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Helen Boussios, MD


https://medicine.duke.edu/faculty/helen-boussios-md

This book is dedicated to the truth that you must take an active role in restoring and maintaining your health asthma symptoms natural remedies albuterol 100 mcg overnight delivery, which may mean recruiting your own team of professionals asthma symptoms juvenile order albuterol australia, including a physician and a psychotherapist asthma 6 step plan generic 100mcg albuterol visa. Be ready to educate your dermatologist about the psychological side of your disease and to explain your skin disease to an otherwise knowledgeable psychotherapist asthma triad order albuterol with amex. This probably means a dermatologist (for some conditions asthma definition tenure buy albuterol 100 mcg fast delivery, an allergist asthma definition cdc generic 100 mcg albuterol visa, urologist, or gynecologist). A referral from your regular family doctor or internist is customary or inquire at a local clinic or hospital. There are three things to look for in a dermatologist (or any doctor whose help you enlist), but only one is essential: technical competence. Thirdly, most of us seek a doctor who is "our kind of person," who shares our basic values and prejudices. Many people come to me after seeing several, even several dozen, dermatologists, each of whom has been disappointing. Counseling for a difficult child or expert care for a serious mental illness sounds perfectly reasonable, but they feel that basically healthy adults should be able to work things out on their own. Your physician or clergyman may know of a good psychologist, psychiatrist, or social worker or friends may have suggestions based on their own experience. Some cities have referral agencies that perform this "matchmaking" service for a small fee. The National Register of Health Service Providers in Psychology is available at most good libraries, along with similar rosters of psychiatrists and social workers; these indicate formal credentials as well as areas of specialization. There are numerous schools of therapy, each with its own approach, and you may wonder which will suit you best. Two highly reputable professional groups publish directories of qualified hypnotherapists: the Society for Clinical and Experimental Hypnosis and the American Institute of Hypnosis. Check your policy (you may have to call the company for clarification) to answer three key questions: Does insurance pay for outpatient mental health services Your policy may pay for psychotherapy but not hypnosis, biofeedback, or relaxation, because these are considered "experimental techniques. Most policies have a yearly or per-session limit on coverage, and some exclude many problems as "preexisting conditions. Group therapy is less expensive and in some cases more useful than individual sessions. They speak to our origins as primates, our dependency on others as children, and our basic need for one another. If the thought of being in a group puts you off, it likely means that you have suffered in one and may need a good group experience all the more. They come in so many shapes, sizes, and types that it is hard to be an educated consumer. There are three main types of groups: psychotherapy groups, professionally led support groups, and self-help/mutual help groups. Psychotherapy groups: these are much more than individual psychotherapy with more people in the room. With one (or possibly two) mental health professionals leading, these groups typically have four to twelve members and meet once or more times a week. The group may begin and terminate at the same time for everyone or continue indefinitely with members entering and exiting on their own timetable. There are groups for all ages, for couples, and for all levels of psychological health. Group members may have common or different therapy agendas and may also be in individual psychotherapy. Group therapy would be a tool to address the emotional issues under your skin and other life issues more than the specific skin symptoms. If the whole idea of working in a group is uncomfortable for you, that likely suggests you are a good candidate for a group. While group treatment can focus on any issue, it has special advantages for certain problems. When someone has realized that old ways of acting are unhelpful, a place to refine and practice new approaches that are not yet ready for "prime time" is helpful. At first, you probably focused on the specifics, bad luck, or a malevolent view of the universe. Inevitably, the same problems will crop up, but you have a room full of people who are committed to identifying and correcting the problem rather than simply playing out the same game one more time. Support groups: these groups are run by people with special training in the area for people who share a common problem, issue, or goal. It might be a group for adult children of alcoholics, parents of kids with disabilities, men with career crises, or whatever. Skin support groups are described in the medical literature at least as far back as the 1940s. They usually focus on support per se and are affiliated with hospital dermatology departments. Self-help or mutual help groups:the distinctive characteristics of these groups may make them just what you are looking for. They are comparable to neighborhoods or extended families; with no professional leader, their emphasis is on the exchange of resources and knowledge. Typical skin groups have a national organization providing written information, research sponsorship, and lobbying for governmental support of research. Some local groups also have newsletters, hot lines, social events, or informational lectures. Try the following approach: Research which of the three types of groups are available and affordable in your area. Psychotherapy and support groups usually charge, but fees may be flexible and there is a good chance your health insurance will be helpful. Mutual help groups are usually free, sometimes with modest dues ($20 to $30) to join the national organization. Whether required or not, think about how much time and energy you are willing to devote. The old cliche may well apply that "you get out of something what you put into it. It is a rare person who could not get a real benefit from a first-rate group of any of the three types. Remember that a group can be a disappointment in some ways but still helpful in others. A good general source, this is the official publication of the American Group Psychotherapy Association. Yalom,the Theory and Practice of Group Psychotherapy (New York: Basic Books, 1970). The local groups usually sponsor the group meetings