C-ACT Scores Research Articles

Improving Asthma in Pediatric Practice

Pediatric asthma is a significant public health problem. It is the third cause of pediatric hospitalizations, costing $20 billion in 2016. In the US, approximately 6 million children have asthma. Despite available guidelines, implementation is lagging with only 35 % of providers using guidelines. The question was does provider compliance of the NAEPP 2007 asthma guidelines improve through an electronic health record (EHR) template in a pediatric primary care practice?" A quality improvement project implemented an EHR template for pediatric asthma visits and provider education to support the compliance of following the NAEEP 2007 asthma guidelines. A retrospective EHR chart review of charts within the same seasonal time frame, ages 5-12yrs was done to determine documentation pre-and post-project implementation. The chi- square was used for statistical significance. Data reviewed were documentation of action plan, severity, adherence to follow-up appointment, prescribing of prevention medication, ED visits and hospitalizations, C-ACT score, spirometry use, education, and missed school days. Documentation of asthma action plan increased from 10 % to 74 % p = 0.001., spirometry rose from 4% to 32 % p =.011, asthma education increased from 60 % to 98% p=.000, follow up adherence rose from 60% to 98% p = .000 and asthma severity categorized improved from 32% to 100 % p=. 011. Statistical significance was shown in 7 out of the 8 quality measurements. The area of prescribing controller medication for persistent asthma showed clinical significance with 58% to 100% improvement, but was not statistically significant (p=.258) because clinical knowledge was present with the providers prior to the intervention on managing persistent asthma. Results support the hypothesis that an EHR template with evidence-based guidelines improved provider documentation of an asthma action plan, severity, follow-up, and prescribing control medication, ED visits, hospitalizations, missed school days, C-ACT score, spirometry and asthma education. View a PDF of this Poster Presentation

A Pragmatic Trial of Symptom-Based Inhaled Corticosteroid Use in African-American Children with Mild Asthma

Symptom-based adjustment (SBA) of inhaled corticosteroids may be an alternative patient-centered approach in which day-to-day inhaled corticosteroid use is adjusted by symptoms and short-acting β-agonist need. To evaluate the effectiveness of SBA in the primary care setting. We conducted a randomized, open-label, pragmatic equivalence trial in African-American children (6-17 years old) with mild asthma managed by 12 primary care providers (PCPs). A total of 206 participants were randomized to SBA (as-needed beclomethasone 80 μg with rescue short-acting β-agonist) or provider-based guideline-directed adjustment (PBA): maintenance beclomethasone 80 μg/d (6-11 years old), 160 μg/d (12-17 years old), with subsequent guideline-based dose adjustment by PCPs. PCPs implemented both treatment assignments, with outcomes measured by blinded staff. All participants received symptom recognition and albuterol use education from peer educators. Primary outcome was change in asthma control (measured by Asthma Control Test [ACT]/childhood ACT [cACT]) over 12 months. Participants had adequately controlled asthma (mean ACT or cACT score= 21.6 ± 2.8) at baseline. After 1 year, there was no significant between-group difference in change in ACT scores (SBA- PBA): ACT: -0.88 (95% CI,-2.19 to 0.42), cACT:-0.73 (-2.09 to 0.62), or combined ACT and cACT (P= .10), and was within the predefined statistical clinical equivalence. The proportion with an exacerbation and measures of lung function were similar between groups. Compared with PBA, SBA led to less beclomethasone use (SBA: 526 μg/mo [95% CI, 412-639 μg] vs PBA: 1961 μg/mo [95% CI, 1681-2241]; P < .0001). More parents in the SBA arm felt they were managing their child's asthma. SBA in African-American children with mild asthma was similar to PBA in asthma control and events when implemented by PCPs with lower inhaled corticosteroid exposure.

