Chris Gillette

Environmental Mercury and Its Toxic Effects

Mercury exists naturally and as a man-made contaminant. The release of processed mercury can lead to a progressive increase in the amount of atmospheric mercury, which enters the atmospheric-soil-water distribution cycles where it can remain in circulation for years. Mercury poisoning is the result of exposure to mercury or mercury compounds resulting in various toxic effects depend on its chemical form and route of exposure. The major route of human exposure to methylmercury (MeHg) is largely through eating contaminated fish, seafood, and wildlife which have been exposed to mercury through ingestion of contaminated lower organisms. MeHg toxicity is associated with nervous system damage in adults and impaired neurological development in infants and children. Ingested mercury may undergo bioaccumulation leading to progressive increases in body burdens. This review addresses the systemic pathophysiology of individual organ systems associated with mercury poisoning. Mercury has profound cellular, cardiovascular, hematological, pulmonary, renal, immunological, neurological, endocrine, reproductive, and embryonic toxicological effects.

Provider Demonstration and Assessment of Child Device Technique During Pediatric Asthma Visits

OBJECTIVE: The purposes of this study were to (a) describe the extent to which children use metered dose inhalers, turbuhalers, diskuses, and peak flow meters correctly, and (b) investigate how often providers assess and demonstrate use of metered dose inhalers, turbuinhalers, diskuses, and peak flow meters during pediatric asthma visits. PATIENTS AND METHODS: Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at 5 pediatric practices in nonurban areas of North Carolina. All of the medical visits were audiotape-recorded. Children were interviewed after their medical visits, and their device technique was observed and rated by the research assistants. RESULTS: Of the patients, 296 had useable audiotape data. Only 8.1% of children performed all of the metered dose inhaler steps correctly. Older children were more likely to get more of the metered dose inhaler steps correct. Of the children, 22% performed all of the diskus steps correctly, 15.6% performed all of the turbuhaler steps correctly, and 24% performed all of the peak flow meter steps correctly. The majority of providers did not demonstrate or assess child use of metered dose inhalers, turbuhalers, diskuses, or peak flow meters during pediatric asthma visits. CONCLUSIONS: There is a need for providers to demonstrate proper asthma medication and monitoring device techniques to children and to have children demonstrate to proficiency. The 2007 National Heart, Lung, and Blood Institute expert panel report on the diagnosis and management of asthma encourages providers to educate children on these techniques.

Communication during Pediatric Asthma Visits and Child Asthma Medication Device Technique 1 Month Later

Objective. This study investigated how provider demonstration of and assessment of child use of asthma medication devices and certain aspects of provider–patient communication during medical visits is associated with device technique 1 month later. Methods. Two hundred and ninety-six children aged 8–16 years with persistent asthma and their caregivers were recruited at five North Carolina pediatric practices. All of the medical visits were audio-tape recorded. Children were interviewed 1 month later and their device technique was observed and rated. Results. If the provider asked the child to demonstrate metered dose inhaler technique during the medical visit, then the child was significantly more likely to perform a greater percentage of inhaler steps correctly 1 month later. Children with higher asthma management self-efficacy scores were significantly more likely to perform a greater percentage of diskus steps correctly. Additionally, children were significantly more likely to perform a greater percentage of diskus steps correctly if the provider discussed a written action plan during the visit. Children were significantly more likely to perform a greater percentage of turbuhaler steps correctly if they asked more medication questions. Conclusions. Providers should ask children to demonstrate their inhaler technique during medical visits so that they can educate children about proper technique and improve child asthma management self-efficacy. Providers should encourage children to ask questions about asthma medication devices during visits and they should discuss asthma action plans with families.