and may also host social events and provide informed individuals with the problems who are available to talk with you. Since local support group information changes so frequently, I have provided only the national office addresses and telephone numbers of the various organizations. You can contact them to obtain a current listing of groups available in your area. Your Skin: Sensing and Responding to the World Around You Find out more at. Beyond the Relaxation Response: How to Harness the Healing of Your Personal Beliefs. Rowlingson, "Hypnosis in the Management of Postherpetic Neuralgia: Three Case Studies. He is on the Professional Advisory Council, and is a Diplomat and a Fellow of the American Board of Medical Psychotherapists. He is on the editorial board of the Medical Psychotherapist and is a reviewer for the Journal of the Society for Clinical and Experimental Hypnosis and the Archives of Dermatology. His other focus is the treatment of major skin, allergic, sexually transmitted, and autoimmune disorders. He has been a pioneer in the use of relaxation, imaging, hypnosis, and psychotherapy in these areas. He is actively involved in public health education via popular magazine articles, radio and television appearances, and national and local self-care groups. Sherman has also been also senior editor for Prevention and executive editor for Executive Fitness Newsletter. The authors are primarily water resources engineers and water resources scientists, as opposed to microbiologists and epidemiologists. Acknowledgements this report was completed by a voluntary committee of stormwater experts associated with the Urban Water Resources Research Council of the Environmental and Water Resources Institute of the American Society of Civil Engineers. This report does not cover any one topic in detail, but instead integrates multi-disciplinary information into one general reference. Several chapters draw upon previously published material, which can be referenced for more detail on specific topics. Stormwater Effects Handbook: A Tool Box for Watershed Managers, Scientists, and Engineers. Illicit Discharge Detection and Elimination: A Guidance Manual for Program Development and Technical Assessments. Project sponsors include: Water Environment Research Foundation, Federal Highway Administration, American Society of Civil Engineers Environmental and Water Resources Institute, U. Wet Weather Enterococci Loads by Land Use for Serra Mesa Subwatershed in the City of San Diego. Summary of Chemical Characteristics of Source Samples Collected in Birmingham, Alabama. Example Tabulation of Results from Microbial Source Tracking Using a Toolbox Approach in San Diego. Non-parametric Wilcoxon Signed Rank Test for Paired Data Observations (Example with and without Birds). Observed Dry-weather Flow-Related Activities for Residential and Commercial Land Uses in San Diego County. Observed Dry-weather Flow-Related Enterococci for Residential and Commercial Land Uses in San Diego County. Potential Fate and Factors that Impact Fate of Microorganisms in Waterbodies and Associated Sediment. Use of Ammonia as a Tracer to Identify Drainage System Sections Contributing Contaminated Flows. Binned Presence/Absence of Discharge Plots for Bioretention Sites with Underdrains178 Figure 8-7. Summary of Detection Frequencies and Method Detection Limits for All Sites and Samples (n ~ 80). These criteria serve as guidance for states for purposes of developing water quality standards. Sanitary surveys, possibly including microbial source tracking techniques, are also important evidence needed for developing site-specific standards in urban areas. For example, illicit discharges may be intermittent, and stormwater discharges occur episodically. Monitoring to identify or confirm the absence of human sources should be a high priority. Robust monitoring datasets are needed for model setup, calibration, and verification; however, watershed-specific datasets are often costly to develop. Where regional or national datasets are used (such as for land-use based concentrations), interpretation of model results should carefully consider results of sensitively and uncertainty analyses, and should recognize current limitations of the state of the practice. Chlorination and ozonation are typically impractical for urban stormwater applications due to needs for dechlorination (to prevent byproduct formation or discharge of toxic residuals) and risks of chemical storage. Recommendations for additional research and policy discussions needed to advance the science and policy on this complex issue are also provided with this report. Many scientific reports related to epidemiology, risk assessment, test methods, and other topics were published as a result of this process (accessible at water. The overall goal of the criteria is to provide public health protection from gastroenteritis. These criteria have evolved over time; therefore, there is variation among the criteria adopted by various states as water quality standards. This historic work formed the basis for the use of fecal coliform and associated numeric criteria for the protection of recreational water quality uses. The magnitude component of the criteria refers to the numeric value and statistical measure. Duration refers to the time period over which compliance with the criteria should be assessed. The general purposes of the studies included: 1) evaluate the water quality at one or two beaches per year; 2) obtain and evaluate a new set of health and water quality data for the new rapid, state-of-the-art methods; and 3) share results to support new state and federal guidelines and limits for water quality indicators of fecal contamination, so that beach managers and public health officials can alert the public about the potential health hazards before exposure to unsafe water can occur. Not all receiving waters are assigned primary contract recreation standards, depending on the beneficial use classification of the particular receiving water. However, in most urban areas, waterbodies are typically subject to primary contact recreation standards due to the potential for waterplay by children. These studies have the potential to set precedence for how such alternative criteria will be developed in the future. For an example, see the various legal proceedings associated with the Natural Resources Defense Council, Inc. The primary concern with regard to pathogens in surface waters is incidental human ingestion of contaminated water during recreational contact with the water, resulting in illness; however, other types of exposure to pathogens can also result in respiratory, skin, ear, and eye infections.