The Relationship between Student Admissions Data and Six-Year Degree Completion

This study examined the six-year bachelor’s degree graduation status of freshmen (N = 1,839) entering the Dale Bumpers College of Agricultural, Food and Life Sciences (AFLS) between 2001 and 2010. The overall graduation rate was 64%, including 23% who had transferred out of AFLS. Multinomial logistic regression was used to determine if student entry data differentiated between graduates and non-graduates and between AFLS and non-AFLS graduates. High school GPA (HSGPA), first-generation status, and year of admission to the university significantly differentiated between graduates and non-graduates. Each standard deviation increase in HSGPA was associated with a 224% increase in the relative odds of graduating. Students entering each subsequent year had a 10% increase in the relative odds of graduating. Being a first-generation student decreased the relative odds of graduating by 52%. Year, major, and composite ACT score (CACT) significantly differentiated between AFLS and non-AFLS graduates. Students entering each subsequent year had a 16% increase in the relative odds of being AFLS graduates, while agriculture majors were about twice as likely to be AFLS graduates. Each standard deviation increase in CACT score was associated with a 26% decrease in the relative odds of being an AFLS graduate.

Effects of Intranasal Cellulose Powder on Asthma Control in Children With Mild-to-Moderate Perennial Allergic Rhinitis: A Randomized, Placebo-Controlled Trial

Perennial allergic rhinitis (PAR) often coexists in asthmatic patients. Intranasal cellulose powder (ICP) was reportedly effective in ameliorating PAR. We investigated whether ICP is equally effective compared with intranasal corticosteroids in improving asthma control as well as nasal symptoms among children with PAR and allergic asthma (AA). Between July 2015 and September 2016, we did a single-center, randomized, placebo-controlled trial. Asthmatic children aged 6 to 11 years with mild-to-moderate PAR were randomly assigned to formoterol/budesonide inhalation (4·5 µg/80 µg, twice daily) plus intranasal budesonide 64 µg twice daily (group A), ICP 250 µg thrice daily (group B), or intranasal placebo 250 µg thrice daily (group C) for 8 weeks. The primary outcome was change in asthma control test for children (C-ACT) score from baseline to week 8 posttreatment. Changes in spirometry, peak expiratory flow (PEF), fractional exhaled nitric oxide (FeNO), and visual analog scale (VAS) for nasal and ocular symptoms were detected as secondary outcomes. We included 121 patients (38 in group A, 41 in group B, and 42 in group C) in full-analysis set. C-ACT score was markedly higher at week 8 compared with baseline (mean difference: 5.11, 6.05, and 4.85 points in groups A, B, and C, respectively; P < .05). There were interactions between baseline and treatment in C-ACT scores ( P < .05). Group B demonstrated greater improvement in C-ACT score than group C among children with baseline C-ACT score of 6 to 18. 95% confidence intervals of group A at baseline overlapped with those of groups B and C. The treatment achieved reduced VAS symptoms in groups A and B but not in group C. Incidence of adverse events was comparable. No serious adverse event was reported. ICP could be recommended for children with PAR and AA who have poorer asthma control.

Association of Asthma and Allergic Rhinitis With Sleep-Disordered Breathing in Childhood.

Objective: Asthma and allergic rhinitis (AR) are the most common chronic conditions in childhood and have previously been linked to sleep-related breathing disorder (SRBD). Aim of the study was to examine the association between SRBD risk and asthma control in children with asthma and with or without AR.Methods: The assessment of FeNO and pulmonary function tests were performed in 140 children (65 with asthma, 57 with both asthma, and AR, 18 with only AR). Children with asthma completed the childhood Asthma Control Test (c-ACT), and the Sleep-Related Breathing Disorder scale, extracted from the Pediatric Sleep Questionnaire (PSQ). C-ACT scores ≤ 19 are indicative of poor asthma control whereas SRBD from PSQ scores ≥ 0.33 are suggestive of high risk for SRBD.Results: Mean age ± SD was 7.8 ± 3.1 years. Mean PSQ ± SD and c-ACT ± SD scores were 0.17 ± 0.14 and 24.9 ± 3.2, respectively. High risk for SRBD was identified in 26 children. Children at high risk for SRBD had significantly decreased c-ACT score (P = 0.048), verified by a negative association between c-ACT and PSQ-SRBD scores (r = −0.356, P < 0.001). Additionally a difference in diagnosis distribution between children at high or low risk for SRBD was observed. More specifically, among children at high risk, 88.5% were diagnosed with both atopic conditions, while this percentage among children at low risk was 29.8%. Asthma was mainly diagnosed in the latter group (P < 0.001).Conclusions: Poor asthma control is associated with SRBD. The presence of AR in children with asthma seems to increase the prevalence of SRBD in that particular population, requiring further investigation toward this direction.

