Mona Tsoukleris

Vancomycin-associated nephrotoxicity in adult medicine patients: incidence, outcomes, and risk factors.

The prevalence of vancomycin‐associated nephrotoxicity (VAN) is reported to vary from 1.0–42.6%, with most data from critically ill patients. Evaluation of VAN among internal medicine patients is lacking. Our objectives were to determine the incidence, time‐course, outcomes, and risk factors of VAN in adult internal medicine patients.

Patterns of Inhaled Antiinflammatory Medication Use in Young Underserved Children With Asthma

BACKGROUND. Asthma guidelines advocate inhaled corticosteroids as the cornerstone treatment of persistent asthma, yet several studies report underuse of inhaled corticosteroids in children with persistent asthma. Moreover, few studies use objective pharmacy data as a measure of drug availability of asthma medications. We examined factors associated with the use of inhaled corticosteroids in young underserved children with persistent asthma using pharmacy records as their source of asthma medications. METHODS. This was a cross-sectional analysis of questionnaire and pharmacy record data over a 12-month period from participants enrolled in a randomized clinical trial of a nebulizer educational intervention. RESULTS. Although exposure to ≥1 inhaled corticosteroids refill was high at 72%, 1 of 5 children with persistent asthma had either no medication or only short-acting β agonist fills for 12 months. Only 20% of children obtained ≥6 inhaled corticosteroids fills over 12 months. Obtaining ≥3 inhaled corticosteroids fills over 12 months was significantly associated with an increase in short-acting β agonist fills and receiving specialty care in the regression models while controlling for child age, asthma severity, number of emergency department visits, having an asthma action plan, and seeking preventive care for the childs asthma. CONCLUSIONS. Overreliance on short-acting β agonist and underuse of inhaled corticosteroid medications was common in this group of young children with persistent asthma. Only one fifth of children obtained sufficient controller medication fills.

Factors Associated with Second-Hand Smoke Exposure in Young Inner-City Children with Asthma

Objectives. To examine the association of social and environmental factors with levels of second-hand smoke (SHS) exposure, as measured by salivary cotinine, in young inner-city children with asthma. Methods. We used data drawn from a home-based behavioral intervention for young high-risk children with persistent asthma post-emergency department (ED) treatment (N = 198). SHS exposure was measured by salivary cotinine and caregiver reports. Caregiver demographic and psychological functioning, household smoking behavior, and asthma morbidity were compared with child cotinine concentrations. Chi-square and ANOVA tests and multivariate regression models were used to determine the association of cotinine concentrations with household smoking behavior and asthma morbidity. Results. Over half (53%) of the children had cotinine levels compatible with SHS exposure and mean cotinine concentrations were high at 2.42 ng/ml (SD 3.2). The caregiver was the predominant smoker in the home (57%) and 63% reported a total home smoking ban. Preschool aged children and those with caregivers reporting depressive symptoms and high stress had higher cotinine concentrations than their counterparts. Among children living in a home with a total home smoking ban, younger children had significantly higher mean cotinine concentrations than older children (cotinine: 3–5 year olds, 2.24 ng/ml (SD 3.5); 6–10 year olds, 0.63 ng/ml (SD 1.0); p < .05). In multivariate models, the factors most strongly associated with high child cotinine concentrations were increased number of household smokers (β = 0.24) and younger child age (3–5 years) (β = 0.23; p < .001, R2 = 0.35). Conclusion. Over half of the young inner-city children with asthma were exposed to SHS, and caregivers are the predominant household smokers. Younger children and children with depressed and stressed caregivers are at significant risk of smoke exposures, even when a household smoking ban is reported. Further advocacy for these high-risk children is needed to help caregivers quit and to mitigate smoke exposure.

Stress and quality of life in caregivers of inner-city minority children with poorly controlled asthma.

INTRODUCTION Caregiver quality of life (QOL) is known to influence asthma management behaviors. Risk factors for low caregiver QOL in families of inner-city children with asthma remain unclear. This study evaluated the interrelationships of asthma control, stress, and caregiver QOL. METHOD Data were analyzed from a home-based behavioral intervention for children with persistent asthma after treatment for asthma in the emergency department. Caregivers reported on baseline demographics, asthma control, asthma management stress, life stress, and QOL. Hierarchical regression analysis examined the contributions of sociodemographic factors, asthma control, asthma management stress, and life stress in explaining caregiver QOL. RESULTS Children (N = 300) were primarily African American (96%) and young (mean age, 5.5 years). Caregivers were predominantly the biological mother (92%), single (70%), and unemployed (54%). Poor QOL was associated with higher caregiver education and number of children in the home, low asthma control, and increased asthma management stress and life stress. The model accounted for 28% of variance in caregiver QOL. DISCUSSION Findings underscore the need for multifaceted interventions to provide tools to caregivers of children with asthma to help them cope with asthma management demands and contemporary life stressors.

