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Beliefs about medications in asthmatic children presenting to emergency department and their parents.

The aim of our study was to assess the relationship of beliefs about medications questionnaire (BMQ) scores of asthmatic children presenting to the emergency department and their parents with asthma severity parameters.

METHODS: Eighty children with asthma presenting to the emergency department with acute asthma findings and their mothers were enrolled in the study. BMQ was applied to all parents and children older than 7 years of age. Asthma severity clinical score was recorded.

RESULTS: The mean age of children (39 males, 41 females) was 49.1 ± 42.8 months. Parent necessity and concerns scores were significantly correlated with their counterparts in children (r = 0.74 and r = 0.60, respectively). Difference between necessity and concerns scores was correlated between parents and children (r = 0.60, p = .002). Child's necessity score was significantly correlated with respiratory severity score (r = -0.43, p = .036).

CONCLUSION: BMQ necessity and concerns scores of asthmatic children in the emergency department and their parents are correlated with asthma severity. Although not assessed in this study, this result may be attributed to the relationship of necessity and concerns with drug adherence. Therefore, increasing the knowledge about asthma medications in asthmatic children and their parents may contribute to asthma control and decrease their emergency visits with acute asthma findings.

Measurement characteristics of the pediatric asthma health outcome measure.

The Pediatric Asthma Health Outcome Measure (PAHOM) was designed to measure quality-adjusted life years (QALYs) in children with asthma. Our objective was to compare parent- and child-reported PAHOM scores to each other, to parent-reported scores on the Juniper Asthma Control Questionnaire (ACQ), and to physician-rated asthma control.

METHODS: A convenience sample of primarily African-American parent-child dyads (N = 261) was recruited from asthma clinics between May 2008 and May 2010. Correlations and differences in scores between the instruments and respondents were compared across variables of interest. The sensitivity and specificity of each, relative to physician-rated asthma control, were estimated.

RESULTS: Mean (SD) parent- and child-reported PAHOM scores were significantly different, 0.91 (0.13) and 0.95 (0.08), respectively, (p < .01) and were weakly correlated (0.24). Parent-reported PAHOM and parent-reported ACQ, 5-item version (ACQ5) scores were moderately correlated (-0.69). Both the parent- and child-reported PAHOM scores distinguished between physician-rated well-controlled and not well-controlled asthma (p < .01 and p < .01, respectively). When compared with physician-rated asthma control, the areas under the receiver operating characteristic (ROC) curves for the parent-reported PAHOM and the ACQ5 were similar (p = .11), but both performed better than the child-reported PAHOM (both p < .01). Discussion. The validity of the PAHOM is supported by its moderate correlation with the ACQ and its association with physician-rated asthma control. Although intended to be administered to children, parent-reported scores were better predictors of physician-rated asthma control.

CONCLUSIONS: A validation study in a more economically and ethnically diverse population is needed. Until then, we recommend the PAHOM to be administered to both parents and children.

Time to seeking emergency department care for asthma: self-management, clinical features at presentation, and hospitalization.

Understanding the events preceding emergency department (ED) asthma visits can guide patient education regarding managing exacerbations and seeking timely care. The objectives of this analysis were to assess time to seeking ED care, self-management of asthma exacerbations, and clinical status on presentation.

METHODS: A total of 296 patients was grouped according to time to seeking ED care: ≤1 day (22%), 2-5 days (44%), and >5 days (34%) and was compared for clinical and psychosocial characteristics. Asthma severity at presentation was obtained from patient report with the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ) and from physicians' ratings using decision to hospitalize as an indicator of worse status.

RESULTS. Mean age was 44 years, 72% were women, 10% had been in the ED in the prior week, and 28% came to the ED by ambulance. Patients who waited longer were more likely to be older, have more depressive symptoms, and have been in the ED in the prior week. They also were more likely to have taken more medications, but they were not more likely to have visited or consulted their outpatient physicians. Patients who waited longer reported worse ACQ (p < .0001) and AQLQ (p = .0002) scores and were more likely to be hospitalized for the current exacerbation (odds ratio 1.9, 95% CI 1.1, 3.2, p = .03).

CONCLUSIONS: Patients who waited longer to come to the ED had worse asthma on presentation, had more functional limitations, and were more likely to be hospitalized. The ability to gauge severity of exacerbations and the use of the ED in a timely manner are important but often overlooked are self-management skills that patients should be taught.

Ventilatory and cardiocirculatory exercise profiles in COPD: the role of pulmonary hypertension.

Pulmonary hypertension (PH) is a well-recognized complication of chronic obstructive pulmonary disease (COPD). The impact of PH on exercise tolerance is largely unknown. We evaluated and compared the circulatory and ventilatory profiles during exercise in COPD-patients without PH, with moderate PH and with severe PH.

METHODS:Forty-seven patients, GOLD-stages II-IV, underwent cardiopulmonary exercise testing and right heart catheterisation at rest and during exercise. Patients were divided into three groups based on mean pulmonary artery pressure at rest: no PH (mPAP<25 mmHg), moderate PH (mPAP 25-39 mmHg) and severe PH (mPAP≥40 mmHg). Mixed venous oxygen saturation (SvO(2)) was used for evaluating the circulatory reserve. Arterial carbon dioxide tension (PaCO(2)) and the calculated breathing reserve were used for evaluation of the ventilatory reserve.

RESULTS:Patients without PH (n=24) had an end-exercise SvO(2) of 48±9%, an increasing PaCO(2) with exercise and a breathing reserve of 22±20%. Patients with moderate PH (n=14) had an exercise SvO(2) of 40±8%, an increasing PaCO(2) and a breathing reserve of 26±15%. Patients with severe PH (n=9) had a significantly lower end- exercise SvO(2) (30%±6), a breathing reserve of 37±11% and an absence of PaCO(2) accumulation.

CONCLUSION:Patients with severe PH showed an exhausted circulatory reserve at the end of exercise. A profile of circulatory reserve in combination with ventilatory impairments was found in COPD-patients with moderate PH or no PH. The results suggest that pulmonary vasodilation might only improve exercise tolerance in COPD patients with severe PH.

Utility of draining pleural effusions in mechanically ventilated patients.

PURPOSE OF REVIEW: Pleural effusions are prevalent in mechanically ventilated patients, and clinicians frequently consider draining the effusions. It is controversial whether patients benefit from pleural drainage in terms of either physiological or clinical outcomes.

RECENT FINDINGS: Pleural drainage may be undertaken for a variety of reasons. Effusions are an important potential source of infection in patients with undifferentiated sepsis. Pleural drainage may improve hypoxemia or lung mechanics, but the physiological response depends on a complex interplay between lung and chest wall compliance, applied positive end-expiratory pressure and drainage volume. Pleural effusions may be associated with significant cyclic lung recruitment and collapse during tidal ventilation. Because effusions are primarily accommodated by descent of the diaphragm, they can also impair diaphragm mechanics significantly. There is very limited data in the literature to support the use of pleural drainage to accelerate liberation from mechanical ventilation, and there are no randomized controlled trials published to date.

SUMMARY: Pleural drainage may benefit certain patient populations based on individual physiological considerations, but randomized controlled trials evaluating the impact on weaning outcomes are lacking. Future research efforts should focus on identifying patient populations most likely to benefit and clarify the mechanisms by which weaning may be accelerated after pleural drainage.

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