Assessment of small airway function and reversibility in symptom-controlled asthma in pediatric patients.

The goals of asthma management aim to control the symptoms and minimize future risk. There is, however, an option to stop controller medication if the patient has been well-controlled for at least 6-12 months. To assess control, both clinical symptom assessment and lung function should be monitored periodically. In practical clinical practice of pediatric patients, lung function is not available at all health centers. to determine lung function with a focus on small airway function and the risk of reversibility among children who have been symptom-controlled. Our participants were symptom-controlled asthmatic children according to GINA Guideline for at least 6 months with low dose inhaled corticosteroid. Written informed-consent was given by the parents and the children. They performed a self-evaluated symptom-controlled test (C-ACT) and a spirometric assessment. Abnormal lung function was defined as FEV1±80%, FEV1/FVC < 80%, and FEF25-75 <65% predicted. Airway reversibility was determined by the change of FEV1 >12% and FEF25-75 >30% post bronchodilator. Forty children (65% male) were enrolled. Age ranged between 6.7 and 15.0 years. The mean C-ACT score was 25.2 ± 1.7. Spirometry results were: mean FEV1 84.0 %, FEV1/FVC 87.8%, and FEF25-75 85.5% predicted. Normal FEV1 was found among 72.5% of participants compared to normal FEF25-75 in 87.5%. Among the abnormal FEV1 and FEF25-75, all were of mild severity as 10% retained airway reversibility. Children with well-controlled asthma, based on their symptom assessment, may have persistent abnormal lung function. Spirometry should be performed before considering cessation of controller medication.

Huaiqihuang granule in adjuvant treatment of childhood asthma: a randomized controlled, multicenter study

Objective To observe the clinical efficacy and safety of GINA regimen and GINA regimen combined with oral Huaiqihuang granule in the treatment of children with bronchial asthma. Methods A randomized, single blind, multicenter, parallel controlled clinical trial wascarried out.A total of 1 128 patients with bronchial asthma in children were randomized into two groups.The observation group were treated with GINA regimen combined with oral Huaiqihuang granule.The GINA regimen treatment group was treated by GINA regimen.Clinical assessment and C-ACT scores was observed in first month, third month, sixth month after treatment.Clinical assessment included the times of upper respiratory tract infection occurrence, bronchitis and pneumonia, asthmatic attacks, application of emergency medicine, hospitalizations due to asthmatic.Drug adverse effect in the two groups was compared. Results The times of upper respiratory tract infection, bronchitis and pneumonia, asthmatic was significantly decreased(P 0.05). Conclusion The treatment of bronchial asthma in children with GINA regimen combined with oral Huaiqihuang granule can significantly reduce the incidence of respiratory infections and the number of asthmatic attacks dramatically and safely improve clinical curative effect, asthma control. Key words: Asthma; Huaiqihuang; Children; Randomized controlled trial; Multicenter study; C-ACT

Effect of Traditional Chinese Medicine on Inflammatory Mediators in Pediatric Asthma