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There is no evidence for an increase in asthma exacerbations after vaccination with inactivated trivalent vaccines compared to placebo asthmatic bronchitis zinc buy albuterol american express. Bronchial thermoplasty involves treatment of the airways during three separate bronchoscopies with a localized 108 108 radiofrequency pulse asthma symptoms emphysema buy albuterol 100 mcg on line. Extended follow up of some treated patients reported a sustained 239 reduction in exacerbations compared with pre-treatment asthma treatment no medication generic albuterol 100 mcg fast delivery. However asthma when sick buy albuterol 100 mcg with amex, longer-term follow up of larger cohorts comparing effectiveness and safety asthma definition 3 dimensional cheap albuterol uk, including for lung function asthma definition honor generic albuterol 100mcg amex, in both active and sham-treated patients is needed. Treating to control symptoms and minimize future risk Task Force on Severe Asthma recommends that bronchial thermoplasty should be performed in adults with severe asthma only in the context of an independent Institutional Review Board-approved systematic registry or a clinical study, 131 so that further evidence about effectiveness and safety of the procedure can be accumulated. In a meta-analysis, benefit for asthma worsenings was seen in some studies, but to date, there is no good-quality evidence that Vitamin D supplementation 241-243 leads to improvement in asthma control or reduction in exacerbations. Unfortunately, many health care providers are 244 unable to correctly demonstrate how to use the inhalers they prescribe. Strategies for ensuring effective use of inhaler devices are summarized in Box 3-11. Treating to control symptoms and minimize future risk 57the above principles apply to all types of inhaler devices. This is particularly important for patients with poor symptom 247,248 control or a history of exacerbations. There is increasing awareness of the importance of poor adherence in chronic diseases, and of the potential to 252 develop interventions to improve adherence. Approximately 50% of adults and children on long-term therapy for 133 asthma fail to take medications as directed at least part of the time. In clinical practice, poor adherence may be identified by an empathic question that acknowledges the likelihood of incomplete adherence and encourages an open discussion. Checking the date of the last prescription or the date on the inhaler may assist in identifying poor adherence. In some health systems, pharmacists can assist in identifying poorly adherent patients by monitoring dispensing records. In clinical studies, poor adherence may be identified by short adherence behavior questionnaires, or from dispensing 253 254 records; dose or pill counting; electronic inhaler monitoring; and drug assay such as for prednisolone. Factors contributing to poor adherence It is important to elicit patients beliefs and concerns about asthma and asthma medications in order to understand the reasons behind their medication-taking behavior. Specific drug and non-drug factors involved in poor adherence are 255 listed in Box 3-12, p. Issues such as ethnicity, health 256,257 142 literacy, and numeracy are often overlooked. Interventions to improve adherence in asthma Few adherence interventions have been studied comprehensively in asthma. Further studies are needed of adherence strategies that are feasible for implementation in primary care. All individuals will require certain core information and skills but most education must be personalized and provided in a number of steps. Adolescents may have unique difficulties regarding adherence, and peer support group 268 education may help in addition to education provided by the health care provider. Regional issues and the 269 adolescents developmental stage may affect the outcomes of such programs. The key features and components of an asthma education program are provided in Box 3-13. Social and psychological support may also be required to maintain positive behavioral change, and skills are required for effective medication delivery. At the initial consultation, 271,272 verbal information should be supplemented with written or pictorial information about asthma and its treatment. Asthma education and training can be delivered effectively by a range of health care providers including pharmacists 247,248 and nurses (Evidence A). Trained lay health educators (also known as community health workers) can deliver 3. Treating to control symptoms and minimize future risk 59 discrete areas of respiratory care such as asthma self-management education, with, in one study, increased symptom 273 free days and reduced healthcare utilization compared with usual care and in another, comparable outcomes to those 274 achieved by practice nurses based in primary care (Evidence B). With doctor directed self-management, patients still have a written action plan, but refer most major treatment decisions to their physician at the time of a planned or unplanned consultation. Benefits include a one-third to two-thirds reduction in asthma-related hospitalizations, emergency department visits and unscheduled doctor or clinic visits, missed work/school days, and 134 nocturnal wakening. It has been estimated that the implementation of a self-management program in 20 patients prevents one hospitalization, and successful completion of such