Reversal of Deficits in Down
Neurologic
Syndrome
Sir.\p=m-\While doing a literature search on the drug amantadine, I came across an anecdotal Letter to the Editor of the Medical Journal of Australia by Dr Gordon White. Dr White reported treating a male infant with classic
with graduated doses of amantadine for "prevention of respiratory complications, particularly those due to A2 influenza virus."1 Dr White claimed that during treatment with amantadine, which began when the infant was 2 weeks old and continued until age 9 months (at which time Dr White wrote his letter), the child had "developed according to the accepted mental-age milestones. On days that the child was not given amantadine, there was a loss in muscle tone, increased floppiness, excessive drooling at the Down
syndrome
mouth, etc."1 Despite this intriguing observation, there have been no further reports in the medical literature
of use of amantadine in Down syndrome. However, the possibility that amantadine could have a beneficial effect in Down syndrome is substantiated by recent research demonstrat¬ ing similar neuropathologic changes in patients with Down syndrome, Alzheimer's disease, and Parkinson's disease,2·3 and neurotransmitter de¬ fects similar to those associated with these conditions.4 Amantadine has shown beneficial effects in the treat¬ ment of advanced Alzheimer's dis¬ ease5-6 and has also been used for treat¬ ment of Parkinson's disease since 1969.7 Most intriguing and relevant to this letter is the dopaminergic system def¬ icits seen in Down syndrome, Alz¬ heimer's disease, and Parkinson's dis¬ ease. Dopamine-ß-hydroxylase lev¬ els and activity are decreased in Down syndrome,8 and Down syndrome, Alzheimer's disease, and Parkinson's disease are all characterized by
marked reduction in choline
Roffman M, Ebstein RP, Goldstein M. Serum acetyl- dopamine-beta-hydroxylase levels in Down's Clin Genet.
transferase,5,9 norepinephrine, and se¬ rotonin.9 Therefore, it should not be surprising that amantadine, which causes release of dopamine from cen¬ tral neurons, facilitates dopamine re¬ lease by nerve impulses,10 and delays the reuptake of dopamine by neural cells,10 would be useful in Down syn¬ drome. Most important, when con¬ sidering the extensive amount of in¬ formation available concerning the pharmacologie aspects and clinical use of amantadine, coupled with its min¬ imal and readily reversible side ef¬ fects, the benefit-risk ratio for use of amantadine in Down syndrome would favor its use. If it is used in patients with Down syndrome, at least one beneficial effect can be an¬
ticipated—protection against
Calcutt NA, Benton M. Alzheimer-like neurotransmitter deficits in adult Down's syndrome brain tissue. J Neurol Neurosurg Psychiatry.
most
strains of influenza A virus.10 Al¬ though amantadine may not be the optimal treatment for any of the re¬ ported neurologic diseases for which it has been suggested, I believe the neurologic similarities between Down syndrome, Alzheimer's disease, and Parkinson's disease warrant con¬ trolled clinical studies to investigate whether amantidine is truly benefi¬ cial in Down syndrome. MICHAEL R. SCHINITSKY, MD 5630 Lake Mendota Dr Madison, WI 53705
Improving babies with Down's Med J Aust. 1974;2:184. 2. Mann DMA. The locus coeruleus and its possible role in ageing and degenerative diseases of the human central nervous system. Mech Ageing Dev. 1983;23:73-94. 3. Mann DMA, Yates PO, Hawkes J. The pathology of the human locus ceruleus. Clin 1. White G.
syndrome.
Neuropathol. 1983;2:1-7. 4. Horiguchi J, Inami Y, Shoda T. Effects of long-term amantadine treatment on clinical symptoms and EEG of a patient in a vegetative state. Clin Neuropharmacol. 1990;13:84-88. 5. Erkulwater S, Pillai R. Amantadine and the end-stage dementia of Alzheimer's type. South Med J. 1989;82:550-554. 6. Muller HF, Dastoor DP, Kinkgner A, Cole M, Boillat J. Amantadine
in senile dementia:
electroencephalographic and
clinical effects.