Objective. To observe the effects of empirical prescriptions of traditional Chinese medicine (TCM) on inflammatory mediators in pediatric asthma and to explore the underlying molecular mechanism in the treatment of asthma. Methods. A total of 182 children with asthma were randomly placed into either the TCM group (n = 97) or the salbutamol and montelukast (SM) group (n = 85). Patients in the TCM group were treated with a series of empirical prescriptions of TCM, while those in the SM group received salbutamol and montelukast. Both groups received their respective treatment for 12 weeks. There were 35 patients in TCM group and 34 patients in SM group providing venous blood. Real-time PCR was used to determine the mRNA expression levels of interleukin- (IL-) 10, IL-17, matrix metalloproteinase-9 (MMP-9), and transforming growth factor β1 (TGF-β1) in peripheral blood mononuclear cells before and after treatment. Enzyme-linked immunosorbent assay was used to measure the levels of IL-10, IL-17, MMP-9, and TGF-β1 in peripheral blood before and after treatment. Results. The mRNA expression of TGF-β1 in the SM group was downregulated (P = 0.00) after treatment. No significant differences were found between the TCM group and the SM group after treatment (P > 0.05). In the TCM group, the levels of IL-10, IL-17, and MMP-9 significantly decreased after treatment (P = 0.01, 0.04, and 0.03, resp.). In the SM group, IL-17, MMP-9, and TGF-β1 levels significantly decreased after treatment (P = 0.00, 0.03, and 0.00, resp.). There was no significant difference between the two groups regarding the levels of IL-10, IL-17, TGF-β1, and MMP-9 (P > 0.05). The difference of the level of IL-17 was negatively correlated with the change of C-ACT score in TCM group and SM group. Conclusion. TCM has a regulatory effect on the balance of some inflammatory mediators in pediatric asthma.

Validation of the Brazilian version of the childhood asthma control test (c-ACT).

Children's perception of their symptoms has proved reliable and relevant to disease management and should be considered when assessing their asthma control. The aim of the study is to validate the Brazilian Portuguese version of the Childhood Asthma Control Test (c-ACT) in children aged 4-11 years. This is a cross-sectional study in children diagnosed with asthma undergoing treatment in a pediatric pulmonology outpatient clinic in Porto Alegre, Brazil. The translation and linguistic adaptation of the instrument were performed in accordance with international recommendations for questionnaire validation. A total of 105 participants were included, aged 4-11 years. all correlations between the total score and items on the questionnaire were significant and obtained values of r ≥ 0.3, and c-ACT means showed statistically significant differences between the GINA categories (P < 0.01). The controlled asthma group showed significantly higher c-ACT scores than those of uncontrolled asthma group (controlled 22.0 ± 2.9 vs. uncontrolled 16.3 ± 5.3 P < 0.01); and partially controlled asthma group showed significantly higher c-ACT scores than those of uncontrolled asthma group (partially controlled 20.0 ± 4.0 vs. uncontrolled 16.3 ± 5.3 P = 0.03). Correlations between the c-ACT total score and spirometry and nitric oxide were poor (r = 0.020; P = 0.866 and r = 0.035; P = 0.753, respectively). Reliability: the α-C coefficient for the c-ACT total score was 0.677 (95%CI 0.573-0763). Sensitivity to change had an effect size of 0.8 and an intraclass correlation coefficient of 0.598. No floor or ceiling effects were observed. The Brazilian version of the Childhood Asthma Control Test proved to be valid and reliable in children aged 4-11 years.

Validation of the Spanish version of the childhood asthma control test (cACT) in a population of Hispanic children

Background: There is a critical need for additional validation studies of questionnaires designed to assess the level of control of asthma in pediatric patients. Objective: To validate the Spanish version of the Childhood Asthma Control Test (cACT) in children aged between 4 and 11 years with physician-diagnosed asthma. Methods: In a prospective cohort validation study, asthmatic children aged between 4 and 11 years and their parents, attended both a baseline and a follow-up visit 2 to 6 weeks later. In these two visits, they completed the information required to assess the criterion validity, construct validity, test-retest reliability, sensitivity to change, internal consistency and usability of the cACT. Results: At baseline, cACT scores were significantly different between patients with controlled, partly controlled and uncontrolled asthma [24.0 (23.0–26.0), 18.0 (18.0–22.0), and 17.5 (13.0–20.0), respectively, p < 0.001], and also between patients for whom this visit resulted in a step-up, no change or step-down in therapy [18.0 (15.0–21.0), 24.0 (23.0–24.0) and 26.0 (23.5–26.0) respectively, p < 0.001]. The score of the cACT correlated positively and significantly with the score of the Pediatric Asthma Caregivers Quality of life Questionnaire - PACQLQ (Spearman's rho = 0.50, p < 0.001). The intraclass correlation coefficient of the measurements in patients with no change in clinical status was 0.849 (95% CI: 0.752–0.908). There were statistical significant differences between baseline and follow-up cACT scores in patients with an improvement in clinical status [19.0 (18.0–22.0) versus 24.5 (24.0–25.0), p < 0.001]. Cronbach's α was 0.8276 for the questionnaire as a whole. Conclusion: The Spanish version of the cACT has adequate criterion validity, adequate construct validity, adequate sensitivity to change, good internal consistency, good test-retest reliability and excellent usability when administered to asthmatic children aged between 4 and 11 years.

