Harsha Kumar

Acetaminophen versus Ibuprofen in Young Children with Mild Persistent Asthma.

BACKGROUND Studies have suggested an association between frequent acetaminophen use and asthma-related complications among children, leading some physicians to recommend that acetaminophen be avoided in children with asthma; however, appropriately designed trials evaluating this association in children are lacking. METHODS In a multicenter, prospective, randomized, double-blind, parallel-group trial, we enrolled 300 children (age range, 12 to 59 months) with mild persistent asthma and assigned them to receive either acetaminophen or ibuprofen when needed for the alleviation of fever or pain over the course of 48 weeks. The primary outcome was the number of asthma exacerbations that led to treatment with systemic glucocorticoids. Children in both groups received standardized asthma-controller therapies that were used in a simultaneous, factorially linked trial. RESULTS Participants received a median of 5.5 doses (interquartile range, 1.0 to 15.0) of trial medication; there was no significant between-group difference in the median number of doses received (P=0.47). The number of asthma exacerbations did not differ significantly between the two groups, with a mean of 0.81 per participant with acetaminophen and 0.87 per participant with ibuprofen over 46 weeks of follow-up (relative rate of asthma exacerbations in the acetaminophen group vs. the ibuprofen group, 0.94; 95% confidence interval, 0.69 to 1.28; P=0.67). In the acetaminophen group, 49% of participants had at least one asthma exacerbation and 21% had at least two, as compared with 47% and 24%, respectively, in the ibuprofen group. Similarly, no significant differences were detected between acetaminophen and ibuprofen with respect to the percentage of asthma-control days (85.8% and 86.8%, respectively; P=0.50), use of an albuterol rescue inhaler (2.8 and 3.0 inhalations per week, respectively; P=0.69), unscheduled health care utilization for asthma (0.75 and 0.76 episodes per participant, respectively; P=0.94), or adverse events. CONCLUSIONS Among young children with mild persistent asthma, as-needed use of acetaminophen was not shown to be associated with a higher incidence of asthma exacerbations or worse asthma control than was as-needed use of ibuprofen. (Funded by the National Institutes of Health; AVICA ClinicalTrials.gov number, NCT01606319.).

Mallampati score and pediatric obstructive sleep apnea

RATIONALE Pediatric obstructive sleep apnea (OSA) is common, and a delay in diagnosis can lead to significant morbidity. Polysomnography (PSG) is the gold standard for the diagnosis of OSA. However, difficulty accessing PSG due to the relative shortage of sleep centers with pediatric expertise can lead to a delay in the diagnosis and management of OSA. OBJECTIVES To assess the utility of Mallampati score (sitting and supine) in predicting the presence and severity of OSA in children. METHODS A retrospective study of 158 children from a single pediatric sleep center. All patients had a PSG and a physical examination documenting Mallampati score. The Mallampati score, tonsillar size, age, sex, and apnea hypopnea index (AHI) were analyzed. Odds ratio of having pediatric OSA (AHI > 1) with increase in Mallampati score and tonsillar size were calculated. MEASUREMENTS AND MAIN RESULTS A significant correlation was found between Mallampati score, tonsillar size, and AHI. For every point increase in the Mallampati score, the odds ratio of having OSA increased by more than 6-fold. For every point increase in tonsillar size, the odds ratio of having OSA increased by more than 2-fold. CONCLUSIONS Mallampati score and tonsillar size are independent predictors of OSA. Oral examination including Mallampati score and tonsillar size should be considered when evaluating a patient for OSA. They can be used to prioritize children who may need PSG.

Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations

BACKGROUND Asthma exacerbations occur frequently despite the regular use of asthma‐controller therapies, such as inhaled glucocorticoids. Clinicians commonly increase the doses of inhaled glucocorticoids at early signs of loss of asthma control. However, data on the safety and efficacy of this strategy in children are limited. METHODS We studied 254 children, 5 to 11 years of age, who had mild‐to‐moderate persistent asthma and had had at least one asthma exacerbation treated with systemic glucocorticoids in the previous year. Children were treated for 48 weeks with maintenance low‐dose inhaled glucocorticoids (fluticasone propionate at a dose of 44 μg per inhalation, two inhalations twice daily) and were randomly assigned to either continue the same dose (low‐dose group) or use a quintupled dose (high‐dose group; fluticasone at a dose of 220 μg per inhalation, two inhalations twice daily) for 7 days at the early signs of loss of asthma control (“yellow zone”). Treatment was provided in a double‐blind fashion. The primary outcome was the rate of severe asthma exacerbations treated with systemic glucocorticoids. RESULTS The rate of severe asthma exacerbations treated with systemic glucocorticoids did not differ significantly between groups (0.48 exacerbations per year in the high‐dose group and 0.37 exacerbations per year in the low‐dose group; relative rate, 1.3; 95% confidence interval, 0.8 to 2.1; P=0.30). The time to the first exacerbation, the rate of treatment failure, symptom scores, and albuterol use during yellow‐zone episodes did not differ significantly between groups. The total glucocorticoid exposure was 16% higher in the high‐dose group than in the low‐dose group. The difference in linear growth between the high‐dose group and the low‐dose group was ‐0.23 cm per year (P=0.06). CONCLUSIONS In children with mild‐to‐moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129.)