J Am Geriatr Soc. 1979;27:9-16. 7. Brain W. Brain's Diseases of the Nervous
System. 9th ed. New York, NY: versity Press Inc; 1985:328-334. 8. Coleman M,
1974;5:312-315. syndrome. 9. Godridge H, Reynolds GP, Czudek C,
Oxford Uni-
Campbell M, Freedman LS,
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/18/2015
1987;50:775-778. 10. Gilman AG, Rail TW, Nies AS, Taylor P,
eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 8th ed. Elmsford NY: Pergamon Press Inc; 1990:472-473,1191.
Misuse of Metered Dose Inhalers by House Staff Members Sir. \p=m-\Medications deliveredbyinhaled aerosols have become the therapy of choice for management of hyperreactive airway disease.1,2 Many aerosol preparations containing B-ago-
nists, anticholinergic agents, steroids,
and cromolyn sodium are available. Medications administered via inhalation are preferred to oral medications because the drug is delivered directly to airway receptor sites in the lungs. Therefore, lower doses can be used, the onset of action is usually more rapid, and the incidence of side effects is reduced. Because of advances in pharmacology and devel-
opments
in
respiratory physiology,
metered dose inhalers are the preferred method for delivery of asthma medications. It is not unusual for patients to require two or three different metered dose inhalers (MDIs) for asthma control. However, the patient must perform a complex series of maneuvers to successfully use the MDI. A number of surveys have shown that anywhere from 14% to 75% of patients in hospital clinics who use MDIs have less than perfect
technique.3,4
It is unclear why the percentage of patients who use MDI correctly var¬ ies so widely. Verbal instructions, me¬ chanical aids, and video presentations
have been used, all with mixed re¬ sults.5 Many physicians have noted that repeated demonstration, along with verbal instructions, has the great¬ est effect in retention of desired skills.
5. A good, slow inspiratory effort (to vital capacity) 6. Only one MDI actuation per breath 7. Holding the breath for at least 5
seconds Either
an
open
or
closed mouth tech¬
nique was accepted. Results.—Oí53 participants in this
study, 52 agreed to demonstrate "proper" MDI technique. Most par¬ ticipants (50 [96%]) were pediatrics
Average number of errors in using metered dose inhalers per year of residency. PGY indicates postgraduate year.
Although numerous studies have evaluated the improper use of MDIs by patients, little has been written on improper physician education and in¬ struction on MDI use.6 It was our be¬ lief that a significant number of phy¬ sicians prescribing MDIs did not know how to properly demonstrate their use. Our study examined the ability of house staff physicians who rou¬ tinely prescribe MDIs to properly demonstrate as well as instruct their patients on the use of MDIs. Methods.— This
study
was
conducted
in March 1991. The participants had com¬ pleted at least 9 months of residency training. A total of 53 house staff physi¬ cians from teaching hospitals in Manhat¬ tan and The Bronx, NY, who were on site during the 2 days of the study were asked to participate. An initial questionnaire
completed by
each participant ascer¬ tained level of training, specialty, whether the participant had prescribed MDIs, and whether the participant felt comfortable (yes or no) educating pa¬ tients on proper MDI technique. Subse¬ quently, each participant was given a placebo MDI and asked to demonstrate proper MDI technique. All subjects were evaluated by at least two experienced ob¬ servers. The seven separate steps evalu¬ ated were as follows: 1. Shaking the MDI and removing the cap 2. Exhaling prior to MDI use 3. Holding the MDI upright 4. Proper timing of MDI actuation (at the start of inspiration)
house staff members, and two (4%) were house staff members in family practice. The level of training varied from postgraduate year-1 to postgrad¬ uate year-4. Only five (10%) of the 52 participants demonstrated perfect MDI technique (all seven steps). The overall incidence of errors by partic¬ ipants was 2.4 errors per person, and the incidence of errors per year of training varied from 3.07 errors per person for postgraduate year-1 par¬ ticipants to 1.75 errors per person for
postgraduate year-4 participants (Fig¬ ure).
