Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

NIH research opportunities for the prevention and treatment for chronic conditions

Chronic conditions constitute the leading cause of death and disability in the USA and constitute 86 per cent of the nation's annual healthcare expenses. Approximately half of all American adults have at least one chronic condition; 25 per cent of these Americans have two or more chronic conditions. The National Institutes of Health have funded many projects that explain epidemiology, risk factors, and prevention and treatment of chronic conditions, though research questions remain. This commentary discusses some past projects, current areas of interest, and funding opportunities from many NIH Institutes, Centers, and Offices.

Unrestricted Weight Bearing and Intensive Physiotherapy after Uncemented Total Hip Arthroplasty

Background and Aims:

The effectiveness of partial weightbearing after hip surgery has been questioned as well as the need of intensive physiotherapy.

Material and Methods:

36 patients (average age 54.4, 19 women) operated with uncemented hip arthroplasty were randomized either to unrestricted weightbearing (UWB) combined with intensive physiotherapy or to partial weightbearing (PWB) for 3 months combined with a short self-training program. The load during walking and the muscle strength (MS) in abduction was measured preoperative and subsequent up to 12 months.

Results:

The average peak load on the operated leg at one week was 39.0 kg for the UWB and 25.8 for the PWB group (P = 0.009) while at three months 70.0 and 31.7 (P = 0.001) respectively. At 6 and 12 months there were no differences between the groups. The muscle strength increased in both groups up to six months but there were no differences between the groups.

Conclusions:

Even though patients applied more load than the recommended 15 kg most patients were able to comply with partial weightbearing fairly well. The effect of intensive physiotherapy on the muscle strength after hip arthroplasty is questionable.

Caring for caregivers and patients: Research and clinical priorities for informal cancer caregiving

Informal/family caregivers are a fundamental source of care for cancer patients in the United States, yet the population of caregivers and their tasks, psychosocial needs, and health outcomes are not well understood. Changes in the nature of cancer care and its delivery, along with the growing population of survivors and their caregivers, warrant increased attention to the roles and demands of caregiving. This article reviews current evidence presented at a 2-day meeting examining the state of the science of informal cancer caregiving that was convened by the National Cancer Institute and the National Institute of Nursing Research. The meeting sought to define who is an informal cancer caregiver, summarize the state of the science in informal cancer caregiving, and describe both the kinds of interventions developed to address caregiving challenges and the various outcomes used to evaluate their impact. This article offers recommendations for moving science forward in 4 areas: 1) improving the estimation of the prevalence and burden of informal cancer caregiving; 2) advancing the development of interventions designed to improve outcomes for cancer patients, caregivers, and patient-caregiver dyads; 3) generating and testing strategies for integrating caregivers into formal health care settings; and 4) promoting the use of technology to support informal cancer caregivers. Cancer 2016;122:1987-95. © 2016 American Cancer Society.

Pharmacological inhibition of nicotinamide phosphoribosyltransferase (NAMPT), an enzyme essential for NAD+ biosynthesis, in human cancer cells: metabolic basis and potential clinical implications

Nicotinamide phosphoribosyltransferase (NAMPT) catalyzes the first rate-limiting step in converting nicotinamide to NAD(+), essential for cellular metabolism, energy production, and DNA repair. NAMPT has been extensively studied because of its critical role in these cellular processes and the prospect of developing therapeutics against the target, yet how it regulates cellular metabolism is not fully understood. In this study we utilized liquid chromatography-mass spectrometry to examine the effects of FK866, a small molecule inhibitor of NAMPT currently in clinical trials, on glycolysis, the pentose phosphate pathway, the tricarboxylic acid (TCA) cycle, and serine biosynthesis in cancer cells and tumor xenografts. We show for the first time that NAMPT inhibition leads to the attenuation of glycolysis at the glyceraldehyde 3-phosphate dehydrogenase step due to the reduced availability of NAD(+) for the enzyme. The attenuation of glycolysis results in the accumulation of glycolytic intermediates before and at the glyceraldehyde 3-phosphate dehydrogenase step, promoting carbon overflow into the pentose phosphate pathway as evidenced by the increased intermediate levels. The attenuation of glycolysis also causes decreased glycolytic intermediates after the glyceraldehyde 3-phosphate dehydrogenase step, thereby reducing carbon flow into serine biosynthesis and the TCA cycle. Labeling studies establish that the carbon overflow into the pentose phosphate pathway is mainly through its non-oxidative branch. Together, these studies establish the blockade of glycolysis at the glyceraldehyde 3-phosphate dehydrogenase step as the central metabolic basis of NAMPT inhibition responsible for ATP depletion, metabolic perturbation, and subsequent tumor growth inhibition. These studies also suggest that altered metabolite levels in tumors can be used as robust pharmacodynamic markers for evaluating NAMPT inhibitors in the clinic.

Ten-year follow-up in a case series of integrative botulinum toxin intervention in adolescents with chronic daily headache and associated muscle pain

INTRODUCTION

A total of 83% of children report headache during a 6-month period. The estimated 1-year prevalence of chronic daily headache (CDH) in children is at least 1 to 2%. Muscle pain is associated with headache severity and chronicity. Muscle pain can be associated with active muscular trigger points, a functional concept still remaining a controversy. An integrated approach including bio-behavioral management is accepted as standard treatment but does not provide sufficient pain relief in all patients.

OBJECTIVE

We report the individual clinical course of five adolescents with treatment-refractory CDH associated with focal muscle pain. We describe a concept of short-term integrative intervention including botulinum toxin (StiBo) in a personalized "follow the referred pain pattern" injection regimen with the focus on long-term follow-up.

