% of pumps were running with short acting analogue. Age specific analysis: A: 2000: 9.1%SA, 0.7%LA vs. 2007: 50.0%SA, 10.0%LA; B: 2000:5.6%SA, 1.4%LA vs. 2007: 36.8%SA, 27.5%LA C: 2000:14.3%SA, 3.4%LA vs. 2007: 45.3%SA, 49.1%LA D: 2000:26.3%SA, 3.2%LA vs. 2007: 59.1%SA, 61.9%LA. This increase in usage of analogues was also found at onset of diabetes. Corrected for age, center and diabetes duration HbA1c was significantly lower in the group with regular insulin (8.18+/-0.047%) than with SA (8.32+/-0.048%) (p<0.0001) and BMI-SDS was only marginal lower in the group with regular insulin (0.45+/-0.01 kg/m (2)) than with SA (0.47+/-0.15) (p>0.007). Similar differences in HbA1c (8.09+/-0.05% vs. 8.40+/-0.05%) and BMI-SDS where seen when NPH was compared with LA respectively. After change to SA the reduction of severe hypoglycemia with (6.1/100 pat.years) and without coma (6.2/100 pat.years) was significant and after change to LA for severe hypoglycemia without coma respectively. CONCLUSIONS: Long-term data for the use of new drugs are sparse. In our analysis patients are followed not under study conditions. Still the higher BMI and HbA1c with either SA or LA usage have to be discussed carefully in the context of increasing use of both, long acting and short acting analogues and possible problems with reimbursement.

Control of atopic eczema with pimecrolimus cream 1% under daily practice conditions: results of a > 2000 patient study.

BACKGROUND: Pimecrolimus cream 1% has been shown to effectively control atopic eczema (AE) when applied twice daily from the first signs or symptoms of AE until clearance. Moreover, pimecrolimus cream 1% has a favourable safety profile, lacking topical corticosteroid-related side-effects such as skin atrophy, making it particularly useful to treat delicate body regions (e.g. the face). OBJECTIVE: The objective of this naturalistic study was to monitor the safety, tolerability and efficacy of pimecrolimus when used in the long-term management of AE in a real-life setting. METHODS: A multicentre, open-label study was conducted in 2034 patients aged >or= 3 months with mild to moderate AE for up to 12 months' duration. Patients applied pimecrolimus cream twice daily, initiating treatment at first signs or symptoms of AE, continuing until clearance. RESULTS: Patients (n= 1847; 91%) completed 3 months of the study. Treatment success (clear or almost clear AE) after 3 months of treatment was observed on the whole body in 59% of patients and on the face in 81% of patients. Disease improvement of whole body and face was seen in 77% and 63% of patients, respectively. Pruritus was absent or mild in 79% of patients. Pimecrolimus cream was well tolerated throughout the study. CONCLUSION: In a daily practice setting, pimecrolimus cream 1% effectively and safely controls AE.

[Dealing with asthma for teachers--needs and possibilities]. / Asthmaschulung für Lehrer - Notwendigkeit und Möglichkeiten.

UNLABELLED: Teachers and schools are confronted with an increasing number of children with asthma. Teachers have to care for 2 to 4 children or adolescents with asthma in an average class; but they feel that they are not adequately informed to cope with such problems. METHODS: In 1999 and 2000, we conducted an inquiry in schools in the region of Osnabrueck. This investigation used approximately the same tools as a previous inquiry in Vienna. Results were similar and demonstrated deficits in the knowledge about asthma and in the ability to manage children with asthma exacerbations. At the same time, we offered a three-hour-programme in 40 schools and nurseries, to be given in the rooms of the schools. We always tried to reach all teachers of one school. Topics were: What is asthma? Self grading of severity; asthma and sports; emergency management; avoidance of triggers. RESULTS: There were 648 participants. There was much interest in the seminars, and we could not always admit all applicans. Theoretical and practical contents taught were, as judged by the participants, helpful in the average school settings. The participants felt that they were now better prepared and more competent in dealing with bronchial asthma in their pupils. CONCLUSION: We conclude that such seminars are helpful for teachers. The program can be conducted with moderate financial and man power resources. One may aim at including such educational units into the regular curriculum of teachers, at least as far as the most common chronic childhood and adolescent diseases are concerned.