The most
frequently observed er¬
follows: failure to hold the breath for at least 5 seconds (28 cases [54%]), failure to shake the MDI before use (25 cases [48%]), failure to exhale before MDI use (21 cases [40%]), and actuating the MDI more than once during a single breath (15 cases [29%]). Thirteen participants (25%) demonstrated poor inspiratory effort, and 12 (23%), poor timing of actuation. The MDI was held upside down by eight participants (15% ), and three participants made other errors, including one participant who failed to remove the MDI mouthpiece cover before use. All participants had pre¬ viously prescribed medications deliv¬ ered via MDIs, and 50 (94%) felt com¬ fortable in educating and demonstrat¬ ing proper MDI technique to their patients. Only 25 participants (49%) had read the manufacturer's instruc¬ tion insert, which is available from numerous sources and is enclosed in all currently available MDI prepara¬ rors were as
Thirty participants (58%) re¬ sponded that they routinely check their patients' MDI technique at fol¬ low-up visits. tions.
Comment. —The use of MDIs for the management of hyperreactive airway disease has become increasingly wide¬ spread. The efficacy of MDIs as a de¬ livery system of medication to the
airways is unquestioned. Although it
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/18/2015
is known that most of the aerosol is deposited in the oropharynx, signif¬ icant bronchodilatation is probably produced only by the 10% to 14% of medication that reaches the lower air¬ ways.47 However, studies3'4 show that proper MDI technique is essential for maximum benefit and that if an op¬ timal technique is used, airway dep¬ osition of medication can almost be
doubled. We believe that physicians who pre¬ scribe MDIs should educate their pa¬ tients on their proper use. To do this effectively, they must have mastered proper MDI technique. Although a less than perfect MDI technique prob¬ ably results in some degree of bron¬ chodilatation, optimal results will be had if an ideal MDI technique is used.2-38 It is obviously not in the pa¬ tient's best interest to be taught an incorrect MDI technique. The impor¬ tance of verifying and correcting MDI technique on follow-up visits has been
previously reported.4-9 More emphasis should
be placed staff house members educating the proper use of MDIs so that they, in turn, are better able to dem¬ onstrate and teach the technique to their patients. These physicians will then be more qualified to evaluate and correct patient MDI technique on follow-up visits. We suggest that each house staff physician be given a placebo MDI and taught proper tech¬ nique during his or her internship. We also suggest that MDI technique be verified periodically during sub¬ sequent training. By teaching and maintaining an ideal MDI technique, physicians will help patients gain maximal benefit from their medica¬ tions. JUAN C. MAS, MD DAVID J. RESNICK, MD DEAN E. FIRSCHEIN, MD B. ROBERT FELDMAN, MD WILLIAM J. DAVIS, MD on on
Columbia-Presbyterian
Medical Center Division of Allergy Department of Pediatrics 3959 Broadway, #107N New York, NY 10032 1. Svedmyr N. The current place of B2agonists in the management of asthma. Lung. 1990;168(suppl):105-110. 2. Crompton GK. The adult patient's difficulties with inhalers. Lung. 1990;168(suppl): 658-662. 3. Buckley D. Assessment of inhaler tech-
nique in general practice. Ir J Med Sci. 1989;158:297-299. 4. Kemp JP, Meltzer EO. Beta 2 adrenergic
oral or aerosol for the treatment of asthma? J Asthma. 1990;27:149-157. 5. McElnay JC, Scott MG, Armstrong AP, Stanford CF. Audiovisual demonstration for patient counselling in the use of pressurized aerosol bronchodilator inhalers. J Clin Pharm Ther. 1989;14:135-144. 6. Frew AJ, MacFarlane JT. Poor inhaler technique may be perpetuated by clinical staff. Practitioner. 1984;228:883. 7. Williams TJ. The importance of aerosol technique: does speed of inhalation matter? Br] Dis Chest. 1982;76:223-228. 8. Allen SC, Prior A. What determines whether an elderly patient uses a metered dose inhaler correctly? Br J Dis Chest.
agonists:
1986;80:45-49. 9. Lee H, Evans HE. Evaluation of inhalation
aids of metered dose inhalers in asthmatic children. Chest. 1987;91:366-369.