RESULTS

StiBo showed short-term efficacy on headache frequency and severity. In the long-term follow-up, CDH was not existent in any of the patients.

CONCLUSION

The treatment may have enabled the patients to draw attention away from a repeated circle of muscle-triggered pain and withdrawal of daily activities toward self-driven activities, thereby potentially preventing the development of further chronification. To prove this hypothesis, a prospective, placebo-controlled study in young adolescents with CDH should be initiated including objective outcome parameters on muscular level.

A novel, selective inhibitor of fibroblast growth factor receptors that shows a potent broad spectrum of antitumor activity in several tumor xenograft models

The fibroblast growth factor receptors (FGFR) are tyrosine kinases that are present in many types of endothelial and tumor cells and play an important role in tumor cell growth, survival, and migration as well as in maintaining tumor angiogenesis. Overexpression of FGFRs or aberrant regulation of their activities has been implicated in many forms of human malignancies. Therefore, targeting FGFRs represents an attractive strategy for development of cancer treatment options by simultaneously inhibiting tumor cell growth, survival, and migration as well as tumor angiogenesis. Here, we describe a potent, selective, small-molecule FGFR inhibitor, (R)-(E)-2-(4-(2-(5-(1-(3,5-Dichloropyridin-4-yl)ethoxy)-1H-indazol-3yl)vinyl)-1H-pyrazol-1-yl)ethanol, designated as LY2874455. This molecule is active against all 4 FGFRs, with a similar potency in biochemical assays. It exhibits a potent activity against FGF/FGFR-mediated signaling in several cancer cell lines and shows an excellent broad spectrum of antitumor activity in several tumor xenograft models representing the major FGF/FGFR relevant tumor histologies including lung, gastric, and bladder cancers and multiple myeloma, and with a well-defined pharmacokinetic/pharmacodynamic relationship. LY2874455 also exhibits a 6- to 9-fold in vitro and in vivo selectivity on inhibition of FGF- over VEGF-mediated target signaling in mice. Furthermore, LY2874455 did not show VEGF receptor 2-mediated toxicities such as hypertension at efficacious doses. Currently, this molecule is being evaluated for its potential use in the clinic.

Concurrent TNFRSF1A R92Q and pyrin E230K mutations in a child with multiple sclerosis

We report a 16-year-old female patient with a severe course of multiple sclerosis and concomitant symptoms suggestive of a hereditary autoinflammatory disease. Genetic analyses revealed that she inherited a TNFRSF1A R92Q mutation from her mother and a pyrin E230K mutation from her father. To our knowledge, this is the first report of a patient with severe childhood multiple sclerosis and mutations in two genes which predispose to hereditary autoinflammatory disorders. We speculate that these mutations contribute to early multiple sclerosis manifestation and enhance the inflammatory damage inflicted by the autoimmune response.

Clinical and functional characterisation of a novel TNFRSF1A c.605T>A/V173D cleavage site mutation associated with tumour necrosis factor receptor-associated periodic fever syndrome (TRAPS), cardiovascular complications and excellent response to etanercept treatment

OBJECTIVES

To study the clinical outcome, treatment response, T-cell subsets and functional consequences of a novel tumour necrosis factor (TNF) receptor type 1 (TNFRSF1A) mutation affecting the receptor cleavage site.

METHODS

Patients with symptoms suggestive of tumour necrosis factor receptor-associated periodic syndrome (TRAPS) and 22 healthy controls (HC) were screened for mutations in the TNFRSF1A gene. Soluble TNFRSF1A and inflammatory cytokines were measured by ELISAs. TNFRSF1A shedding was examined by stimulation of peripheral blood mononuclear cells (PBMCs) with phorbol 12-myristate 13-acetate followed by flow cytometric analysis (FACS). Apoptosis of PBMCs was studied by stimulation with TNFalpha in the presence of cycloheximide and annexin V staining. T cell phenotypes were monitored by FACS.

RESULTS

TNFRSF1A sequencing disclosed a novel V173D/p.Val202Asp substitution encoded by exon 6 in one family, the c.194-14G>A splice variant in another and the R92Q/p.Arg121Gln substitution in two families. Cardiovascular complications (lethal heart attack and peripheral arterial thrombosis) developed in two V173D patients. Subsequent etanercept treatment of the V173D carriers was highly effective over an 18-month follow-up period. Serum TNFRSF1A levels did not differ between TRAPS patients and HC, while TNFRSF1A cleavage from monocytes was significantly reduced in V173D and R92Q patients. TNFalpha-induced apoptosis of PBMCs and T-cell senescence were comparable between V173D patients and HC.

CONCLUSIONS

The TNFRSF1A V173D cleavage site mutation may be associated with an increased risk for cardiovascular complications and shows a strong response to etanercept. T-cell senescence does not seem to have a pathogenetic role in affected patients.

Using rare diseases as models for biobehavioral research: allergic bronchopulmonary aspergillosis

Biobehavioral science explores links between biological, psychosocial, and behavioral factors and health. Maintaining positive health outcomes over time and across a variety of populations and settings requires understanding interactions among biological, behavioral, and social risk factors as well as other variables that influence behavior. Some barriers to biobehavioral research are related to performing biobehavioral research along the natural history of an illness, limitations in existing methodologies to assess the biological impact of behavior, the unknowns relating to impact of behavior on biology, and lack of valid and reliable biobehavioral methods to assess outcomes. A rare disease, such as allergic bronchopulmonary aspergillosis (ABPA) can be used as a model of biobehavioral research. ABPA complicates asthma and cystic fibrosis. It is a hypersensitivity reaction to Aspergillus fumigatus in most cases. ABPA can be classified into five stages: acute, remission, exacerbation, steroid-dependent asthma, and fibrotic or end stage. Because of its rarity, there can be delays in diagnosis. Treatment has used oral corticosteroids and antifungal agents in addition to management of asthma or cystic fibrosis. The National Institute of Nursing Research held an invitational 2-day working group meeting on July 15-16, 2004 with biobehavioral, biological, and immunologic science experts to examine current knowledge of biobehavioral research and to provide recommendations for additional research. The focus was on biobehavioral methods of measurement and analysis with interdisciplinary/biobehavioral approaches. This article is an outcome of this meeting.