Prescription fill patterns in underserved children with asthma receiving subspecialty care

BACKGROUND Children with asthma receiving specialty care have been found to have improved asthma outcomes. However, these outcomes can be adversely affected by poor adherence with controller medications. OBJECTIVE To analyze pharmacy fill patterns as a measure of primary adherence in a group of underserved minority children receiving allergy subspecialty care. METHODS As part of a larger 18-month nebulizer use study in underserved children (ages 2-8 years) with persistent asthma, 53 children were recruited from an urban allergy practice. Pharmacy records were compared with prescribing records for all asthma medications. RESULTS Allergist controller prescriptions were written in 30-day quantities with refills and short-acting β-agonists (SABAs) with no refills. Only 49.1% of inhaled corticosteroid (ICS), 49.5% of combination ICS and long-acting β-agonist, and 64.5% of leukotriene modifier (LTM) initial and refill prescriptions were ever filled during the 18-month period. A mean of 5.1 refills (range, 0-14) for SABAs were obtained during 18 months, although only 1.28 SABA prescriptions were prescribed by the allergist. Mean times between first asthma prescription and actual filling were 30 days (range, 0-177 days) for ICSs, 26.6 days (range, 0-156 days) for LTMs, and 16.8 days (range, 0-139 days) for SABAs. CONCLUSION Underserved children with asthma receiving allergy subspecialty care suboptimally filled controller prescriptions, yet filled abundant rescue medications from other prescribers. Limiting albuterol prescriptions to one canister without additional refills may provide an opportunity to monitor fill rates of both rescue and controller medications and provide education to patients about appropriate use of medications to improve adherence.

Stress and Quality of Life in Urban Caregivers of Children With Poorly Controlled Asthma: A Longitudinal Analysis

INTRODUCTION The intent of this analysis was to examine the longitudinal effects of risk and protective factors on quality of life (QOL) in caregivers of minority children with asthma. METHOD Caregivers (n = 300) reported on demographics, child asthma characteristics, daily asthma caregiving stress, general life stress, social support, and QOL. Latent growth curve modeling examined changes in QOL across 12 months as a function of stress, asthma control, and social support. RESULTS Caregivers were primarily the biological mother (92%), single (71%), unemployed (55%), and living in poverty. Children were African American (96%), Medicaid eligible (92%), and had poorly controlled asthma (93%). Lower QOL was associated with higher life stress, greater asthma caregiving stress, and lower asthma control over time. DISCUSSION Findings underscore the importance of assessing objective and subjective measures of asthma burden and daily life stress in clinical encounters with urban, low-income caregivers of children with poorly controlled asthma.

Seasonal Patterns of Controller and Rescue Medication Dispensed in Underserved Children with Asthma

Objective. To determine whether temporal trends exist for short-acting beta agonist (SABA), oral corticosteroid (OCS), and anti-inflammatory prescription fills in children with persistent asthma. Method. This was a longitudinal analysis of pharmacy record data and health information data obtained by parent report over 12 months for children with persistent asthma 2 to 9 years of age. Eligible children had to report current nebulizer use and one or more emergency department visits or hospitalizations within the past 12 months. Results. Children were primarily African-American (89%), male (64%), received Medicaid health insurance (82%), and were a mean age of 4.5 years (SD 2.1). Few families (11%) reported any problems paying for their childs asthma medications at baseline or at the 12-month follow-up. There was a high degree of association between filling a rescue (SABA or OCS) and controller (leukotriene modifier, inhaled corticosteroid, cromolyn) medication during the same month for all months with Pearsons correlation coefficients ranging from a low of 0.28 for October to a high of 0.53 in September. Short-acting beta agonist fills were significantly more likely to be filled concurrently with inhaled corticosteroid fills. However, significantly fewer prescription fills were obtained in the summer months with an acceleration of medication fills in September through December and an increase in early spring. Conclusions. There was a summer decline in both inhaled corticosteroid and SABA fills. Timing of asthma monitoring visits to occur before peak prescription fill months, i.e., August and December for an asthma “tune-up,” theoretically could improve asthma control. During these primary care visits children could benefit from more intensive monitoring of medication use including monitoring lung function, frequency of prescription refills, and assessment of medication device technique to ensure that an effective dose of medication is adequately delivered to the respiratory tract. Additionally, scheduling non-urgent asthma care visits at pre-peak prescription fill months can take advantage of “step down” during decreased symptom periods and when appropriate restart daily controller medications to “step up” prior to peak asthma periods.