Pediatric Medical Advice Enhanced With Use of Video Sir.\p=m-\Countless times every day, pediatricians repeat standard medical advice to parents and patients at office visits. There is variable understanding and retention of information.1 Use of video can enhance patient education, but there has been a delay in the introduction of video into the pediatric office because administering video programs has been impractical and cumbersome in busy pediatric offices due to space and time limitations. It is popular to show general pediatric videos in the waiting room, but such administration is not educationally effective2 and is not meant to
give specific diag-
nosis-based medical advice. Most Evaluation
existing videotapes
are
long,
cum-
bersome, and inefficient to administer; most do not use television-
quality production techniques to increase comprehension and hold viewer attention. If properly administered, high-quality videos can enhance patient understanding and retention of information as well as improve clinical compliance.3 They can also enable clinicians to more easily demonstrate home management techniques in the office4 and to dramatize the danger signs that parents should know.5 In 10 private pediatric offices where 204 patients with common pediatric
diagnoses were treated, our survey revealed that pediatricians believed that a videotape would "perhaps" be useful for 45% of visits and would "definitely" be useful for 44% of vis¬ its. Parents and patients wanted to see a video about the diagnosis 81% of the time. Production.—
apply
atric offices, short "news were
developed
with
videos in
pedi¬
spot" programs
emphasis
portant medical advice for
on
im¬
treatment of
pediatric conditions. To be eas¬ ily administered and effectively used in the office, video programs had to be practical, universal, and succinct. Each script was developed based on results of a survey of pediatricians about their most important advice for the care and treat¬ common
ment of each condition.
Four broadcast-quality programs were produced: Cold & Flu Virus (3 minutes),
(3 minutes), Middle-Ear Infection (2.5 minutes), and Chest Therapy (1.5 minutes). In each, voice-over views of patients and parents were presented that Fever
gave information and showed treat-
ments, while frequent scene changes and intimate close-ups enhanced viewer in¬ terest and promoted better understand¬ ing of material.
Frequent rewinding of tapes and searching for topic programs on one se¬ rial tape are impractical. Accordingly, for each topic, a separate tape was assembled that repeated the same program many
times and therefore enabled instant ac¬ cess to the same topic. There was no need to rewind or search after each viewing. Administration. —Initially, after each pediatric examination, the patient and parent were moved from the examina¬ tion room to an education room where the appropriate advice video was admin¬ istered by the pediatrician. While the patient watched the selected short pro¬ gram, the pediatrician completed the medical record and wrote prescriptions. The tape was ejected by the patient each time a program was finished. The pedia¬ trician then returned for follow-up dis¬ cussion.
Later, more efficiency was achieved by installing a closed-circuit television mon¬
itor in each examination room, with dif¬ ferent programs continuously repeating on separate channels. Evaluation. Questionnaires were anonymously completed by viewers and dropped in a box. Responses from pa¬ tients and parents were very positive, and written comments were very en¬ thusiastic. The number of individual re¬ sponses and the mean responses on a Likert scale (1 through 4 points) for each question are shown in the Table. Pediatricians strongly believed that vid¬ eotapes were helpful and saved them much demonstration time. The initial response to this video approach was so positive that many other pediatricians requested the videotapes for their use. A pilot study of otitis treatment and —
follow-up suggested improved compli¬ ance
with video
use.
Questionnaire for a Video Program on Colds and Influenza* Points
on
the Likert Scale
1
2
(A Little)
(Some)
(Pretty Much)
(A Lot)
Mean Score on the Likert Scale
3 0
32
43
37
2.8
2
32
83
3.5
1
7
30
80
3.4
7
20
50
40
2.9
9 30
29
33
43
2.8
42
11
22
2.1
2
16
27
71
3.3
3 1 how much did like the video? Overall, you "Values for columns 1 through 4 are number of responses for each
7
39
65
3.3
7
38
69
3.4
How much did you learn from it? Was it easy for you to understand? Is it a good idea to use the video in the doctor's office?