Discovery of cercosporamide, a known antifungal natural product, as a selective Pkc1 kinase inhibitor through high-throughput screening

The Pkc1-mediated cell wall integrity-signaling pathway is highly conserved in fungi and is essential for fungal growth. We thus explored the potential of targeting the Pkc1 protein kinase for developing broad-spectrum fungicidal antifungal drugs through a Candida albicans Pkc1-based high-throughput screening. We discovered that cercosporamide, a broad-spectrum natural antifungal compound, but previously with an unknown mode of action, is actually a selective and highly potent fungal Pkc1 kinase inhibitor. This finding provides a molecular explanation for previous observations in which Saccharomyces cerevisiae cell wall mutants were found to be highly sensitive to cercosporamide. Indeed, S. cerevisiae mutant cells with reduced Pkc1 kinase activity become hypersensitive to cercosporamide, and this sensitivity can be suppressed under high-osmotic growth conditions. Together, the results demonstrate that cercosporamide acts selectively on Pkc1 kinase and, thus, they provide a molecular mechanism for its antifungal activity. Furthermore, cercosporamide and a beta-1,3-glucan synthase inhibitor echinocandin analog, by targeting two different key components of the cell wall biosynthesis pathway, are highly synergistic in their antifungal activities. The synergistic antifungal activity between Pkc1 kinase and beta-1,3-glucan synthase inhibitors points to a potential highly effective combination therapy to treat fungal infections.

A+ Asthma Rural Partnership coloring for health: an innovative rural asthma teaching strategy

Asthma is the leading chronic illness in children, affecting about 4.8 million children in the United States. Recent reports indicate a lack of asthma educational resources for rural school health nurses to use in their practice. This article describes the development of the My Asthma Coloring Book educational tool for children and their families living in rural communities. My Asthma Coloring Book was developed to provide asthma information in a short-story format for children with asthma. The coloring book content is described, including its utilization as part of the A+ Asthma Rural Partnership research project funded by the National Institute of Nursing Research (R01NR05062-01).

Asthma management practices at home in young inner-city children

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with children's asthma morbidity. Caregivers of 100 inner-city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.

General principles of asthma management: environmental control

Environmental control is one of the major goals of asthma management. House dust mite environmental control and the reduction of other indoor environmental allergen triggers, such as animal dander, cockroaches, and mold spores, are important for individuals with asthma. Patients who have sensitivities to the allergens they produce should receive advice on environmental control reduction measures to prevent asthma symptoms. Nurses are in a key position to make proper environmental control recommendations to patients.

Caregiver-physician medication concordance and undertreatment of asthma among inner-city children

OBJECTIVE

To assess the extent to which caregivers and their child's physician agree about the prescribed asthma medication regimen and evaluate factors associated with medication concordance.

METHODS

A cross-sectional, descriptive survey was administered to 318 caregivers of inner-city children with asthma, aged 5 to 12 years, and their caregiver-identified primary care physician at elementary schools and participants' homes. Concordance between caregiver- and physician-reported controller medication prescription was measured.

RESULTS

Only 42% of physicians and 32% of caregivers reported a controller medication prescription (78% agreement, kappa = 0.54; 95% confidence interval: 0.45-0.63) despite that 73% of the children were rated by their caregiver as currently experiencing persistent asthma symptoms. When the physician reported a controller prescription, 38% of the caregivers denied use of a controller. Having a course of oral steroids in the past year (chi(2) = 9.85) and positive caregiver beliefs toward asthma care (chi(2) = 18.40) were associated with caregiver-physician concordance. Multivariate analysis found that when caregivers had high Asthma Beliefs Scale summary scores versus low scores, they were almost 10 times as likely to be concordant with the physician (odds ratio: 9.76; 95% confidence interval: 2.85-33.46).

CONCLUSIONS

Our data support previous reports of physician underprescribing of controller medication among inner-city children. However, even when prescribed by a physician, more than one third of caregivers did not report a controller prescription, and this discordance was related to caregivers' beliefs about treatment. Efforts to improve physician adherence to asthma guidelines will not result in proper treatment unless caregiver-physician communication about asthma therapy is improved.

Computer game for inner-city children does not improve asthma outcomes

INTRODUCTION

The purpose of this randomized control trial was to evaluate the effects of a computer-assisted instructional (CAI) game on asthma symptoms (eg, coughing, wheezing, shortness of breath, and nighttime awakenings) in 7- to 12-year-old inner-city children over 12 weeks.

METHOD

A CAI that focused on reducing environmental irritants/allergens and the correct use of prescribed medications to prevent asthma symptoms was used with 101 children (56 in the intervention group and 45 in the control group). The primary outcome evaluated a change in children's asthma symptoms as measured by responses to nine symptom questions in Juniper's Pediatric Asthma Quality of Life Questionnaire (PAQOL) and measurements of lung function.

RESULTS

No significant changes in asthma symptoms occurred between the two groups before and after the intervention. No significant changes were noted in PAQOL scores for activities, emotions, and total PAQOL score, lung function measurements, and asthma severity between the two groups. Asthma knowledge of both groups was high before intervention, but there were no significant changes between groups after the intervention.