Coping with asthma in racially and ethnically diverse urban children: The role of emotional problems in disease control

ABSTRACT This study examined cross-sectional associations among coping, mental health, and asthma outcomes in racially/ethnically diverse urban children. Children (N = 42; 65% female) ages 9 to 17 (M = 11.9) years old and their parents reported on the child’s coping, emotional and conduct problems, asthma control, and school missed due to asthma. Higher child and parent reported secondary control coping was correlated with fewer mental health problems and better child reported asthma control. Child reported emotional problems partially accounted for associations between child and parent reported secondary control coping and child reported asthma control. Secondary control coping may improve asthma by reducing emotional difficulties.

A computable phenotype for asthma case identification in adult and pediatric patients: External validation in the Chicago Area Patient-Outcomes Research Network (CAPriCORN)

ABSTRACT Objective: Comprehensive, rapid, and accurate identification of patients with asthma for clinical care and engagement in research efforts is needed. The original development and validation of a computable phenotype for asthma case identification occurred at a single institution in Chicago and demonstrated excellent test characteristics. However, its application in a diverse payer mix, across different health systems and multiple electronic health record vendors, and in both children and adults was not examined. The objective of this study is to externally validate the computable phenotype across diverse Chicago institutions to accurately identify pediatric and adult patients with asthma. Methods: A cohort of 900 asthma and control patients was identified from the electronic health record between January 1, 2012 and November 30, 2014. Two physicians at each site independently reviewed the patient chart to annotate cases. Results: The inter-observer reliability between the physician reviewers had a κ-coefficient of 0.95 (95% CI 0.93–0.97). The accuracy, sensitivity, specificity, negative predictive value, and positive predictive value of the computable phenotype were all above 94% in the full cohort. Conclusions: The excellent positive and negative predictive values in this multi-center external validation study establish a useful tool to identify asthma cases in in the electronic health record for research and care. This computable phenotype could be used in large-scale comparative-effectiveness trials.

Physician Perceptions of Children’s Coping With Asthma Are Associated With Children’s Psychosocial and Disease Functioning.

Introduction: Low-income, ethnic minority children disproportionately face poor asthma control, and poorly controlled asthma is related to psychosocial difficulties. This study assessed physician reports of coping in child patients and examined associations between physician reports of child coping and parent and child reports of children’s coping, psychosocial, and asthma outcomes (asthma-related stress, emotional and behavioral problems, asthma control, and school missed due to asthma). Method: Physicians reported on coping in their patients (N = 67) ages 5–17 with asthma. Parents reported on child coping, asthma-related stress, emotional and behavioral problems, asthma control, and school missed due to asthma. Children ages 9–17 provided self-reports. Results: Physicians’ reports of primary control coping (e.g., problem solving) and secondary control coping (e.g., cognitive restructuring) were not associated with parent ratings of corresponding coping strategies, but physician reports of disengagement coping (e.g., avoidance) were correlated with parent reports of disengagement and secondary control coping. Physician perceptions of higher child primary control, and lower disengagement, were correlated with less parent-reported stress, better asthma control, and for primary control, fewer partial days of school missed. Physician reports were not correlated with child reports of coping, but physician reports of disengagement were correlated with child-reported conduct problems. Discussion: Findings suggest that physician reports of child coping provide independent information from parent and child reports of coping, and could be leveraged to identify and intervene with patients who are at elevated risk for poor outcomes.

Polysomnographic Findings during Wakefulness in Joubert Syndrome

Joubert syndrome is an autosomal-recessive disorder characterized by hypotonia, brainstem and cerebellar malformations, tachypnea, apnea, congenital ataxia, oculomotor apraxia, andmental retardation (1–3). Polysomnographic (PSG) findings of tachypnea (as high as 100–200 breaths/min) alternating with prolonged apneas (as long as 1 min) are seen during wakefulness or sleep, more often during non–rapid eye movement sleep (1, 4). The onset of abnormal breathing is typically seen in the neonatal period and improves with age, usually after infancy (5). Short episodes of tachypnea are still present in some school-aged children. Figure 1.