Selective Provision of Asthma Self-Management Tools to Families


Published online April 1, 2008
PEDIATRICS Vol. 121 No. 4 April 2008, pp. e900-e905 (doi:10.1542/peds.2007-1559)

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ARTICLE

Selective Provision of Asthma Self-Management Tools to Families

Michael D. Cabana, MD, MPHa,b,c, D. Curt Chaffin, MDd, Leah G. Jarlsberga, Shannon M. Thyne, MDa and Noreen M. Clark, PhDe

a Department of Pediatrics
b Department of Epidemiology and Biostatistics
c Institute for Health Policy Studies, University of California, San Francisco, California
d Division of Allergy, Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan
e Center for Managing Chronic Disease, University of Michigan, Ann Arbor, Michigan

OBJECTIVE. Providing asthma education in a primary care setting can be challenging because of time and resource constraints. The purpose of this work was to determine factors associated with the provision of different asthma self-management tools.

METHODS. We conducted a cross-sectional survey with 896 parents of children with asthma (age 2–12 years). We collected information regarding demographics and asthma care, including parent receipt of an asthma action plan, a symptom diary, and asthma information materials; whether an asthma management plan was sent to the child’s school; and whether the physician reviewed written instructions on use of a metered-dose inhaler. We used multivariate logistic regression methods to determine factors associated with receipt of different asthma self-management tools controlling for demographic factors.

RESULTS. For families where parents only completed high school, there was greater likelihood of receipt of an asthma action plan and physician review of written instructions about how to use an inhaler. For families with a household income less than twice the poverty line, there was greater likelihood of receipt of an asthma action plan, the physician sending a letter to the child’s school regarding the child’s asthma, and receipt of an asthma symptom diary.

CONCLUSIONS. In our sample, primary care pediatricians do not routinely provide asthma education in accordance with National Heart, Lung, and Blood Institute asthma guidelines and “triage” which families receive additional asthma education. We believe that the use of targeted asthma education is a symptom of the limited time and competing demands during a typical visit. As a result, those involved in quality improvement need to help physicians become more efficient and effective at providing asthma education within such time constraints or develop alternative systems of providing asthma education.

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Escepticemia


Escepticemia


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Colesteroles

05 Oct 2007

Sobre las múltiples caras de una molécula demonizada

Al colesterol le ha tocado el papel de malo en esa película sobre la salud cuyo guión lo escriben día a día y mano a mano investigadores, médicos y medios de comunicación. De poco sirve recordar que es una molécula esencial para la vida, pues tanto el papel de malo como el de bueno (piénsese, por ejemplo, en las vitaminas o los antioxidantes) parecen imprimir carácter. Aunque los guionistas diferencian un colesterol bueno de otro malo, la audiencia no está para refinamientos. Algunos creen que la cruzada contra el colesterol es desproporcionada, y llaman la atención sobre algunos estudios para revisar la consideración de una sustancia de la que todavía queda mucho por conocer.

En uno de estos estudios, publicado en la revista Pediatrics de octubre, se confirma que los niveles elevados de colesterol se asocian con un mayor riesgo de partos prematuros. Pero lo sorprendente es que los niveles bajos de colesterol también se asociaban con un mayor riesgo de partos prematuros o el nacimiento de bebés de bajo peso. De las 1.058 mujeres evaluadas, tuvieron un parto prematuro el 5% de las que tenían niveles de colesterol moderado (de 159 a 261 mg/dl) frente al 21% de las que tenían unos niveles bajos de colesterol sanguíneo (menos de 159 mg/dl). Probablemente son pocas mujeres para sacar conclusiones firmes, pero el estudio apunta que tan perjudiciales pueden ser los niveles demasiado altos como los demasiado bajos durante el embarazo, un periodo en el que este lípido es esencial para el desarrollo de la placenta y del propio bebé, incluido su cerebro. Otra investigación, publicada en el número del 31 de julio en el Journal of the American College of Cardiology, ha sacado a la luz otra sorprendente asociación epidemiológica: los bajos niveles de colesterol malo se asocian con un mayor riesgo de cáncer. Los investigadores pretendían averiguar por qué las estatinas usadas para bajar el colesterol producen algunos efectos secundarios, en especial la lesión de las células hepáticas y musculares, y se encontraron con un caso adicional de cáncer por cada 1.000 pacientes con bajos niveles de colesterol LDL, en relación con las personas con niveles de colesterol superiores. Aunque está por demostrar que la reducción del colesterol produzca cáncer, este estudio plantea al menos algunas dudas sobre el buen uso de las estatinas.

La consideración de los niveles elevados de colesterol como uno de los principales factores de riesgo cardiovascular está sobradamente demostrada y no va a cambiar por unos pocos datos. Sin embargo, estos y otros estudios similares sí deberían servir de alerta ante el encarnizamiento terapéutico para reducir los niveles de colesterol a toda costa, un objetivo que parece importante conseguir en prevención secundaria pero que en prevención primaria podría ser discutible. El colesterol, como la glucosa o cualquier otra molécula esencial para la vida, no es ni bueno ni malo si está dentro de unos parámetros. Pero las demonizaciones suelen tener efectos secundarios.

Intussusception After Administration of the Rhesus Tetravalent Rotavirus Vaccine (Rotashield): The Search for a Pathogenic Mechanism.


Maureen Lynch, Wun-Ju Shieh, Joseph S. Bresee, Kathleen M. Tatti, Jon R. Gentsch, Tara Jones, Baoming Jiang, Erik Hummelman, Christopher M. Zimmerman, Sherif R. Zaki, and Roger I. Glass Intussusception After Administration of the Rhesus Tetravalent Rotavirus Vaccine (Rotashield): The Search for a Pathogenic Mechanism. Pediatrics, May 2006; 117: e827 – e832.

OBJECTIVES. The rhesus tetravalent rotavirus vaccine (RRV) was withdrawn from the routine program for childhood immunization in the United States because of the rare and unexpected occurrence of intussusception in the 2-week period after
administration of the first dose.
METHODS. To search for the pathogenesis of this association, we compared the pathology of surgical specimens from infants who had surgical reduction of their intussusceptions within 2 weeks of receiving the vaccine (case patients; n _ 8) with the pathology of specimens from children who had surgery _2 weeks after
immunization (n _ 6) or who had never been immunized (n _ 26). Tissue was examined for evidence of the vaccine strain of rotavirus by reverse transcriptasepolymerase chain reaction (RT-PCR), in situ hybridization, and immunohistochemical
staining.
RESULTS. RRV was identified by RT-PCR in tissue samples from 7 of the 8 case patients and in 2 of the 6 children who received the vaccine at a more distant time (29 and 58 days before surgery), but it was not identified in samples from any of the nonvaccinated children. No evidence of rotavirus tissue involvement was
detected in any of the children by in situ hybridization or immunohistochemical staining. Pathologic evidence (for example, inclusion bodies, smudge cells) of adenovirus infection was present in 35% of the 37 specimens examined by routine
staining and immunohistochemistry.
CONCLUSIONS. The fact that RRV was detected by RT-PCR but not by either of the other assays could be explained by RRV being present in the lumen of the gut but not in the tissues of appendix, ileum, or Peyer’s patches. The Peyer’s patches were not hyperplastic, and we could not establish the pathogenic mechanism for this association.

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