Ambulatory blood pressure and marital distress in employed women.

In this investigation, the relationship between marital distress and blood pressure during daily life in a sample of married employed women was examined. It was hypothesized that greater marital distress would be associated with elevated blood pressure in the home environment, but not in the workplace. Participants were 50 married employed women, aged 25 to 45 years. Participants underwent ambulatory blood pressure monitoring on a typical workday. The women with higher levels of marital distress exhibited greater negative emotions and higher levels of blood pressure at home. These results suggest that the physiological concomitants of stress and emotional upset associated with marital distress are manifest in elevated blood pressure that is most pronounced in the home environment.

A genome-wide search for linkage to asthma. German Asthma Genetics Group.

Asthma is among the most frequent chronic diseases in childhood. Although numerous environmental risk factors have already been identified, the basis for familial occurrence of asthma remains unclear. Previous genome screens for atopy in British/Australian families and for asthma in different American populations showed inconsistent results. We report a sib pair study of a sample of 97 families, including 415 persons and 156 sib pairs. Following an extensive clinical evaluation, all participants were genotyped for 351 polymorphic dinucleotide markers. Linkage analysis for asthma identified four chromosomal regions that could to be linked to asthma: chromosome 2 (at marker D2S2298, P = 0.007), chromosome 6 (around D6S291, lowest P = 0.008), chromosome 9 (proximal to D9S1784, P = 0.007), and chromosome 12 (D12S351, P = 0.010). These linkage regions could be reproduced for all loci by analysis of total or specific immunoglobulin E (minimum P values at these regions were 0. 003, 0.001, 0.010, and 0.015, respectively).

[Reduced passive smoking exposure of children--parental behavior, possibilities for change and determinants]. / Minderung der Passivrauchexposition von Kindern--elterliches Verhalten, Anderungsmöglichkeiten und deren Determinanten.

So far there have been hardly any investigations as to under what conditions parents can avoid or reduce their children's exposure to passive smoking similarly, there has not been much investigation on physician's influence on parental behaviour. In an anonymous questionnaire given to 105 parents (only one parent), one half of the children were constantly exposed to smoke. In households with both parents smoking a very high level of exposure is to be expected due to behaviour and cigarette-consumption. The problem is aggravated by visitors and partners who also smoke. A lack of parents' awareness of passive smoking cannot be regarded as relevant. The main thing that puts a stop to changing this seems to be taking a decision and is also dependent on the amount of cigarette smoke. Only 46% of the participants reported to have been addressed by their physician on this subject. No negative reactions to this intervention on behalf of the physicians were reported in this survey. Instead, talking about it rather made the patient feel he had a bad conscience. Hence, the doctors' concern about a negative reaction does not seem to be justified. Structured intervention strategies which can be introduced in hospitals or in a physician's general practice should be developed and tested.

Blood pressure reactivity and marital distress in employed women.

OBJECTIVE: The impact of marital distress on cardiovascular responses to an "ecologically valid" laboratory stressor (a marital conflict recall task) was examined in maritally distressed and non-distressed women. It was hypothesized that the presence of high levels of marital distress would be associated with elevated blood pressure and heart rate responses to a marital conflict task. METHOD: Fifty married, employed women, aged 25-45, were recruited into high and low marital distress groups, based on total scores on the Dyadic Adjustment Scale. Subjects participated in three laboratory stress tasks: a marital conflict recall task, a work conflict recall task, and a serial subtraction task. RESULTS: During the marital conflict recall task, women characterized as high in marital distress exhibited higher systolic blood pressure (M = 21.4 +/- 9.1 vs. 17.3 +/- 7.7) (p < .05) and heart rate (M = 13.6 +/- 9.5 vs. 10.9 +/- 6.5) (p < .01) responses, compared with low-distress women. However, the association between marital distress and cardiovascular response was statistically significant only after aggregate responses to the control stressors were used as covariates. CONCLUSION: These data indicate that the stress associated with recalling a marital conflict was manifest in elevated blood pressure and heart rate, particularly among women characterized as experiencing high levels of distress in their marriage. Future research is needed to determine whether the blood pressure differences between women who are satisfied with their marriage, versus those that are chronically distressed are clinically meaningful. In addition, examination of the "ecological validity" of laboratory stressors suggests that a useful methodology may be to assess task responses, while controlling for nonspecific individual differences in cardiovascular reactivity.