Did it answer your questions or concerns? Did it add to what the doctor told you? Would you like to watch it again? Would you recommend it to others? Is it good for explaining the medical problem and treatment?
point on
4
the Likert scale.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/18/2015
Neurologic
Syndrome
Sir.\p=m-\While doing a literature search on the drug amantadine, I came across an anecdotal Letter to the Editor of the Medical Journal of Australia by Dr Gordon White. Dr White reported treating a male infant with classic
with graduated doses of amantadine for "prevention of respiratory complications, particularly those due to A2 influenza virus."1 Dr White claimed that during treatment with amantadine, which began when the infant was 2 weeks old and continued until age 9 months (at which time Dr White wrote his letter), the child had "developed according to the accepted mental-age milestones. On days that the child was not given amantadine, there was a loss in muscle tone, increased floppiness, excessive drooling at the Down
syndrome
mouth, etc."1 Despite this intriguing observation, there have been no further reports in the medical literature
of use of amantadine in Down syndrome. However, the possibility that amantadine could have a beneficial effect in Down syndrome is substantiated by recent research demonstrat¬ ing similar neuropathologic changes in patients with Down syndrome, Alzheimer's disease, and Parkinson's disease,2·3 and neurotransmitter de¬ fects similar to those associated with these conditions.4 Amantadine has shown beneficial effects in the treat¬ ment of advanced Alzheimer's dis¬ ease5-6 and has also been used for treat¬ ment of Parkinson's disease since 1969.7 Most intriguing and relevant to this letter is the dopaminergic system def¬ icits seen in Down syndrome, Alz¬ heimer's disease, and Parkinson's dis¬ ease. Dopamine-ß-hydroxylase lev¬ els and activity are decreased in Down syndrome,8 and Down syndrome, Alzheimer's disease, and Parkinson's disease are all characterized by
marked reduction in choline
Roffman M, Ebstein RP, Goldstein M. Serum acetyl- dopamine-beta-hydroxylase levels in Down's Clin Genet.
transferase,5,9 norepinephrine, and se¬ rotonin.9 Therefore, it should not be surprising that amantadine, which causes release of dopamine from cen¬ tral neurons, facilitates dopamine re¬ lease by nerve impulses,10 and delays the reuptake of dopamine by neural cells,10 would be useful in Down syn¬ drome. Most important, when con¬ sidering the extensive amount of in¬ formation available concerning the pharmacologie aspects and clinical use of amantadine, coupled with its min¬ imal and readily reversible side ef¬ fects, the benefit-risk ratio for use of amantadine in Down syndrome would favor its use. If it is used in patients with Down syndrome, at least one beneficial effect can be an¬
ticipated—protection against
Calcutt NA, Benton M. Alzheimer-like neurotransmitter deficits in adult Down's syndrome brain tissue. J Neurol Neurosurg Psychiatry.
most
strains of influenza A virus.10 Al¬ though amantadine may not be the optimal treatment for any of the re¬ ported neurologic diseases for which it has been suggested, I believe the neurologic similarities between Down syndrome, Alzheimer's disease, and Parkinson's disease warrant con¬ trolled clinical studies to investigate whether amantidine is truly benefi¬ cial in Down syndrome. MICHAEL R. SCHINITSKY, MD 5630 Lake Mendota Dr Madison, WI 53705
Improving babies with Down's Med J Aust. 1974;2:184. 2. Mann DMA. The locus coeruleus and its possible role in ageing and degenerative diseases of the human central nervous system. Mech Ageing Dev. 1983;23:73-94. 3. Mann DMA, Yates PO, Hawkes J. The pathology of the human locus ceruleus. Clin 1. White G.
syndrome.
Neuropathol. 1983;2:1-7. 4. Horiguchi J, Inami Y, Shoda T. Effects of long-term amantadine treatment on clinical symptoms and EEG of a patient in a vegetative state. Clin Neuropharmacol. 1990;13:84-88. 5. Erkulwater S, Pillai R. Amantadine and the end-stage dementia of Alzheimer's type. South Med J. 1989;82:550-554. 6. Muller HF, Dastoor DP, Kinkgner A, Cole M, Boillat J. Amantadine
in senile dementia:
electroencephalographic and
clinical effects.
