Summary of the 2020 focused updates to U.S. Asthma Management Guidelines: What has changed and what hasn\u27t?

Despite the availability of effective medications, the majority of pediatric and adult patients with persistent asthma have uncontrolled symptoms. This has been attributed to patient nonadherence and poor self-management, but clinicians also contribute through inaccurate assessment of asthma and lack of familiarity with best practice guidelines for medication management. Thus, improving patient outcomes will require improving clinical management by health care providers, including utilization of evidence-based practice guidelines. In this report, we briefly summarize key points of the national guidelines for asthma management and delineate important changes enacted by 2020 Expert Panel Report-4 updates. These include revised recommendations on the use of fractional exhaled nitric oxide testing, indoor allergen mitigation, bronchial thermoplasty, adjunctive immunotherapy, and important modifications to medication management that are likely to have widespread impact on prescribing throughout the United States. In particular, for all patients aged five years and older taking stepwise therapy levels 3–4, it is now recommended to use Single Maintenance and Reliever Therapy, whereas the use of intermittent inhaled corticosteroids (ICSs) administered at the same time as short-acting beta agonist is recommended for step 2 to reduce symptom burden, improve control, and minimize total ICS dose

How can I teach Emotional Literacy to Junior Infants using Picturebooks?

The purpose of this self-study action research intervention was to discover how I could improve my teaching of Emotional Literacy to junior infants using picturebooks. With mental health issues a growing concern for Irish children and facing into a new era of education following the initial impact of the COVID-19 pandemic, the responsibility to support the wellbeing of their pupils has never been more present for Irish teachers. As the country resumes schooling after the lockdown, the government also recognises the need to support teachers’ wellbeing. This study took place in a junior infant class in a mixed junior national school in North County Dublin. The group sample comprised of nine girls and seven boys, five of whom were attending support for English as an Additional Language, and all of whom were all 4-5 years old at the beginning of the intervention. I followed the action research paradigm, planning to change my practice to live more closely to my values of empathy and care. I received ethical consent and assent from the children and their parents and used both quantitative and qualitative methods of data collection. Rigour and validity were established through reflexivity and collaborative dialogue with critical friends and a validation group. The study found that picturebooks effectively taught new emotional vocabulary which was used by the children in school, at home and in response to the emotional states of their peers. The children expressed a list of 83 emotion words, far more than the 16 named by the current curricular content. Teacher-guided questions of picturebook stories allowed inferences to be drawn as to the internal thoughts and feelings of characters not explicitly named in the narrative. These picturebook discussions indicated that children were demonstrating emotional understanding usually expected of children aged 7-11. The study fostered a positive classroom environment allowing the children to lead their learning using a class display. As the children were given choice with the display, they felt listened to and safe to contribute, which built a sense of self-efficacy. This thematic learning of Emotional Literacy, supporting the expression and autonomy of the children within a positive climate, enhanced the children’s wellbeing. Recommendations from this study suggest that a more cohesive curriculum be developed employing a whole-school, thematic approach. It also recommends that greater attention be given to teacher-wellbeing and toward improving teacher training regarding effective support of the Emotional Literacy

Which extended paramedic skills are making an impact in emergency care and can be related to the UK paramedic system? A systematic review of the literature

BACKGROUND: Increasing demand on the UK emergency services is creating interest in reviewing the structure and content of ambulance services. Only 10% of emergency calls have been seen to be life-threatening and, thus, paramedics, as many patients’ first contact with the health service, have the potential to use their skills to reduce the demand on Emergency Departments. This systematic literature review aimed to identify evidence of paramedics trained with extra skills and the impact of this on patient care and interrelating services such as General Practices or Emergency Departments. METHODS: International literature from Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest, Scopus and grey literature from 1990 were included. Articles about any prehospital emergency care provider trained with extra skill(s) beyond their baseline competencies and evaluated in practice were included. Specific procedures for certain conditions and the extensively evaluated UK Emergency Care Practitioner role were excluded. RESULTS: 8724 articles were identified, of which 19 met the inclusion criteria. 14 articles considered paramedic patient assessment and management skills, two articles considered paramedic safeguarding skills, two health education and learning sharing and one health information. There is valuable evidence for paramedic assessing and managing patients autonomously to reduce Emergency Department conveyance which is acceptable to patients and carers. Evidence for other paramedic skills is less robust, reflecting a difficulty with rigorous research in prehospital emergency care. CONCLUSIONS: This review identifies many viable extra skills for paramedics but the evidence is not strong enough to guide policy. The findings should be used to guide future research, particularly into paramedic care for elderly people