a program by 8 patients prevents one emergency 134,276 department visit. Less intensive interventions that involve self-management education but not a written action plan 277 270 are less effective, and information alone is ineffective. Treating to control symptoms and minimize future risk Self-monitoring of symptoms and/or peak flow Patients should be trained to keep track of their symptoms (with or without a diary), and notice and take action if necessary when symptoms start to worsen. The efficacy of self-management education is similar regardless of whether patients self-adjust their medications 277 according to an individual written plan or whether the medication adjustments are made by a doctor (Evidence A). Examples of written asthma action plan templates, including for patients with low literacy, can be found on several websites. Details of the specific treatment adjustments that can be recommended for written asthma action plans are described in the next chapter (Box 4-2, p. Treating to control symptoms and minimize future risk 61 Regular review by a health care providerthe third component of effective asthma self-management education is regular review by a health care provider. Follow-up by tele-healthcare is unlikely to benefit in mild asthma but may be of benefit in those 278 with severe disease at risk of hospital admission. Comorbidities may contribute to respiratory symptoms and impaired quality of life, and some contribute to poor asthma control. Active management of comorbidities is recommended because they may contribute to symptom burden, impair 285 quality of life, and lead to medication interactions. Obesity Clinical features 286-289 Asthma is more difficult to control in obese patients. Because of other potential contributors to dyspnea and wheeze in obese patients, it is important to confirm the diagnosis of asthma with objective measurement of variable 47 airflow limitation (Box 1-2, p. Asthma is more common in obese than non-obese patients, but both over and under 43,48 diagnosis of asthma occur in obesity. Weight reduction should be included in the treatment plan for obese patients with asthma 290 (Evidence B). Increased exercise alone appears to be insufficient (Evidence B); however a weight loss program plus twice-weekly aerobic and strength exercises improved symptom control, lung function and inflammatory markers 291 compared with weight loss alone (Evidence B). Weight loss improves asthma control, lung function, health status and 292,293 reduces medication needs in obese patients, but the quality of some studies is poor. Asymptomatic gastroesophageal reflux is 285 not a likely cause of poorly controlled asthma. For patients with asthma and symptoms suggestive of reflux, an empirical trial of anti-reflux medication, such as a proton pump inhibitor or motility agent, may be considered, as in the general population. If the symptoms do not resolve, specific investigations such as 24-hour pH monitoring or endoscopy may be considered. In general, benefits of proton pump inhibitors in asthma 298 appear to be limited to patients with both symptomatic reflux and night-time respiratory symptoms. Other treatment options include motility agents, lifestyle changes and fundoplication. In summary, symptomatic reflux should be treated, but patients with poorly controlled asthma should not be treated with anti-reflux therapy unless they also have symptomatic reflux (Evidence A). Anxiety and depression Clinical features 301 Psychiatric disorders, particularly depressive and anxiety disorders, are more prevalent among people with asthma. Psychiatric comorbidity is also associated with worse asthma symptom control and medication adherence, and worse 302 asthma-related quality of life. Anxious and depressive symptoms have been associated with increased asthma-related 303 exacerbations and emergency visits. Where appropriate, patients should be referred to psychiatrists or evaluated with a disease-specific psychiatric diagnostic tool to identify potential cases of depression and/or anxiety. Management There have been few good quality pharmacological and non-pharmacological treatment trials for anxiety or depression in patients with asthma, and results are inconsistent. A Cochrane review of 15 randomized controlled trials of psychological interventions for adults with asthma included cognitive behavior therapy, psychoeducation, relaxation, and 304 biofeedback. Results for anxiety were conflicting, and none of the studies found significant treatment differences for 305 depression. Drug treatments and cognitive behavior therapy have been described as having some potential in 64 3. Treating to control symptoms and minimize future risk patients with asthma; however, current evidence is limited, with a small number of studies and methodological shortcomings. Food allergy and anaphylaxis Clinical features Rarely, food allergy is a trigger for asthma symptoms (<2% of people with asthma). In patients with confirmed food induced allergic reactions (anaphylaxis), co-existing asthma is a strong risk factor for more severe and even fatal 91 reactions. An analysis of 63 anaphylaxis-related deaths in the United States noted that almost all had a past history of asthma; peanuts and tree nuts were the foods 306 most commonly responsible. Children with food allergy have a four-fold 308 increased likelihood of having asthma compared with children without food allergy. This may include appropriate allergy testing such