DISCUSSION

Findings indicate that this CAI game was not effective in improving asthma symptoms in this group of children.

Asthma management practices and education needs of head start directors and staff

Limited information exists regarding asthma management practices and education needs of Head Start directors and staff. This paper describes asthma management practices and education needs of Head Start directors and staff in 15 Baltimore, Md., Head Start programs. From February to December 2000, all Head Start staff and directors were asked to complete a survey. Data from 268 Head Start staff and 12 Head Start directors were analyzed. Results revealed discrepancies between Head Start staff and directors regarding location of asthma medications and presence of asthma action plans in programs. Both Head Start staff and directors stated they had no curriculum to teach Head Start children how to manage asthma. This finding provides evidence that asthma education is needed in Head Start programs. Findings also indicate a need for improved communication between Head Start directors and staff.

Environmental tobacco smoke exposure and nocturnal symptoms among inner-city children with asthma

BACKGROUND

Environmental tobacco smoke (ETS) is a frequent exposure and is linked to asthma among inner-city children.

OBJECTIVE

We sought to examine the relationship among ETS exposure, select asthma symptoms, and consequences among inner-city children with asthma.

METHODS

Data from interviews with primary caregivers of inner-city elementary school children with asthma were evaluated (n = 590). Caregiver reports of child asthma symptoms, exercise limitations, asthma management, health care use, and ETS exposure were examined.

RESULTS

Smoking in the home was reported by 29.4% of primary caregivers. ETS exposure (yes/no) was not related to frequency of child nocturnal symptoms or other select asthma morbidity markers. However, among children exposed to ETS, the frequency and severity of child nocturnal symptoms were highest among children exposed to moderate-to-heavy levels of ETS. After controlling for child age, anti-inflammatory medication use, asthma primary care, and caregiver's education, exposure to higher levels of ETS was associated with nearly a 3-fold increase in nocturnal symptoms in children (odds ratio, 2.83; 95% CI, 1.22-6.55).

CONCLUSION

Among elementary school inner-city children with asthma, exposure to higher levels of ETS was associated with increased frequency of nocturnal symptoms. Reducing the exposure of children with asthma to ETS should be a clear priority in developing effective asthma management plans for inner-city families.

Using standardized patients in advanced practice nursing education

Standardized patient encounters, a pedagogic approach to helping students develop appropriate clinical skills, are widely used in medical education and are being adopted by advanced practice nursing programs. Two types, simulated clinical encounters, in which students complete an episodic or comprehensive visit, and objective structured clinical experiences, multiple stations each presenting a different clinical problem, are used for formative and summative evaluation. Graduating adult and pediatric nurse practitioner students (N = 26) completed a simulated clinical encounter for an episodic visit. Students' performance on the simulated clinical encounter did not reflect their performance on other clinical evaluation measures or their performance on national certifying examinations. This one-time simulated clinical encounter was shown to lack the necessary reliability and validity to appropriately evaluate the clinical skills of nurse practitioner students. Videotaped, simulated patient encounters are useful, however as formative learning experiences. This reinforced our position that multiple site visits by faculty to students and their preceptors at all their clinical sites are necessary to accurately evaluate students' clinical performance.

Role of rural school nurses in asthma management

Environmental, socioeconomic, psychological and familial factors in rural communities predispose children to asthma. This is not only the case in the US but also in the UK, New Zealand and other Western countries. Asthma prevalence ranges from 2.2 to 15%. Because children spend at least 6 hours of their day in school, school health personnel must be attentive to, and skilled in managing the needs and issues faced by children with asthma while at school. Rural school nurses or their deputies need to advise children with asthma about avoiding aeroallergens from hay, smoke, dust, grain in silos and animal dander from cattle and sheep. In the case of children with asthma in rural areas, symptoms may be accepted as long as the child can go to school and play. Parents in rural areas may not believe in routine preventive care for asthma as part of public health practice. Rural nurses need to be aware of current asthma guidelines and apply the concepts to prevention. They need to be proactive and engage in primary, secondary and tertiary prevention. Rural school nurses can begin by using existing resources and adapting these resources for use in rural school environments. Worldwide asthma education is fundamental to asthma patient management.

Children with asthma and nebulizer use: parental asthma self-care practices and beliefs

We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.

Rural school nurses' asthma education needs

School nurses play an important role in identifying children with asthma and providing care during school hours. Educational programs designed to improve nurses' asthma knowledge and practices have concentrated on urban settings. The purpose of this investigation was to determine asthma-related practices and educational needs of rural school nurses. A survey about asthma was mailed to school nurses in all counties of the state of Maryland and in Washington, D.C. Responses were compared between rural Maryland counties and counties from the remainder of Maryland and Washington, D.C. The survey addressed attitudes and beliefs, function and roles, medication administration, and educational needs about asthma. We found that rural nurses used peak flow meters less often to assess and monitor asthma, requested fewer referrals for asthma, had fewer interactions with health room assistants, and had reduced access to asthma educational resources. Also, they provided less asthma education in the schools than other school nurses. These results suggest a need for comprehensive asthma educational programs in rural areas that are based on national guidelines, and that address the unique needs of rural school nurses. These programs should also emphasize the need for open communication between rural school nurses, health room assistants, primary care providers, and parents/caregivers.

Patient priorities and needs for diabetes care among urban African American adults

PURPOSE

This study was conducted to determine diabetes care priorities and needs in a group of urban African American adults with type 2 diabetes mellitus.

METHODS

One hundred nineteen African American adults with type 2 diabetes, aged 35 to 75, received behavioral/educational interventions from a nurse case manager, a community health worker, or both. Priorities and needs were assessed during 3 intervention visits.