J Am Geriatr Soc. 1979;27:9-16. 7. Brain W. Brain's Diseases of the Nervous
System. 9th ed. New York, NY: versity Press Inc; 1985:328-334. 8. Coleman M,
1974;5:312-315. syndrome. 9. Godridge H, Reynolds GP, Czudek C,
Oxford Uni-
Campbell M, Freedman LS,
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/18/2015
1987;50:775-778. 10. Gilman AG, Rail TW, Nies AS, Taylor P,
eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 8th ed. Elmsford NY: Pergamon Press Inc; 1990:472-473,1191.
Misuse of Metered Dose Inhalers by House Staff Members Sir. \p=m-\Medications deliveredbyinhaled aerosols have become the therapy of choice for management of hyperreactive airway disease.1,2 Many aerosol preparations containing B-ago-
nists, anticholinergic agents, steroids,
and cromolyn sodium are available. Medications administered via inhalation are preferred to oral medications because the drug is delivered directly to airway receptor sites in the lungs. Therefore, lower doses can be used, the onset of action is usually more rapid, and the incidence of side effects is reduced. Because of advances in pharmacology and devel-
opments
in
respiratory physiology,
metered dose inhalers are the preferred method for delivery of asthma medications. It is not unusual for patients to require two or three different metered dose inhalers (MDIs) for asthma control. However, the patient must perform a complex series of maneuvers to successfully use the MDI. A number of surveys have shown that anywhere from 14% to 75% of patients in hospital clinics who use MDIs have less than perfect
technique.3,4
It is unclear why the percentage of patients who use MDI correctly var¬ ies so widely. Verbal instructions, me¬ chanical aids, and video presentations
have been used, all with mixed re¬ sults.5 Many physicians have noted that repeated demonstration, along with verbal instructions, has the great¬ est effect in retention of desired skills.
5. A good, slow inspiratory effort (to vital capacity) 6. Only one MDI actuation per breath 7. Holding the breath for at least 5
seconds Either
an
open
or
closed mouth tech¬
nique was accepted. Results.—Oí53 participants in this
study, 52 agreed to demonstrate "proper" MDI technique. Most par¬ ticipants (50 [96%]) were pediatrics
Average number of errors in using metered dose inhalers per year of residency. PGY indicates postgraduate year.
Although numerous studies have evaluated the improper use of MDIs by patients, little has been written on improper physician education and in¬ struction on MDI use.6 It was our be¬ lief that a significant number of phy¬ sicians prescribing MDIs did not know how to properly demonstrate their use. Our study examined the ability of house staff physicians who rou¬ tinely prescribe MDIs to properly demonstrate as well as instruct their patients on the use of MDIs. Methods.— This
study
was
conducted
in March 1991. The participants had com¬ pleted at least 9 months of residency training. A total of 53 house staff physi¬ cians from teaching hospitals in Manhat¬ tan and The Bronx, NY, who were on site during the 2 days of the study were asked to participate. An initial questionnaire
completed by
each participant ascer¬ tained level of training, specialty, whether the participant had prescribed MDIs, and whether the participant felt comfortable (yes or no) educating pa¬ tients on proper MDI technique. Subse¬ quently, each participant was given a placebo MDI and asked to demonstrate proper MDI technique. All subjects were evaluated by at least two experienced ob¬ servers. The seven separate steps evalu¬ ated were as follows: 1. Shaking the MDI and removing the cap 2. Exhaling prior to MDI use 3. Holding the MDI upright 4. Proper timing of MDI actuation (at the start of inspiration)
house staff members, and two (4%) were house staff members in family practice. The level of training varied from postgraduate year-1 to postgrad¬ uate year-4. Only five (10%) of the 52 participants demonstrated perfect MDI technique (all seven steps). The overall incidence of errors by partic¬ ipants was 2.4 errors per person, and the incidence of errors per year of training varied from 3.07 errors per person for postgraduate year-1 par¬ ticipants to 1.75 errors per person for
postgraduate year-4 participants (Fig¬ ure).