Child- and caregiver-reported problems and concerns in using asthma medications

Objectives. The purpose of the study was to (a) describe the types of medication problems/concerns that asthmatic children and their caregivers reported and (b) examine the association between child and caregiver demographic and sociocultural characteristics and reported asthma medication problems/concerns. Methods. Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in nonurban areas of North Carolina. Children were interviewed and caregivers completed questionnaires after their childs medical visits about reported problems/concerns in using asthma medications. Multivariate logistic regression was used to analyze the data. Results. Three hundred and twenty children were recruited. Eighty-seven percent of the children reported a problem or concern in using their asthma medications. Approximately 40% of children reported side effects and a similar percent stated that it was hard to understand the directions on their medicines; in addition 60% reported that it was hard to remember when to take their medicines. Females and non-White children were significantly more likely to report they were not sure how to use an inhaler than males and White children. Younger and non-White children were significantly more likely to report it was hard to understand the directions on their medicines than older and White children. Caregivers were most likely to report that their children were bothered a little or a lot by side effects (31%) and a similar percent (29%) were not sure their children were using their inhalers properly. Caregivers without Medicaid were significantly more likely to report difficulty paying for the asthma medications. Conclusions. Medication side effects are a significant problem area for both children and their caregivers, and inhaler skill–based training is particularly needed for non-White children. Health care providers should discuss with children and their caregivers the types of problems/concerns that children may have when using their asthma medications.

Communication and education about triggers and environmental control strategies during pediatric asthma visits

OBJECTIVE To determine the extent to which providers, caregivers, and pediatric asthma patients discussed environmental trigger control during primary care visits, and any demographic characteristics associated with having these discussions. METHODS Children ages 8-16 with persistent asthma and their caregivers were recruited at five pediatric practices in non-urban areas of North Carolina. All of the medical visits were audio-tape recorded. We administered questionnaires to the childs caregiver following the visit. RESULTS Two hundred and ninety-six patients had useable audio-tape data. Providers typically discussed at least one type of asthma trigger during these visits (86% of visits). The most common discussions were about exercise (70%), the weather/season (42%), and allergies/pollen (35%). Environmental control strategies were discussed less frequently (27% of visits). Providers educated the patient and their caregiver about environmental control strategies during 14% of the visits. CONCLUSION Although providers frequently discuss some environmental triggers and provide education, there is room for more comprehensive discussions of these issues, which may contribute to decreased asthma exacerbations. PRACTICE IMPLICATIONS Providers, or alternatively, asthma health educators, should devote more time to discussing environmental asthma triggers and control strategies with pediatric asthma patients and their families, as they are important components of overall asthma control.

Caregiver rating of provider participatory decision-making style and caregiver and child satisfaction with pediatric asthma visits

OBJECTIVE The purpose of this study was to examine the relationship between caregiver ratings of provider use of a participatory decision-making style and caregiver and child satisfaction with their pediatric asthma visits. METHODS Children ages 8 through 16 with persistent asthma and their caregivers were recruited at five pediatric practices. Children were interviewed and caregivers completed questionnaires after their childs medical visits. Generalized estimating equations were used to analyze the data. RESULTS Three hundred and twenty children were recruited. Caregivers were significantly more satisfied with providers who they perceived as using more of a participatory decision-making style (beta=17.80, p<0.001). Children (beta=-0.10, p<0.05) and caregivers (beta=-0.21, p<0.01) were significantly more satisfied with younger providers. Children were significantly more satisfied with providers who knew them better as a person (beta=2.87, p<0.001). CONCLUSIONS Caregivers were more satisfied with providers who they perceived as involving them more during treatment decisions made during pediatric asthma visits. PRACTICE IMPLICATIONS Providers should attempt to use a more participatory decision-making style with families during pediatric asthma visits.