RESULTS

The most frequently reported priorities for diabetes care were glucose self-monitoring (61%), medication adherence (47%), and healthy eating (36%). The most frequently addressed diabetes needs were glucose self-monitoring and medication adherence. Most of the intervention visits (77%) addressed non-diabetes-related health issues such as cardiovascular disease (36%) and social issues such as family responsibilities (30%).

CONCLUSIONS

Participants' self-reported priorities for diabetes care directly reflected the diabetes needs addressed. Needs beyond the focus of traditional diabetes care (social issues and insurance) are important to address in urban African Americans with type 2 diabetes. Interventions designed to address comprehensive health and social needs should be included in treatment and educational plans for this population.

Asthma severity, atopic status, allergen exposure and quality of life in elderly persons

BACKGROUND

Although asthma can be associated with significant airflow obstruction in those over the age of 65, it is often underdiagnosed and undertreated.

OBJECTIVE

To describe severity of asthma, allergy skin test sensitivities, indoor allergen exposures, and the impact on quality of life (QOL) and health status in elderly persons with asthma.

METHODS

A cross-sectional data analysis with 80 elderly persons with asthma recruited from medical, geriatric, and allergy/immunology tertiary care centers. Asthma severity was determined by symptoms and measurements of lung function. House dust specimens were collected from mattresses and bedroom carpets and analyzed separately for the major allergens of house dust, using monoclonal antibody-based immunoenzymetric assays. QOL was measured using Juniper's Asthma Quality of Life Questionnaire. Health status was measured using the Short Form Health Survey Medical Outcome Questionnaire which included Ferrans and Powers' Quality of Life Index subscales.

RESULTS

Two-thirds of participants had either moderate or severe persistent asthma. Skin tests to a battery of common airborne allergens were positive to at least one allergen in 56 of the 75 participants tested (74.7%). Reservoir dust allergen levels were often high enough to place participants at risk of symptoms or at risk of developing sensitization. Increased asthma severity was associated with significantly lower QOL and a trend toward decreased health status.

CONCLUSIONS

Asthma is a significant chronic problem in the elderly. Atopy was common. Asthma severity impacts on these participants' QOL and health status. Results support interventions aimed at identifying allergens precipitating attacks and reducing them in the home.

Asthma education in rural communities

Asthma is a common disease of airway obstruction in school-aged children. Adequate management of asthma in children leads to fewer missed school days, fewer hospitalizations, fewer emergency room visits, and an increase in quality of life. Most asthma educational programs and evaluations have focused on urban rather than rural populations. The purpose of this study was to identify parental asthma needs, develop rural asthma education materials, and evaluate the effectiveness of these educational materials in improving the knowledge and asthma care effectiveness of parents of children with asthma in a rural community. Seven parents were contacted by telephone and administered a pre- and posttest questionnaire analyzing their level of knowledge about asthma and their quality of life. Asthma educational materials were mailed to all parents in the study before administering the posttest. Results indicated that all parents needed additional education about asthma, especially regarding medications. Pre- and posttest scores showed improvements in three areas of knowledge: long-term asthma medications, controlling roaches in the home, and daily peak flow monitoring. There was a significant improvement between pre- and posttest results from the activity domain of quality of life. Eighty-five percent of the parents reported that they had either initiated changes in their home, or planned to in the future, from reading the educational materials. The parents' response to the educational materials that they received by mail was positive, indicating that they may not have received enough information about how to care for children with asthma before our study. The data suggest that distribution of asthma educational materials in rural communities can increase parental knowledge about asthma and lead to positive changes in behavior that can improve their children's health.

House dust mite and cockroach exposure are strong risk factors for positive allergy skin test responses in the Childhood Asthma Management Program

BACKGROUND

Children with asthma have a high prevalence of environmental allergies, especially to indoor allergens. The relationships of exposure to indoor allergens (dust mites, cat, dog, cockroach, and molds) and other host factors to allergy sensitization have not been evaluated simultaneously in a large cohort.

OBJECTIVES

We studied 1041 children aged 5 to 12 years with mild-to-moderate asthma to determine risk factors associated with having positive allergy skin test responses to indoor allergens. Also, we described, compared, and contrasted 6 allergens in the home environments of these children from 8 North American cities.

METHODS

Data were used from baseline visits of the Childhood Asthma Management Program. Patients' sensitivities to house dust mites (Dermatophagoides farinae and Dermatophagoides pteronyssinus), cats, dogs, cockroaches, and molds were examined for relationships to demographic variables, home dust allergen exposures, number of other positive allergy skin test responses, total serum IgE levels, and smoking in the home.

RESULTS

San Diego (78.5%) and Toronto (59.3%) had the topmost percentages of homes with moderate-to-high house dust mite levels. Boston (21.5%), St Louis (16.3%), and Baltimore (13.4%) had the highest percentages of homes with detectable levels of cockroach allergen. For house dust mites, the higher the level of allergen exposure, the more likely patients were to have positive allergy skin test responses, with relative odds of 9.0 (95% confidence interval, 5.4-15.1) for those exposed to high mite levels (>10.0 microg/g dust) relative to those unexposed. Even exposure to low levels of mite allergen (0.020-2.0 microg/g) was found to be a significant risk factor for sensitization. For cockroach allergen, those with detectable home exposure were more likely to have positive skin test responses (relative odds, 2.2; 95% confidence interval, 1.3-3.8) than those with undetectable exposure. In contrast, levels of exposure to cat, dog, and mold allergens were not related to sensitization rates. For cat allergen, this may reflect lower rates of cat ownership among highly sensitized subjects. Furthermore, the number of allergy skin test responses that were positive, excluding the test for the outcome of interest for each model, and total serum IgE levels were strong independent predictors of sensitization.