Factors associated with completion of a behavioral intervention for caregivers of urban children with asthma.

Background. Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma. Objective. The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters. Methods. Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child’s primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables. Results. Children were African-American (95%), Medicaid insured (91%), and young (aged 3–5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3–5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention. Conclusions. The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.

Influence of Caregiver and Provider Communication on Symptom Days and Medication Use for Inner-City Children With Asthma

Background. Effective pediatric guideline-based asthma care requires the caregiver to accurately relay the childs symptom frequency, pattern of rescue and controller medication use, and level of asthma control to the childs primary care clinician. Objective. This study evaluated the longitudinal effects of a caregiver-clinician asthma communication education intervention (ACE) relative to an asthma education control group (CON) on symptom days and controller medication use in inner-city children with asthma. Participants and Methods. 231 inner-city children with asthma, recruited from urban pediatric emergency departments (EDs) and community practices, were followed for 12 months. Data included number of symptom days and nights, ED visits, hospitalizations, presence of limited activity, and controller medication use over 12 months. Pharmacy records were used to calculate controller to total asthma medication ratios as a proxy of appropriate controller medication use. Multivariate logistic regression models were used to identify factors associated with number of symptom days and nights over the past 30 days at the 12-month follow-up. Results. Most caregivers rated the communication with their childs clinician as high. Unadjusted and adjusted rates of symptom days and nights did not differ by group at follow-up. ACE children trended towards a higher controller to total medication ratio at 12 months as compared to CON children (mean ratio: ACE: 0.54, SD 0.3; CON, 0.45, SD 0.4; p = .07). Activity limitation due to asthma and persistent asthma severity were the only factors significantly associated with reporting any symptom day within the past 30 days, adjusting for treatment group, number of oral corticosteroid courses and number of clinician visits in the last 6 months, seasonality, insurance type, and controller to total asthma medication ratio covariates. Conclusion. A home-based caregiver asthma communication educational intervention was not associated with decreased symptom days. However, a trend was noted in higher controller to total medication ratios in the intervention group. Inner-city caregivers of children with asthma may require a health systems approach to help convey the childs asthma health information to their clinician.

Factors associated with high short-acting β2-agonist use in urban children with asthma

BACKGROUND One goal of guideline-based asthma therapy is minimal use of short-acting β₂ agonist (SABA) medications. Inner-city children with asthma are known to have high SABA use. OBJECTIVE To examine factors associated with high SABA use in inner-city children with asthma. METHODS One hundred inner-city children with persistent asthma were enrolled into a randomized controlled trial of an emergency department (ED) and home intervention. All children underwent serologic allergen specific IgE and salivary cotinine testing at the ED enrollment visit. Pharmacy records for the past 12 months were obtained. Number of SABA fills during the past 12 months was categorized into low- to moderate- vs high-use groups. SABA groups were compared by the number of symptom days and nights, allergen sensitization, and exposures. Regression models were used to predict high SABA use. RESULTS Mean number of SABA fills over 12 months was 3.12. Unadjusted bivariate analysis showed that high SABA users were more than 5 times more likely to have an asthma hospitalization, almost 3 times more likely to have an asthma intensive care unit admission, and more than 3 times more likely to have prior specialty asthma care or positive cockroach sensitization than low to moderate SABA users. In the final regression model, for every additional inhaled corticosteroid fill, a child was 1.4 times more likely and a child with positive cockroach sensitization was almost 7 times more likely to have high SABA use when controlling for prior intensive care unit admission, receipt of specialty care, child age, and income. CONCLUSION Providers should closely monitor SABA and controller medication use, allergen sensitization, and exposures in children with persistent asthma. TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT01981564.