Efficacy of a self-management program for childhood asthma--a prospective controlled study.

Asthma training programs for parents and children have been developed to increase both the self-management skills of asthmatic children and compliance with medical regimes. In order to evaluate two training programs for asthmatic children aged 7-14, 81 patients were randomly assigned to three groups. Group 1 consisted of 27 patients and their parents who participated in a five-day standardized family-oriented clinical asthma training program. They had monthly follow-up meetings with the training team for a period of six months. Group 2 (n = 29) had the same clinical training without follow-up interventions; a control group (n = 25) received regular medical treatment according to the international guidelines at the asthma clinics without a training program and served as control group. Questionnaires regarding self-management aspects, coping and anxiety were filled out by patients, parents, family doctors and the training team prior to as well as twelve months after the training. The results indicate that Training group 1 benefitted most with respect to active asthma self-management, Training group 2 to some degree while the control group showed no significant effects. The differences after one year between the three groups regarding physical parameters such as lung-function and days missed in school did not reach the level of significance. Our results indicate that the long-term efficacy of self management courses for asthmatic children is enhanced by regular follow-up training sessions.

Relation of mood ratings and neurohormonal responses during daily life in employed women.

Diurnal variations in urinary norepinephrine, epinephrine, cortisol, and self-reported mood states were examined in 101 employed women. Urine was collected on 2 consecutive workdays at 3 time periods: (1) overnight, (2) daytime, and (3) evening. Self-reports of 14 mood states were combined to correspond with the urinary collection periods. Factor analyses revealed 3 mood factors: Pressured (rushed, busy, stressed, hassled, and tense), Distressed (afraid, depressed, bored, and nervous), and Contented (satisfied, thoughtful, excited, and calm). The Distressed factor was significantly associated with norepinephrine excretion (p <.001). The Pressured factor was significantly associated with cortisol, epinephrine, and norepinephrine excretion (p <.001) independent of age, ethnicity, marital status, parental status, department within the company and activity level. Secretion of urinary hormones and the Pressured factor followed the same diurnal pattern. Specifically, as women's self-ratings of feeling pressured initially increased and then decreased over the course of the workday, urinary hormones also peaked and then dropped. Once time of day was statistically controlled, however, the mood factors were no longer significantly related to the urinary hormones.

[Cost-effectiveness studies of ambulatory educational programs for children with asthma and their families]. / Kosten-Nutzen-Untersuchungen bei ambulanten Schulungsmassnahmen für asthmakranke Kinder und ihre Familien.

Increasingly, economic aspects become important in public health which makes necessary the quantification to economical and operational efficiency. One of the instruments applied in this process is cost-benefit-analysis, comparing preventive, curative and rehabilitative services under the aspect of cost and benefit and effectiveness. In this context, we have evaluated a project of ambulant training of asthmatic children and of their parents. We included 142 affected children and their parents, who were trained in the offices of 24 physicians. Evaluation was done with a questionnaire in which data were collected on asthma-management, on quality of life, and on cost-effectiveness. We looked at the year before starting the training and on the year after completion of the training. Treatment costs were decreased by training, life quality improved. Thus, ambulant training of asthmatic children and of their family is a useful and efficient part of preventive rehabilitation.

[Outcome of structured asthma education in childhood and adolescence]. / Ergebnis einer strukturierten Asthmaschulung im Kindes-und Jugendalter.