The most
frequently observed er¬
follows: failure to hold the breath for at least 5 seconds (28 cases [54%]), failure to shake the MDI before use (25 cases [48%]), failure to exhale before MDI use (21 cases [40%]), and actuating the MDI more than once during a single breath (15 cases [29%]). Thirteen participants (25%) demonstrated poor inspiratory effort, and 12 (23%), poor timing of actuation. The MDI was held upside down by eight participants (15% ), and three participants made other errors, including one participant who failed to remove the MDI mouthpiece cover before use. All participants had pre¬ viously prescribed medications deliv¬ ered via MDIs, and 50 (94%) felt com¬ fortable in educating and demonstrat¬ ing proper MDI technique to their patients. Only 25 participants (49%) had read the manufacturer's instruc¬ tion insert, which is available from numerous sources and is enclosed in all currently available MDI prepara¬ rors were as
Thirty participants (58%) re¬ sponded that they routinely check their patients' MDI technique at fol¬ low-up visits. tions.
Comment. —The use of MDIs for the management of hyperreactive airway disease has become increasingly wide¬ spread. The efficacy of MDIs as a de¬ livery system of medication to the
airways is unquestioned. Although it
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/18/2015
is known that most of the aerosol is deposited in the oropharynx, signif¬ icant bronchodilatation is probably produced only by the 10% to 14% of medication that reaches the lower air¬ ways.47 However, studies3'4 show that proper MDI technique is essential for maximum benefit and that if an op¬ timal technique is used, airway dep¬ osition of medication can almost be
doubled. We believe that physicians who pre¬ scribe MDIs should educate their pa¬ tients on their proper use. To do this effectively, they must have mastered proper MDI technique. Although a less than perfect MDI technique prob¬ ably results in some degree of bron¬ chodilatation, optimal results will be had if an ideal MDI technique is used.2-38 It is obviously not in the pa¬ tient's best interest to be taught an incorrect MDI technique. The impor¬ tance of verifying and correcting MDI technique on follow-up visits has been
previously reported.4-9 More emphasis should
be placed staff house members educating the proper use of MDIs so that they, in turn, are better able to dem¬ onstrate and teach the technique to their patients. These physicians will then be more qualified to evaluate and correct patient MDI technique on follow-up visits. We suggest that each house staff physician be given a placebo MDI and taught proper tech¬ nique during his or her internship. We also suggest that MDI technique be verified periodically during sub¬ sequent training. By teaching and maintaining an ideal MDI technique, physicians will help patients gain maximal benefit from their medica¬ tions. JUAN C. MAS, MD DAVID J. RESNICK, MD DEAN E. FIRSCHEIN, MD B. ROBERT FELDMAN, MD WILLIAM J. DAVIS, MD on on
Columbia-Presbyterian
Medical Center Division of Allergy Department of Pediatrics 3959 Broadway, #107N New York, NY 10032 1. Svedmyr N. The current place of B2agonists in the management of asthma. Lung. 1990;168(suppl):105-110. 2. Crompton GK. The adult patient's difficulties with inhalers. Lung. 1990;168(suppl): 658-662. 3. Buckley D. Assessment of inhaler tech-
nique in general practice. Ir J Med Sci. 1989;158:297-299. 4. Kemp JP, Meltzer EO. Beta 2 adrenergic
oral or aerosol for the treatment of asthma? J Asthma. 1990;27:149-157. 5. McElnay JC, Scott MG, Armstrong AP, Stanford CF. Audiovisual demonstration for patient counselling in the use of pressurized aerosol bronchodilator inhalers. J Clin Pharm Ther. 1989;14:135-144. 6. Frew AJ, MacFarlane JT. Poor inhaler technique may be perpetuated by clinical staff. Practitioner. 1984;228:883. 7. Williams TJ. The importance of aerosol technique: does speed of inhalation matter? Br] Dis Chest. 1982;76:223-228. 8. Allen SC, Prior A. What determines whether an elderly patient uses a metered dose inhaler correctly? Br J Dis Chest.
agonists:
1986;80:45-49. 9. Lee H, Evans HE. Evaluation of inhalation
aids of metered dose inhalers in asthmatic children. Chest. 1987;91:366-369.