Disparities in assessments of asthma control between children, parents, and physicians

Assessment of asthma control in children by physicians, patients and their parents was compared, assuming parents may underestimate symptoms in asthmatic children and exploring whether physicians tend to agree with them. Asthma control perception was assessed in 4- to 11-year-old asthmatic children and their parents, using C-ACT, during 2011-2012. Pediatric pulmonologists used GINA guidelines for their assessment; pediatricians, not having spirometry, used the information given in addition to physical examination. The C-ACT scores given by the children and their parents were further analyzed separately, and compared with their physicians' assessment. Statistical methods, which also measured possible influence of different variables, included kappa, Chi-square, linear-by-linear association, McNemar test and logistic regression. The study comprised 354 parents and children aged 4-11 years with moderate-severe asthma; 129 (36.4%) were treated by 23 pediatricians; 225 (63.6%) by 11 pediatric pulmonologists. The C-ACT was generally found valid in assessing asthma control (P < 0.001; κ 0.529; CI 0.441, 0.617) and showed that in 229/354 (53%) of children the asthma was uncontrolled. Nevertheless, of the 229 children who indicated their asthma was uncontrolled, 124 (54.1%) of their parents (κ 0.245; CI 0.15, 0.34) and 96 (41.9%) of their physicians believed it to be controlled (κ 0.331; 0.24, 0.43). Comparing the physician-child discordance vis-à-vis the parents, the significant difference was when 96/229 children (41.9%) and 34/126 parents (27.0%) indicated the asthma was uncontrolled while the physician determined it controlled (OR 1.95; 1.19, 3.24). There were no significant differences between pediatric pulmonologists and pediatricians. In addition to increasing awareness of parents to symptoms in their asthmatic children, physicians should question the child appropriately, as well as using the children's responses to C-ACT as an information source for properly assessing asthma control.

Relationship between exhaled leukotriene and 8-isoprostane levels and asthma severity, asthma control level, and asthma control test score

ObjectiveExhaled breath condensate (EBC) is a completely non-invasive method for the collection of airway secretions to measure intense inflammation in the airways of asthmatics. It has been shown that the childhood asthma control test (c-ACT) is a good tool for use in the evaluation of asthmatics. Whether the c-ACT score and asthma control level correlate with the airway inflammation is not well known. We aimed to evaluate the relationship between exhaled cysteinyl leukotrienes (Cys-LTs) and 8-isoprostane levels and asthma severity, asthma control level and c-ACT score in asthmatic children. MethodsThirty asthmatic children were evaluated with c-ACT score and pulmonary function tests. Asthma severity and asthma control level were assessed according to GINA. EBC was collected and Cys-LTs and 8-isoprostane concentrations were determined using a specific immunoassay kit. ResultsExhaled 8-isoprostane level in patients with moderate persistent asthma [114 (55–146)pg/ml] was higher than in the mild persistent group [52 (21–91)pg/ml] (p=0.05, Mann–Whitney U [MWU]). EBC 8-isoprostane in children with 1–4 asthma exacerbations/year [52 (16–80)pg/ml] was significantly lower than in children with >4 asthma exacerbations/year [114 (57–129)pg/ml] (p<0.05, MWU). No significant relation was determined between exhaled 8-isoprostane and Cys-LTs levels and c-ACT score and asthma control level. Exhaled 8-isoprostane correlated negatively with bronchodilator response (p=0.015, r=−0.45). ConclusionsExhaled 8-isoprostane, as an oxidative stress specifier, was found to be increased in relation with asthma exacerbation frequency and oxidative stress increases with the severity of asthma. In contrast to asthma severity level, c-ACT score and asthma control level may not reflect airway inflammation.