Variation in Treatment of Patients With Inflammatory Bowel Diseases at Major Referral Centers in the United States

We performed a prospective study of patients with inflammatory bowel diseases to examine variations in treatment among medical centers. In a prospective cohort study of 1659 patients with CD and 946 patients with UC seen at 7 high-volume referral centers, we collected data on demographics, disease characteristic, and medical and surgical treatments. We used logistic regression to determine differences in treatment among centers, controlling for potential confounders. We found significant variations among centers in treatment of CD with immunomodulators (odds ratio [OR], 3.34; 95% confidence interval [CI], 2.09 – 5.32) but not anti-tumor necrosis factor agents (OR, 1.64; 95% CI, 0.97 – 2.77). There was less variation in treatment of UC; we found no difference in use of immunomodulators (OR,1.83 95% CI, 1.00 – 3.36) or anti-TNF therapy (OR, 0.81; 95% CI, 0.40 – 1.65). Development and implementation of evidence-based standards of care for IBD may help reduce variation and improve outcomes

Longitudinal Patterns of Mexican and Puerto Rican Children’s Asthma Controller Medication Adherence and Acute Healthcare Utilization

Rationale: Researchers tend to study Latinos as a single group but recent asthma research confirmed differences among Latino subgroups. Variations in controller medication adherence may be a factor in the observed health disparities between Mexican and Puerto Rican children. Adherence is not a stable phenomenon, however, there is a paucity of data on patterns of adherence, sociodemographic predictors of patterns, and variations in asthma-related acute healthcare utilization by adherence pattern among Latino sub-groups. Objectives: Identify patterns of inhaled corticosteroid medication adherence over twelve months among Mexican and Puerto Rican children with persistent asthma; examine sociodemographic predictors of adherence patterns by ethnicity; and investigate asthma-related acute healthcare utilization based on these patterns. Methods: We analyzed controller medication Doser data from Mexican and Puerto Rican children (n=123; ages 5-12 years) with persistent asthma who participated with their caregivers in a longitudinal, non-intervention study (Phoenix, AZ and Bronx, NY). Interview and medical record data were collected at enrollment, 3, 6, 9, and 12 months post-enrollment. Results: 47%-53% of children had poor adherence ( Conclusions: This study demonstrated that unique ethnicity within Latino populations may be associated with different risk levels for suboptimal controller medication adherence which may be a factor in the observed asthma health disparities between Mexican and Puerto Rican children. Increased understanding of and attention to children’s controller medication adherence patterns will provide evidence needed to identify children at highest risk for acute healthcare utilization and offer more intensive intervention using less-intensive approaches for those at low risk

Forced Smoking Abstinence: Not Enough for Smoking Cessation

Importance: Millions of Americans are forced to quit smoking as they enter tobacco-free prisons and jails, but most return to smoking within days of release. Interventions are needed to sustain tobacco abstinence after release from incarceration. Objective: To evaluate the extent to which the WISE intervention (Working Inside for Smoking Elimination), based on motivational interviewing (MI) and cognitive behavioral therapy (CBT), decreases relapse to smoking after release from a smoke-free prison. Design: Participants were recruited approximately 8 weeks prior to their release from a smoke-free prison and randomized to 6 weekly sessions of either education videos (control) or the WISE intervention. Setting: A tobacco-free prison in the United States. Participants: A total of 262 inmates (35% female). Main Outcome Measure: Continued smoking abstinence was defined as 7-days point-prevelance abstinence validated by urine cotinine measurement. Results: At the 3-week follow-up, 25% of the participants in the WISE intervention (31 of 122) and 7% of the control participants (9 of 125) continued to be tobacco-abstinent (odds ration [OR], 4.4; 95% CI, 2.0-9.7). In addition to the intervention, Hispanic ethnicity, a plan to remain abstinent, and being incarcerated for more than 6 months were all associated with increased likelihood of remaining abstinent. In the logistical regression analysis, participants randomized to the WISE intervention were 6.6 times more likely to remain tobacco abstinent at the 3-week follow up than those randomized to the control condition (95% CI, 2.5-17.0). Nonsmokers at the 3-week follow-up had an additional follow-up 3 months after release, and overall 12% of the participants in the WISER intervention (14 of 122) and 2% of the control participants (3 of 125) were tobacco free at 3 months, as confirmed by urine cotinine measurement (OR, 5.3; 95% CI, 1.4-23.8). Conclusions and Relevance: Forced tobacco abstinence alone during incarceration has little impact on postrelease smoking status. A behavioral intervention provided prior to release greatly improves cotinine-confirmed smoking cessation in the community. Trial Registration: clinicaltrials.gov Identifier: NCT0112258