CONCLUSIONS

Levels of exposure determined by house dust analysis are important determinants of sensitization for dust mite and cockroach allergen. This relationship was not demonstrable for cat, dog, or mold allergens, possibly because of confounding factors. For all allergens studied, the degree of atopy, determined by the total number of positive skin test responses or by total serum IgE levels, is an important contributing risk factor for sensitization.

Nebulizer use in inner-city children with asthma: morbidity, medication use, and asthma management practices

OBJECTIVE

To assess the frequency of nebulizer use, describe morbidity and patterns of medication administration, and examine the potential relationships between inhaled anti-inflammatory medication administration, asthma morbidity, and asthma management practices in children with asthma using a nebulizer compared with children with asthma not using a nebulizer.

RESEARCH DESIGN

A cross-sectional, descriptive survey of previous events.

SETTING

Elementary schools and participants' homes in Baltimore, Md, and Washington, DC.

PARTICIPANTS

Six hundred eighty-six families of children aged 5 to 12 years with a diagnosis of at least mild, persistent asthma.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Asthma morbidity, health care utilization, pattern of asthma medication administration, nebulizer use, and asthma management data were collected by telephone survey administered to caregivers. Nebulizer use was defined as use at least 1 or more days per month during the last 6 months. Of 686 children identified, 231 (33%) reported current nebulizer use. Nebulizer users had significantly increased lifetime hospital admissions, hospitalizations, and emergency department visits in the last 6 months compared with nonnebulizer users. Inhaled corticosteroid administration was low for both groups (nonnebulizer users, 8%; nebulizer users, 15%). In the nebulizer users group, administration of inhaled anti-inflammatory medications was associated with increased asthma morbidity (increased hospitalizations, days and nights with symptoms, and oral steroid use).

CONCLUSIONS

Nebulizer use by inner-city children with asthma is higher than anticipated but is not associated with reduced asthma morbidity. This group of high-risk children was undertreated with inhaled corticosteroids for long-term control of asthma despite reports of adequate monitoring by a primary care physician.

Genetics of asthma and allergies

This article is a literature review focusing on the underlying concepts of human genetics related to asthma and allergies. Asthma is classified as a complex genetic disorder with genetic susceptibility and an appropriate environmental stimulus necessary for the expression of disease. Intermediate phenotypes of asthma, which are used to study the disease, include the total IgE levels, the specific immune response, and end organ response. Because gene products cause the inflammation in asthma and allergies, the molecular cell biology of these events is reviewed. Although no one gene is implicated in causing asthma, candidate genes involved in the multiple phenotypic expressions of asthma are described.

Factors associated with medication self-administration in children with asthma

This study investigated factors associated with early self-administration of inhaled asthma medications by minority children. Specifically, the study evaluated: (1) the reasons parents allow early administration of inhaled medications, (2) childhood activities associated with early medication administration, (3) parent's perception of the child's ability to use a metered-dose inhaler (MDI), (4) the child's actual ability to use an MDI, and (5) concordance/discordance between physician-parent reports and parent-child reports of asthma medications. Study results indicated that 93% of the children were taking inhaled asthma medications without adult supervision. Early self-administration of asthma medications was related to the parent's employment status and the performance of other childhood behaviors such as completion of homework independently and crossing the street alone. Only 7% of the children had effective MDI skills, but 60% of the parents rated their child's MDI skills as excellent. Twenty percent, 67%, and 50%, respectively, of the parents' reports of beta-agonists, daily inhaled steroids, and cromolyn were discordant with the physician's actual prescriptions. Sixty-two percent, 57%, and 79%, respectively, of the children's reports for inhaled beta-agonists, daily inhaled steroids, and cromolyn were discordant with their parents' reports. Implications for anticipatory guidance, future educational strategies, and supervision of MDI technique are provided.

Assessing pediatric clinical asthma practices and perceptions: a new instrument

Over the past 20 years, the most substantial increases in prevalence, morbidity, and mortality of asthma have been observed among children aged 5-14 years. A survey instrument designed to measure clinical asthma management practices of primary care physicians was developed and evaluated. Study participants included 127 practitioners providing pediatric asthma care in inner-city communities in Baltimore, MD and Washington, DC. Study results found that the instrument assessed four separate dimensions of clinical assessments and five dimensions of physician perceptions. These dimensions should be considered in future research protocols and may be used to design tailored interventions to improve asthma care.

Emergency department visits by urban African American children with asthma

BACKGROUND

Asthma morbidity among African American children has been identified as a significant national health concern. High emergency department use is one index of this morbidity and may reflect disease severity, disease management, and social factors.

OBJECTIVE

This study examined the prevalence and correlates of emergency department use and other indices of asthma morbidity among a sample of urban, low-income, African American children.

METHODS

Parents of 392 elementary school children with asthma who had consented to participate in an asthma education program were interviewed by phone according to a standardized protocol.

RESULTS

Children had a mean of 6.2 days of restricted activity (SD 8.1) and 7.9 symptomatic nights (SD 8.1). The mean number of school days missed because of asthma was 9.7 (SD 13.5). Among children with asthma symptoms in the past 12 months, 73.2% could identify a specific physician or nurse who provided asthma care. For those families without an identified asthma primary care provider, 39.3% received their usual asthma care from the emergency department. A total of 43.6% of the children had been to the emergency department for asthma care without hospitalization in the previous 6 months. Close to 80% of children reported using one or more prescribed asthma medication, and of these only 12% reported using inhaled anti-inflammatory medications. Families of children who had used the emergency department in the prior 6 months reported more asthma symptoms, lower social support, problems paying for health care, and the absence of a hypoallergenic mattress cover and that they had seen a physician for regular asthma care in the past 6 months.