Pediatric Medical Advice Enhanced With Use of Video Sir.\p=m-\Countless times every day, pediatricians repeat standard medical advice to parents and patients at office visits. There is variable understanding and retention of information.1 Use of video can enhance patient education, but there has been a delay in the introduction of video into the pediatric office because administering video programs has been impractical and cumbersome in busy pediatric offices due to space and time limitations. It is popular to show general pediatric videos in the waiting room, but such administration is not educationally effective2 and is not meant to
give specific diag-
nosis-based medical advice. Most Evaluation
existing videotapes
are
long,
cum-
bersome, and inefficient to administer; most do not use television-
quality production techniques to increase comprehension and hold viewer attention. If properly administered, high-quality videos can enhance patient understanding and retention of information as well as improve clinical compliance.3 They can also enable clinicians to more easily demonstrate home management techniques in the office4 and to dramatize the danger signs that parents should know.5 In 10 private pediatric offices where 204 patients with common pediatric
diagnoses were treated, our survey revealed that pediatricians believed that a videotape would "perhaps" be useful for 45% of visits and would "definitely" be useful for 44% of vis¬ its. Parents and patients wanted to see a video about the diagnosis 81% of the time. Production.—
apply
atric offices, short "news were
developed
with
videos in
pedi¬
spot" programs
emphasis
portant medical advice for
on
im¬
treatment of
pediatric conditions. To be eas¬ ily administered and effectively used in the office, video programs had to be practical, universal, and succinct. Each script was developed based on results of a survey of pediatricians about their most important advice for the care and treat¬ common
ment of each condition.
Four broadcast-quality programs were produced: Cold & Flu Virus (3 minutes),
(3 minutes), Middle-Ear Infection (2.5 minutes), and Chest Therapy (1.5 minutes). In each, voice-over views of patients and parents were presented that Fever
gave information and showed treat-
ments, while frequent scene changes and intimate close-ups enhanced viewer in¬ terest and promoted better understand¬ ing of material.
Frequent rewinding of tapes and searching for topic programs on one se¬ rial tape are impractical. Accordingly, for each topic, a separate tape was assembled that repeated the same program many
times and therefore enabled instant ac¬ cess to the same topic. There was no need to rewind or search after each viewing. Administration. —Initially, after each pediatric examination, the patient and parent were moved from the examina¬ tion room to an education room where the appropriate advice video was admin¬ istered by the pediatrician. While the patient watched the selected short pro¬ gram, the pediatrician completed the medical record and wrote prescriptions. The tape was ejected by the patient each time a program was finished. The pedia¬ trician then returned for follow-up dis¬ cussion.
Later, more efficiency was achieved by installing a closed-circuit television mon¬
itor in each examination room, with dif¬ ferent programs continuously repeating on separate channels. Evaluation. Questionnaires were anonymously completed by viewers and dropped in a box. Responses from pa¬ tients and parents were very positive, and written comments were very en¬ thusiastic. The number of individual re¬ sponses and the mean responses on a Likert scale (1 through 4 points) for each question are shown in the Table. Pediatricians strongly believed that vid¬ eotapes were helpful and saved them much demonstration time. The initial response to this video approach was so positive that many other pediatricians requested the videotapes for their use. A pilot study of otitis treatment and —
follow-up suggested improved compli¬ ance
with video
use.
Questionnaire for a Video Program on Colds and Influenza* Points
on
the Likert Scale
1
2
(A Little)
(Some)
(Pretty Much)
(A Lot)
Mean Score on the Likert Scale
3 0
32
43
37
2.8
2
32
83
3.5
1
7
30
80
3.4
7
20
50
40
2.9
9 30
29
33
43
2.8
42
11
22
2.1
2
16
27
71
3.3
3 1 how much did like the video? Overall, you "Values for columns 1 through 4 are number of responses for each
7
39
65
3.3
7
38
69
3.4
How much did you learn from it? Was it easy for you to understand? Is it a good idea to use the video in the doctor's office?
Did it answer your questions or concerns? Did it add to what the doctor told you? Would you like to watch it again? Would you recommend it to others? Is it good for explaining the medical problem and treatment?
point on
4
the Likert scale.
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