Provider Discussion, Education, and Question-Asking about Control Medications during Pediatric Asthma Visits

Background. Few studies have explored how providers communicate about control medications during pediatric asthma visits. Objectives. The purpose of this study was to: (a) describe the extent to which providers discuss, educate, and ask children and their caregivers questions about control medications and (b) examine how child, caregiver, and provider characteristics are associated with provider communication about control medications during pediatric asthma visits. Methods. Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in nonurban areas of North Carolina. After audio-tape recording medical visits, caregivers completed questionnaires and children were interviewed. Generalized estimating equations were used to analyze the data. Results. Providers educated families about control medications during 61% of the visits, and they asked questions about control medications during 67% of visits. Providers were significantly more likely to discuss control medications if a child was taking a control medication, if the child had moderate to severe persistent asthma, and if the child was present for an asthma-related visit. Conclusion. Providers need to educate and ask more questions of families about side effects and how well control medications are working.

Inhaler Technique in Children With Asthma: A Systematic Review

BACKGROUND Pediatric asthma is an important public health problem worldwide. The primary methods of medication delivery are inhalation devices. OBJECTIVES This systematic review examined: 1) what is the prevalence of correct inhaler technique among children with asthma, 2) are educational interventions associated with improved rates of correct inhalation technique, and 3) is improved inhaler technique associated with improved asthma outcomes? DATA SOURCES We included experimental and observational studies through searches of PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL Complete, and clinicaltrials.gov. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS Studies were eligible for this review if at least 1 outcome measure of the study included and reported results of child/adolescent inhaler technique. STUDY APPRAISAL AND SYNTHESIS METHODS The following information was extracted from each included study: study design (experimental vs observational), and outcomes data. The Downs and Black checklist was used to appraise study quality. RESULTS Twenty-eight studies were eligible for inclusion. We found that inhaler technique is generally very poor among children, but is better when children use their metered-dose inhalers (MDIs) with spacers. Technique in using turbuhalers and diskus inhalers is better than in MDI, but still poor. Counseling children on correct inhaler technique was associated with improved technique among children in multiple studies. LIMITATIONS We examined articles published in English. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Inhaler technique in children is generally poor. Physicians and other members of the health care team should instruct children and their caregivers on the proper use of their inhalation devices at every opportunity and correct mistakes when made to ensure effective medication delivery. REGISTRY This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO CRD42015025070 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015025070).

Discussions between medical providers and children/caregivers about the benefits of asthma-control medications

OBJECTIVES To describe the content of discussions between general pediatric providers and children and their caregivers about the benefits of asthma-control medication; describe the extent to which these discussions occur; and examine factors that are associated with medication benefit discussions. DESIGN Cross-sectional secondary analysis of audiotaped medical visits. SETTING Five primary care pediatric clinics in North Carolina. PARTICIPANTS 35 pediatric providers and 248 children with persistent asthma and their caregivers. MAIN OUTCOME MEASURES Presence of discussion about benefits associated with asthma-control medications. RESULTS Providers discussed benefits associated with asthma-control medications during 56% of medical visits. Benefits were more likely to be discussed when the child was younger and when medication adherence was discussed during the visit. When providers discussed benefits of asthma-control medications, they were most likely to ask questions and make statements regarding symptom control/prevention. CONCLUSION General pediatric medical providers often do not discuss the benefits of asthma-control medications. Pharmacists could fill this information gap by counseling both children and their caregivers about benefits that a child with asthma can expect as a result of treatment.

How Often Do Providers Discuss Asthma Action Plans With Children? Analysis of Transcripts of Medical Visits

Objective. To examine how often providers discussed asthma action plans with children and their caregivers and child, clinical, and provider characteristics that were associated with those discussions. Method. This was a cross-sectional analysis of audio-recorded visits between 35 general pediatric providers and 260 children (8-16 years old) with asthma and their caregivers. The visits were transcribed into text. The transcripts were coded for discussions about written asthma action plans. Results. Providers discussed written asthma action plans with 21.0% of children and caregivers. Providers were significantly more likely to discuss asthma action plans when the child was enrolled in Medicaid, the visit was asthma related, the visit was longer, the provider was not White, or more provider education. Conclusion. In our sample, providers rarely discussed action plans with children and their caregivers. Providers should discuss asthma action plans with every child with persistent asthma and their caregivers and revise them regularly.