CONCLUSIONS

We conclude that asthma management for children in the inner city relies on episodic care and emergency care, that asthma medication management does not conform to current guidelines, and that asthma symptoms resulting in school absences and workdays lost are prevalent.

The relationships among environmental allergen sensitization, allergen exposure, pulmonary function, and bronchial hyperresponsiveness in the Childhood Asthma Management Program

BACKGROUND

Sensitivity and exposure to indoor allergens constitutes a risk factor for the development and persistence of asthma in children.

OBJECTIVE

Our purpose was to evaluate the relationship between sensitivity and exposure to inhalant allergens and lung function and bronchial responsiveness in a group of children (n = 1041) aged 8.9 +/- 2.1 years with mild to moderate asthma enrolled in the Childhood Asthma Management Program (CAMP).

METHODS

With use of the extensive CAMP baseline cross-sectional data on spirometry, bronchial responsiveness, allergen sensitivities, and household allergen levels, the relationship of sensitization and exposure to allergens to lung function and methacholine sensitivity was evaluated. Children who enrolled in CAMP stopped all antiasthma medication except rescue use of albuterol and prednisone for exacerbations during the 5- to 16-week screening period. During the last 2 of these weeks they underwent spirometry and methacholine challenge. Indoor allergen exposures were determined from questionnaires completed by the parent. Household levels of indoor allergens (mite, cat, dog, cockroach, mold) were determined on house dust samples. Allergen sensitivity was determined by percutaneous skin testing with a standard battery of allergens plus locally important pollen and fungal spores. Lung function and bronchial hyperresponsiveness were compared for children sensitive and not sensitive to both indoor and outdoor allergens on skin testing and, if sensitive, for exposed and not exposed to the allergens to which they were positive on skin testing.

RESULTS

There was a strong direct correlation between increased sensitivity to inhaled methacholine and skin test sensitivity to tree, weed, Alternaria, cat, dog, and indoor molds. When the relationship was examined by stepwise regression, the skin test sensitivities showing the strongest associations with the concentration of methacholine that caused a 20% fall in FEV(1) were dog (P =.003), Alternaria (P =.01), and cat (P =.05). Children sensitive to any one of the aeroallergens tested were compared for the presence or absence of exposure to that allergen at the time that the methacholine challenge was performed. Those who were sensitive and exposed to weed and cat had greater methacholine sensitivity than those similarly sensitive but not exposed (P =.003 and P =.02, respectively).

CONCLUSIONS

Sensitivity to dog or cat dander or Alternaria by skin testing was associated with increased bronchial responsiveness but not decreased lung function in children with mild to moderate asthma. These findings support the important role that sensitization to certain allergens plays in modulating bronchial responsiveness.

Asthma knowledge, roles, functions, and educational needs of school nurses

In October 1997, 790 school nurses in Maryland and the District of Columbia were surveyed to determine their attitudes, knowledge, and beliefs about asthma. Results for 550 (70%) nurses indicated school nurses possess a generally appropriate level of knowledge concerning asthma, and most asthma myths have been replaced with knowledge. However, school nurses also have varied responsibilities that affect their ability to provide health education and support services to children with asthma at school. Little time is available for a proactive role. Concerns about the criteria and follow-up for delegating medication administration within the school setting were reported. A lack of communication existed with parents about the child's asthma. Open communication between school nurses and the family is recommended to establish a partnership and improve asthma management outcomes. In addition, school policies and procedures should be updated to meet the demands of children with asthma.

Medications used by children with asthma living in the inner city

OBJECTIVE

The purpose of the study was to examine medication use reported by families participating in an urban school-based community intervention program and to relate this use to other social and medical variables.

DESIGN

The design of the study was a cross-sectional questionnaire survey.

SETTING

Patients and their families recruited from elementary schools in a community setting were interviewed between December 1991 and January 1992.

PARTICIPANTS

A total of 508 children with asthma were identified by school health records and teacher surveys. Their families confirmed the diagnosis and agreed to enter the study. Questionnaires were completed by 392 families.

INTERVENTION

The 392 families participated in a controlled trial of asthma education after providing the data that are the basis of this report.

RESULTS

More than half of the children took two or more medications for asthma. Thirty-one percent took theophylline alone or in combination with an adrenergic agent; 11% took some form of daily antiinflammatory medication, either cromolyn (8%) or inhaled steroids (3%). The pattern of medication use related to measures of severity and to regular visits to physicians or nurses. In general, however, children were undermedicated. A total of 78 children (20%) reported no medication or over-the-counter medication use, although 37% reported asthma severe enough to be associated with >/=20 days of school missed per month, and 37% had had an emergency room visit for asthma in the past 6 months. More than half of children >/=9 years old supervised their own medication.

CONCLUSIONS

We concluded that undermedication is common in poor children with asthma living in urban areas. Antiinflammatory medications are used less commonly than in the general population, and theophylline is used more often. School children may be likely to supervise their own medication.

Moving health care education into the community

The A+ Asthma Club, an educational program developed for elementary school children in inner-city schools, is offered through a series of six sessions during school hours with an additional three booster sessions. This article describes how the program was designed, its theoretical basis, the curriculum and its staffing.