as skin prick testing and/or blood testing for specific IgE. They, and their family, must be educated in appropriate food avoidance strategies, and in the medical notes, they should be flagged as being at high risk. Rhinitis, sinusitis and nasal polyps Clinical features 309 Evidence clearly supports a link between diseases of the upper and lower airways. Rhinosinusitis is defined as inflammation of the nose and paranasal sinuses characterized by more than two symptoms including nasal blockage/obstruction and/or nasal discharge 311 (anterior/posterior nasal drip). Other symptoms may include facial pain/pressure and/or a reduction or loss of smell. Rhinosinusitis is defined as acute when symptoms last <12 weeks with complete resolution, and chronic when symptoms occur on most days for at least 12 weeks without complete resolution. Chronic rhinosinusitis is an inflammatory condition of the paranasal sinuses that encompasses two clinically distinct entities: chronic rhinosinusitis 312 without nasal polyposis and chronic rhinosinusitis with nasal polyposis. Diagnosis Rhinitis can be classified as either allergic or non-allergic depending on whether allergic sensitization is demonstrated. Examination of the upper airway should be arranged for patients with severe asthma. Also refer to the Diagnosis of respiratory symptoms in special populations section of Chapter 1 (p. It is possible to build capacity of primary health care teams, including nurses and other health professionals, for the development of an integrated 321 approach to the most common diseases and symptoms, including asthma. Adolescents Clinical features Care of teenagers with asthma should take into account the rapid physical, emotional, cognitive and social changes that occur during adolescence. Asthma control may improve or worsen, although remission of asthma is seen more 322 commonly in males than females. Adolescents and their parent/carers should be encouraged in the transition towards asthma self-management by the adolescent. During consultations, the adolescent should be seen separately from the parent/carer so that sensitive issues such as smoking, adherence and mental health can be discussed privately, and confidentiality agreed. Information and self-management strategies should be tailored to the patients stage of psychosocial development and desire for autonomy; adolescents are often focused on short-term rather than long-term outcomes. Medication regimens should be tailored to the adolescents needs and lifestyle, and 66 3. Treating to control symptoms and minimize future risk reviews arranged regularly so that the medication regimen can be adjusted for changing needs. Information about local youth-friendly resources and support services should be provided, where available. However, shortness of breath or wheezing during exercise may also relate to obesity or a lack of fitness, or to comorbid or alternative conditions such as vocal cord 17 dysfunction.

He was started on antibiotics for pneumonia asthma 15 month old albuterol 100 mcg with amex, a 5-day course of oral steroids asthma treatment 4 hives buy albuterol 100 mcg on line, and controller and rescue inhalers asthmatic bronchitis sound discount albuterol online american express. The rationale for treating with antibiotics was the infections persistence and the unilateral nature suggestive of a secondary bacterial pneumonia; of note asthma treatment delhi purchase generic albuterol from india, it cleared soon after treatment asthma symptoms 7dpo effective albuterol 100mcg. Most likely asthma treatment emergency cheap 100mcg albuterol amex, the parainfluenza was the trigger or contributed to the asthma exacerbation that prompted the hospitalization. Long-term Follow-up His primary care pediatrician enrolled him in a medical home for children with both chronic medical conditions and housing instability. A medical home coordinator and a community health worker were assigned to his case and the implementation of an asthma action plan. The child continues to be seen by both his pediatrician and pediatric pulmonologist. He has had several mild asthma exacerbations but has not required further hospitalization for asthma. He was eventually diagnosed with obstructive sleep apnea secondary to enlarged tonsils secondary to recurrent tonsillitis. He successfully underwent a tonsillectomy and adenoidectomy, which resulted in significant improvement in his sleep apnea. Takeaways In our program, we see many refugees, which introduces additional medical-legal elements to the needs of our patients that we work hard to address, and that is critical to the successful care of our patients. Although trauma is in the background of many of our patients, the type of trauma experienced by our refugee patients requires special sensitivity and insight, which has been proven critical to their care. Finally, when seeing foreign-born patients from certain countries, it will be important for clinicians to be familiar with the infectious disease risks that may necessitate different screenings, and also cultural/folk remedies and perceptions of health and wellness that are frequently used and need to be considered. This case highlights a number of important points in the care of children with asthma. It highlights the heterogeneity and diversity among families experiencing homelessness. Each family comes from different backgrounds and family histories with unique circumstances that contribute to their housing