From 1988 onwards inpatient asthma training courses have been conducted in Berlin and Osnabrück. A controlled study on asthma training was carried out from 1990 to 1992 at both centres with the support of the Robert Bosch Foundation. In the first intervention group a subsequent training course of 6 months' duration was conducted with the inclusion and participation of the relevant family doctors in addition to the main training course. Scrutiny of the result was done before (T1), directly after (T2) and 12 months subsequent to the training course (T3). Improvements are seen in somatic data or cost-relevant data (emergency referral to the hospital or family physician, inpatient hospital periods, referral because of mild obstruction, days of non-attendance in school due to illness, severity of asthma, incidence of symptoms, stress endurance in sports). There is also a marked improvement in the self-assessment ability of the children and in the management of asthma, as well as a decrease in the asthma-specific feeling of anxiety. Self-reliance and independence, as well as early intervention, are improved as seen by the parents, whereas on the other hand unfavourable factors such as arguments on the proper asthma therapy are diminished. Especially with regard to confidence in controls on the state of health or disease there are significant changes that are more marked in the group subjected to subsequent training than in the group without such additional training, compared with the control group. Structured asthma training exercises a strongly positive effect on the daily management of asthma bronchiale by the families on different planes of coping with the disease. These effects are enhanced by subsequent aftercare by the family physician. Intensive care in the asthma outpatient wards alone does not sufficiently modify the factors contributing to good coping with the disease.

[Analysis of the current status of asthma education for children and adolescents in German-speaking countries]. / Analyse zur gegenwärtigen Situation der Asthmaschulung für Kinder und Jugendliche im deutschsprachigen Raum.

Systematic training of children and adolescents to cope with asthma has been practised in Germany for long years parallel to the development of training for adult asthmatics. An analysis conducted in mid-1992 revealed a considerable gap between the actual need for such training and the available training facilities. The analysis covered asthma training both for outpatients and inpatients including those referred to rehabilitation hospitals. The analysis revealed that there have been some achievements in the topics that were analysed (general framework of conditions for training, target groups of patients, agreement on the direction in which to proceed with regard to scope and aims, follow-up and aftercare, interdisciplinary exchange of ideas and actions, financing and government-piloted sponsorship by the compulsory health insurance bodies, qualification of the asthma pupils and evaluation), whereas in many cases these achievements are in the nature of a pilot study or of a matured model without meeting as yet the essential conditions for a full-range and adequate asthma training offer that can be realised in a sufficiently large area. However, a general consensus has been reached recently on medical contents of the training, on problems of methods and didactic approach and also on standards of evaluation. The paper expressing this general consensus was passed on the occasion of the 3rd Annual General Meeting of the Work Team for Asthma Training in Childhood and Adolescence. This means that the essential prerequisites for expanding the training programme from a local to a large-area programme have now been created.

[Neurodermatitis and food allergy. Clinical relevance of testing procedures]. / Neurodermitis und Nahrungsmittelallergie. Klinische Relevanz von Testverfahren.

In 132 children with neurodermitis, we measured specific IgG and IgE antibodies against components of cow's milk, soy milk, and egg. In addition we performed epidermal tests by rubbing the nutrients onto the intact skin. The results were compared to the effect of complete omission of milk, egg, and soy during four weeks and with the outcome of subsequent reexposition. We used standardized scales to evaluate the neurodermitis and the skin reactions and for the clinical response to the oral challenge. The best prediction for the outcome of the oral challenge was obtained by the epidermal test which had to be done with whole milk, soy milk and egg white; there was no further advantage in testing egg yolk or soy oil. IgE antibodies followed next in their predictive value. No further precision was gained by the combination of epidermal testing with IgE results, by the measurement of IgE antibodies to the constituents of cow's milk, of IgG antibodies, and of the platelet count during oral challenging. Positive reactions to oral administration after four weeks' omission of allergenic food were relatively frequent in the age group below three years, but rare in school children and adolescents.