Adherence issues in clinical practice

To combat the millions of days of restricted activity and the billions of dollars spent in respiratory clinical practice, national health objectives are targeting people with asthma. Research data depict nurses and other health care providers as encountering patients with asthma and allergies who do not adhere to their medical and nursing care management plans. The skills and success with which these professional caregivers are able to assist these patients depends on an understanding of how to measure and evaluate compliance and adherence issues. In turn, this implementation of effective strategies for optimal patient outcomes can be actualized. Patient-related, practice-related, and health care provider-related factors must be considered to ensure that patients get the best chance to succeed and to be compliant. Achieving adherence with regimens not only reduces health care expenditures but ultimately results in patients' reaching their highest level of wellness.

Controlling allergies by assessing risks in the home

Nurses and other health care providers will encounter children with allergies and asthma in virtually all practice sites. The skills with which they are able to assist these children and their families will depend on their understanding of the precipitating allergens and the most economical, feasible, and effective ways to reduce exposure to them.

Social factors associated with behavioral problems in children with asthma

The objective of this study was to describe the proportion of children with a behavior problem and examine which independent variables are associated with the presence of a behavior problem in a group of 392 inner-city children with asthma. Data on child asthma symptoms, medication use, health-care utilization, and school absences were obtained from the parent during a structured telephone interview. Included in the interview was a measure of behavior problems and social support questions. Children classified with a high level of asthma symptoms were more than twice as likely to experience a behavior problem than children classified with a low level of asthma symptoms (P = 0.002). Use of theophylline medication was not correlated with behavior problems (P = 0.45). Significant variables were low level of social support and high or moderate level of asthma symptoms. We have identified a group of children at risk for behavior problems, specifically in families that lack adequate social and financial resources.

Mite allergen control with acaricide fails

BACKGROUND

We compared the effects of an acaricide, benzyl benzoate, with the effects of baking soda control applied to bedroom and living room carpets on house dust mite allergen levels, lung function, and medication use in 12 adult patients with asthma for 12 months.

METHODS

This was a randomized, double-blind, placebo-controlled study. Patients were enrolled from the allergy clinic of a large tertiary care center in a metropolitan area. All patients had positive dust mite puncture test results. Six patients used benzyl benzoate, and six used baking soda. Other aggressive mite control measures were implemented uniformly in each group. Subjects were to make two carpet applications, at baseline and at 6 months according to the manufacturer's recommendations. Dust samples were collected in bedroom and living room carpets at 0, 3, 6, 9, and 12 months; and quantities of Der p I and Der f I allergens were determined. Spirometry was done every 3 months, and peak flow rates were recorded for 10 days after each dust sampling.

RESULTS

There were no significant differences in mean allergen levels between the two groups over time at either site. There were no significant changes in lung function or medication use for either group.

CONCLUSIONS

Benzyl benzoate powder applications may not be effective when done according to manufacturer's instructions. Further studies are necessary to test effectiveness when applied more frequently and for longer periods.

Use of community health workers with inner-city children who have asthma

Use of community health workers (CHWs) to obtain health, social, and environmental information from African-American inner-city children with asthma was one component of a larger intervention study designed to reduce morbidity in African-American children with asthma. A subset of 140 school-aged children with asthma was recruited and enrolled in a program to receive home visits by CHWs for the purposes of obtaining medical information and teaching basic asthma education to the families. Data obtained by the CHWs revealed low inhaled steroid use, high beta 2 agonist use, frequent emergency-room visits, decreased primary-care visits, and increased allergen and irritant exposure. Appropriately recruited and trained CHWs are effective in obtaining useful medical information from inner-city families with children with asthma and providing basic asthma education in the home.

Home environmental risk factors in urban minority asthmatic children

Urban minority families with children with asthma often live in homes with allergen and irritant exposures harmful to these children. We enrolled 392 African-American asthmatic children, male and female, aged 5 to 12, from 42 schools in Washington, DC and Baltimore, MD. The project is designed to test the effectiveness of school-based asthma education interventions, community-based asthma health workers' programs, and the combination on these children. Baseline telephone interviews were carried out with the primary home care-givers for demographic data and for environmental home exposures that exacerbated asthma. Exposures stated to cause wheezing in the children were cigarette smoke in 72%, dust in 53%, cats in 34%, dogs in 27%, and roach exposure in 15%. Fifty-six percent of children live with cigarette smoke exposure, 73% of which is from mothers. This was a highly symptomatic group with 44% reporting two or more days per week of restricted activity and 62% reporting two or more episodes of night symptoms per week. Those with mattress covers on beds had significantly fewer emergency department visits in the past 6 months than those without covers. Over one-third of parents reported children taking two bronchodilators without anti-inflammatory agents. Less than 20% were reported using anti-inflammatory medications. Decreasing asthma severity in this population entails the prevention and control of known risk factors in the home environment. Emphasis must be placed on cigarette smoking cessation programs, covering mattresses, and dust and animal dander control. Primary care physicians require education on the role of anti-inflammatory medications.

Allergen avoidance in the treatment of dust-mite allergy and asthma

House-dust-mite allergen is one of the primary causes of asthma. In many instances, asthma is an immunoglobulin gamma E mediated atopy (i.e., allergen-specific hypersensitivity) that leads to non-specific bronchial hyper-reactivity and subsequent symptom manifestations. These symptoms may range from an annoying cough to full-blown respiratory failure. Allergen-avoidance measures should be a primary mode of treatment for atopic asthmatics. This article focuses on the dust-mite allergen and its relationship to asthma. It details specific avoidance measures that should be implemented by the majority of asthmatics. Studies are cited that support the aggressive use of these measures to decrease allergen exposure, and to subsequently prevent or significantly reduce asthma symptoms. When health care providers have a better understanding of avoidance measures and the rationale underlying their use, these measures are more likely to be valued and given greater emphasis in education and treatment plans. Renewed emphasis on an immunomodulatory approach to asthma treatment may help to reverse the rise in asthma morbidity and mortality rates.