instability. It was through the communication between the Health Care for the Homeless Project with the primary care provider and pediatric pulmonologist that resulted in the enrollment in a medical home with a community health worker that helped to provide continuity of medical care as well as access to additional community resources and services. When possible, a team approach may be preferable to limiting the history-taking to the clinician. As many of the pertinent historical details require a significant amount of trust and patient disclosure, when appropriate, it may be useful to optimize a patients connection to team-members other than the physician or prescribing clinician as a strategy to increase efficiency. Parents are sometimes reticent to disclose information that they feel could reflect negatively on their caregiving. Some may have child protective services cases open and may worry children will be taken away. As always, do appropriately assess any risk to the child and act accordingly in the childs best interest. Regardless, it will also be important to create as safe and supportive and environment as possible for the parent to establish a therapeutic relationship with you. For asthmatics, of particular importance are current prescription medication use (especially controller use), dosage and interval; over-the counter medications; and herbal medications, vitamins, folk remedies, and any other alternative medication or treatment used. There may be significant differences in what a patient has been prescribed and what they have been able to access in terms of treatment and medication. It is often important to explicitly clarify the difference, as patients may not offer this information prior to the establishment of a trusting relationship with the provider. Similar attention may be important in accurately eliciting risk factor/behavior information. As with all asthmatics, review previous hospitalizations, intensive care stays and intubations; and immunization history. Ask about exercise-induced symptoms and treat accordingly to prevent children from being excluded from physical activities. Ask specifically about vocal cord dysfunction, eczema, and allergic rhinitis, comorbidities that may individually worsen asthma. Ask about exercise-induced symptoms, as they may influence the asthma severity, control classification, and the care plan. All clinicians should be familiar with the latest guidelines and be able to use them to care for patients with asthma. Undiagnosed Asthma Many families who are unstably housed have not had consistent medical care. Even if the parent/guardian/child does not report a history of asthma, ask whether the child has a frequent cough, particularly at night. Inquire whether the patient has ever been prescribed an inhaler, diagnosed with wheezing, bronchitis/bronchiolitis, or pneumonia. Medical Home Inquire if the child has a medical home (a regular source of coordinated primary care). Common barriers include, but are not limited to , lack of health insurance, change in health insurance, lack of transportation, lack of accessible clinic hours, and unaffordable co-pays. Significant Allergies Allergies can be triggers that can hinder the control of asthma. Keep in mind that many children may spend some of their time in day care or other environments with additional triggers. The results of the assessment may affect the severity/control score, treatment plan, and understanding of support services needed. Ask whether the child was smaller than normal at birth (provide a point of reference) or born prematurely. Continuity of Care Children experiencing homelessness may lack continuity of care and see many different providers because of frequent relocation. Try to identify and allay confusion about different drugs prescribed or conflicting information conveyed by multiple providers. As highlighted in the above scenario, many children who end up in homeless shelters have had multiple providers and poor continuity of care. If possible, have the parent/guardian sign a release of information to obtain the records. Ask specific questions to guide priorities, risk assessment, and treatment considerations. Especially for street youth, assess safety and ability to secure and administer medication. Environment Clearly document environmental factors that may trigger or exacerbate the patients asthma. Discuss mold, dust, cockroaches, mice, pets, and proximity to tunnels and busy highways nearby (air pollution). Inquire whether any member of the household smokes cigarettes, marijuana, and other substances that can create fumes, and if so, counsel appropriately. If the patient has been seen before, ascertain whether environmental conditions have improved or deteriorated. Many patients may not know their triggers, so this part of the assessment can be a good opportunity for education. Ask how the family obtains medicine, with respect to both cost and transportation. Domestic Violence and Abuse As with all patients, routinely screen for domestic violence, child abuse, neglect, and exposure to violence in the community. Family Health/Stress Understand that the family may have experienced significant access barriers to care or have an incomplete understanding of the childs condition or treatment needs. Other shelters have full cooking facilities in the patients apartment, but the patient may have limited funds to use for food. Patients may live in a neighborhood with minimal access to healthy, affordable food. Those who live on the streets may be primarily living off scavenged food items that others have discarded. School Attendance It is not uncommon for a child who becomes homeless or enters the shelter system to be placed in a different school district, requiring re-enrollment. A student who is regularly missing more than 2 days per month is considered chronically absent by the Department of Educations standards. Being chronically absent has an impact on learning, grade promotion, reading level, etc. In addition to lack of symptom control and frequent exacerbations, many parents keep their asthmatic children home when it is cold or rainy, in the fear that conditions will induce asthma attacks. In children experiencing homelessness, this is often made worse by lack of access to appropriate warm clothing. Recognize that this may be a sensitive topic for parents and they may be hesitant to disclose information for fear of getting in trouble. Assess how many days of school the child missed in the prior year because of asthma, and also in the last few months. Work to address the causes of absences through medication control, health education, and even social work support, when needed. Parental Health Poor health of a parent is a common reason for a child to miss school or have uncontrolled asthma. Arranging other methods of getting a child to school is a practical way to prevent a parents illness from affecting their childs attendance. Children living in shelters are entitled to be bused to school through the McKinney Vento Homeless Assistance Act of 1987, a federal law mandating that students with temporary housing receive transportation to school. Parental Missed Work It is important to be aware that a childs asthma may impact a parents ability to work with the possibility of being fired from a job because of missing work when a child is sick. Parents should be provided with any work-related documentation they need to support missed work days. Literacy Level It is important to identify caregivers and older patients who cannot read well. This information may not be readily offered, but is important for safe and effective care. Create a sensitive, shame-free environment in which individuals can feel comfortable revealing any difficulty they may have with reading. If the patient is willing, you can assess basic literacy by encouraging the patient to read something for you, in a private space. If written educational materials are not available at an appropriate literacy level or in the patients primary language, consider using pictograms, but make sure the patient understands the pictures before leaving the clinic. Routinely ask or assess the reading abilities of families in a nonjudgmental way, offer assistance, and modify the care plan and health education as needed. Similarly, be aware that some people have adequate general literacy, but poor health literacy. Additionally, developmental surveillance and screening as recommended by standard clinical guidelines, such as American Academy of Pediatrics Bright Futures. This may be your only contact with the patient; many children experiencing homelessness rarely see a primary care provider because of transportation issues and limited access to health care. If spirometry is not available, do not delay treatment; treat empirically based on the history and physical exam. If available, perform spirometry at the initial visit, and on follow up as needed. Consider referral to pulmonology for severe asthmatics, but assess your patients transportation or other access barriers to specialty care. Allergy Testing Testing should be considered when available, to identify any allergens that trigger the childs asthma symptoms. The high rate of asthma among children experiencing homelessness is thought to be related, in part, to the presence of mold, animal dander, dust, cockroaches, and cigarette smoke in shelters, or other challenging living situations. Families experiencing homelessness may have less control over their environments than housed families. Children with unexplained, severe, or difficult to control asthma symptoms should be referred for allergy testing. As above, when referring to a specialist, assess the patients transportation limitations and other access barriers to care. For persistent asthmatics, daily use of inhaled corticosteroids is the first-line recommendation for controllers. Long-acting bronchodilators can be helpful in older children and adolescents, but should not be used for patients who, in the clinicians judgment, are at high risk for overusing them. Spacers are available with masks for younger children and without for older children. If you are unable to obtain a spacer for a patient, one can be made from a one-liter soda bottle. The improvised spacer can be easily replaced if lost or if the patient cannot carry a spacer with him or her. Nebulizers Nebulizers are larger and less portable than inhalers and require electricity for operation; for these reasons, they are rarely the best option for a child requiring urgent medication administration. If a family uses a nebulizer, ensure they are aware of necessary cleaning and maintenance regimen for safe use. As the provider for the child, you may need to refer asthmatic parents or caregivers to an appropriate adult provider and support access if they have had barriers in getting their own medicine. Medication Refills Assure that prescriptions are written with an adequate number of refills.

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Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children asthma jake hoffman cheap albuterol 100 mcg overnight delivery. Treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid asthma mayo clinic 100 mcg albuterol free shipping. Preemptive use of high-dose fluticasone for virus-induced wheezing in young children asthmatic bronchitis icd-9 code buy discount albuterol 100mcg on line. Quadrupling the dose of inhaled corticosteroid to prevent asthma exacerbations: a randomized asthmatic bronchitis prevention buy genuine albuterol line, double-blind asthma treatment remedies buy cheapest albuterol, placebo-controlled asthma treatment toddler cheap 100 mcg albuterol otc, parallel-group clinical trial. Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. A comparison of albuterol administered by metered-dose inhaler and spacer with albuterol by nebulizer in adults presenting to an urban emergency department with acute asthma. Washing plastic spacers in household detergent reduces electrostatic charge and greatly improves delivery. Perrin K, Wijesinghe M, Healy B, Wadsworth K, Bowditch R, Bibby S, Baker T, et al. Randomised controlled trial of high concentration versus titrated oxygen therapy in severe exacerbations of asthma. Hasegawa T, Ishihara K, Takakura S, Fujii H, Nishimura T, Okazaki M, Katakami N, et al. Duration of systemic corticosteroids in the treatment of asthma exacerbation; a randomized study. Prospective, placebo controlled trial of 5 vs 10 days of oral prednisolone in acute adult asthma. Evaluation of SaO2 as a predictor of outcome in 280 children presenting with acute asthma. As-required versus regular nebulized salbutamol for the treatment of acute severe asthma. Need for intravenous hydrocortisone in addition to oral prednisolone in patients admitted to hospital with severe asthma without ventilatory failure. A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children. A randomized trial of single dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma. Addition of intravenous aminophylline to inhaled beta(2)-agonists in adults with acute asthma. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Magnesium sulfate is effective for severe acute asthma treated in the emergency department. Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Heliox-driven beta2-agonists nebulization for children and adults with acute asthma: a systematic review with meta-analysis. Oral montelukast in acute asthma exacerbations: a randomised, double-blind, placebo-controlled trial. Efficacy and safety of budesonide/formoterol compared with salbutamol in the treatment of acute asthma. A randomized, placebo-controlled study to evaluate the role of salmeterol in the in-hospital management of asthma. Non invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. 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Clinical phenotypes of chronic obstructive pulmonary disease and asthma: recent advances. Sputum eosinophilia predicts benefit from prednisone in smokers with chronic obstructive bronchitis. External validity of randomised controlled trials in asthma: to whom do the results of the trials apply Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway responsiveness in mid-childhood. Distinguishing phenotypes of childhood wheeze and cough using latent class analysis. Just J, Saint-Pierre P, Gouvis-Echraghi R, Boutin B, Panayotopoulos V, Chebahi N, Ousidhoum-Zidi A, et al. Wheeze phenotypes in young children have different courses during the preschool period. Patient characteristics associated with improved outcomes with use of an inhaled corticosteroid in preschool children at risk for asthma. Reference values of exhaled nitric oxide in healthy children 1-5 years using off-line tidal breathing. 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Cat ownership is a risk factor for the development of anti-cat IgE but not current wheeze at age 5 years in an inner-city cohort. Influence of early and current environmental exposure factors on sensitization and outcome of asthma in pre-school children. Exposure to furry pets and the risk of asthma and allergic rhinitis: a meta-analysis. Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age. Residential dampness and molds and the risk of developing asthma: a systematic review and meta-analysis. Primary prevention of asthma and atopy during childhood by allergen avoidance in infancy: a randomised controlled study. Is there any role for allergen avoidance in the primary prevention of childhood asthma The Canadian Childhood Asthma Primary Prevention Study: outcomes at 7 years of age. Multifaceted allergen avoidance during infancy reduces asthma during childhood with the effect persisting until age 18 years. 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Paper stamp checklist tool enhances asthma guidelines knowledge and implementation by primary care physicians. Medical treatments help to control many others, but schools and child care centers must continue to play an important role in controlling the spread of communicable disease. By enforcing the state communicable disease regulations, excluding children who are ill, and promptly reporting all suspected cases of communicable disease, personnel working with children can help ensure the good health of the children in their care. Be alert for signs of illness such as elevated temperature, skin rashes, inflamed eyes, flushed, pale or sweaty appearance. If a child shows these or other signs of illness, pain or physical distress, he/she should be evaluated by a health care provider. Children or staff with communicable diseases should not be allowed to attend or work in a school or child care setting until they are well. Recommendations for exclusion necessary to prevent exposure to others are contained in this document. Please report all suspected cases of communicable disease promptly to your city, county or state health department. Additional information concerning individual communicable diseases is contained in the Communicable Disease Investigation Reference Manual located on the Department of Health and Senior Services website at: health. A variety of infections have been documented in children attending childcare, sometimes with spread to caregivers and to others at home. Infants and preschool-aged children are very susceptible to contagious diseases because they 1) have not been exposed to many infections, 2) have little or no immunity to these infections, and 3) may not have received any or all of their vaccinations. Close physical contact for extended periods of time, inadequate hygiene habits, and underdeveloped immune systems place children attending childcare and special needs settings at increased risk of infection. For instance, the spread of diarrheal disease may readily occur with children in diapers and others with special needs due to inadequate handwashing, environmental sanitation practices, and diaper changing.

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