BACKGROUND: Dexamethasone, a long-acting corticosteroid successfully used in acute treatment of croup, may prevent more relapses than prednisone in asthmatic children.

POPULATION STUDIED: The authors studied known asthmatic persons (defined by 2 or more episodes of wheezing treated with b-agonists with or without steroids) aged 2 to 18 years presenting to a children’s health hospital emergency department (ED) with an acute asthma exacerbation requiring more than 1 albuterol nebulizer treatment. Nursing staff assessed asthma severity based on either peak expired flow rates or a validated asthma severity scoring system. Children were excluded for recent oral corticosteroid treatment, history of intubation, recent varicella exposure, stridor, possible foreign body, and certain chronic diseases. During an 11-month period, 628 subjects enrolled, of whom 533 (85%) completed the study. Two thirds were men, 84% were black, and the average age was between 6 and 7 years. Fifty-six percent of the children were classified as moderate asthma severity at presentation; the remainder was evenly distributed between mild and severe.

STUDY DESIGN AND VALIDITY: This controlled trial assigned children to receive oral prednisone (2 mg/kg, maximum 60 mg, n= 261) on odd days and dexamethasone (0.6 mg/kg, maximum 16 mg, n=272) on even days. The first dose was given in the ED; the prednisone group was sent home with a prescription for 4 daily doses, the dexamethasone group was given a prepackaged dose for the following day. Children who vomited 2 doses of steroid or were directly admitted to the hospital from the ED were dropped from the study.This was a quasirandomized study, in that children were placed on one drug on even days and the other steroid on odd days. As a result, the allocation to the specific treatment groups was not concealed. Although patient severity is unlikely to have varied systematically on even and odd days, a large potential exists for a bias to be introduced into this study. Nurses who believed one treatment was superior to another could have systematically altered enrollment of children into the study based on the treatment of that day. These 2 issues—lack of randomization and concealed allocation—could invalidate the results of the study. The majority of subjects were black. Asthma prevalence, morbidity, and mortality are higher among black children, especially those in urban settings.¹ There is also some evidence of physiologic predisposition in this population, namely, higher serum immunoglobulin E levels and increased airway responsiveness.² However, no literature suggests that there is a difference in asthma treatment response between black children and children of other races or ethnicities.

OUTCOMES MEASURED: The primary outcome was rate of relapse within 10 days of discharge from the ED. Secondary outcomes were rate of hospitalization, frequency of vomiting, medication compliance, persistence of symptoms, and work or school days missed.

RESULTS: By evaluating the children who completed the study, the authors determined that the relapse rates were similar between the 2 groups, 7.4% in the dexamethasone group and 6.9% in the prednisone group (P = NS). Intention-to-treat analysis also found no difference between treatments. The number of admissions after relapse and the prevalence of persistent symptoms was also similar between the 2 groups. More children in the prednisone group missed 2 or more school days (P =.05), and more parents in this group reported not giving the medication at home (P =.004).

BACKGROUND: Dexamethasone, a long-acting corticosteroid successfully used in acute treatment of croup, may prevent more relapses than prednisone in asthmatic children.

POPULATION STUDIED: The authors studied known asthmatic persons (defined by 2 or more episodes of wheezing treated with b-agonists with or without steroids) aged 2 to 18 years presenting to a children’s health hospital emergency department (ED) with an acute asthma exacerbation requiring more than 1 albuterol nebulizer treatment. Nursing staff assessed asthma severity based on either peak expired flow rates or a validated asthma severity scoring system. Children were excluded for recent oral corticosteroid treatment, history of intubation, recent varicella exposure, stridor, possible foreign body, and certain chronic diseases. During an 11-month period, 628 subjects enrolled, of whom 533 (85%) completed the study. Two thirds were men, 84% were black, and the average age was between 6 and 7 years. Fifty-six percent of the children were classified as moderate asthma severity at presentation; the remainder was evenly distributed between mild and severe.

STUDY DESIGN AND VALIDITY: This controlled trial assigned children to receive oral prednisone (2 mg/kg, maximum 60 mg, n= 261) on odd days and dexamethasone (0.6 mg/kg, maximum 16 mg, n=272) on even days. The first dose was given in the ED; the prednisone group was sent home with a prescription for 4 daily doses, the dexamethasone group was given a prepackaged dose for the following day. Children who vomited 2 doses of steroid or were directly admitted to the hospital from the ED were dropped from the study.This was a quasirandomized study, in that children were placed on one drug on even days and the other steroid on odd days. As a result, the allocation to the specific treatment groups was not concealed. Although patient severity is unlikely to have varied systematically on even and odd days, a large potential exists for a bias to be introduced into this study. Nurses who believed one treatment was superior to another could have systematically altered enrollment of children into the study based on the treatment of that day. These 2 issues—lack of randomization and concealed allocation—could invalidate the results of the study. The majority of subjects were black. Asthma prevalence, morbidity, and mortality are higher among black children, especially those in urban settings.¹ There is also some evidence of physiologic predisposition in this population, namely, higher serum immunoglobulin E levels and increased airway responsiveness.² However, no literature suggests that there is a difference in asthma treatment response between black children and children of other races or ethnicities.

OUTCOMES MEASURED: The primary outcome was rate of relapse within 10 days of discharge from the ED. Secondary outcomes were rate of hospitalization, frequency of vomiting, medication compliance, persistence of symptoms, and work or school days missed.

RESULTS: By evaluating the children who completed the study, the authors determined that the relapse rates were similar between the 2 groups, 7.4% in the dexamethasone group and 6.9% in the prednisone group (P = NS). Intention-to-treat analysis also found no difference between treatments. The number of admissions after relapse and the prevalence of persistent symptoms was also similar between the 2 groups. More children in the prednisone group missed 2 or more school days (P =.05), and more parents in this group reported not giving the medication at home (P =.004).

BACKGROUND: Dexamethasone, a long-acting corticosteroid successfully used in acute treatment of croup, may prevent more relapses than prednisone in asthmatic children.

POPULATION STUDIED: The authors studied known asthmatic persons (defined by 2 or more episodes of wheezing treated with b-agonists with or without steroids) aged 2 to 18 years presenting to a children’s health hospital emergency department (ED) with an acute asthma exacerbation requiring more than 1 albuterol nebulizer treatment. Nursing staff assessed asthma severity based on either peak expired flow rates or a validated asthma severity scoring system. Children were excluded for recent oral corticosteroid treatment, history of intubation, recent varicella exposure, stridor, possible foreign body, and certain chronic diseases. During an 11-month period, 628 subjects enrolled, of whom 533 (85%) completed the study. Two thirds were men, 84% were black, and the average age was between 6 and 7 years. Fifty-six percent of the children were classified as moderate asthma severity at presentation; the remainder was evenly distributed between mild and severe.

STUDY DESIGN AND VALIDITY: This controlled trial assigned children to receive oral prednisone (2 mg/kg, maximum 60 mg, n= 261) on odd days and dexamethasone (0.6 mg/kg, maximum 16 mg, n=272) on even days. The first dose was given in the ED; the prednisone group was sent home with a prescription for 4 daily doses, the dexamethasone group was given a prepackaged dose for the following day. Children who vomited 2 doses of steroid or were directly admitted to the hospital from the ED were dropped from the study.This was a quasirandomized study, in that children were placed on one drug on even days and the other steroid on odd days. As a result, the allocation to the specific treatment groups was not concealed. Although patient severity is unlikely to have varied systematically on even and odd days, a large potential exists for a bias to be introduced into this study. Nurses who believed one treatment was superior to another could have systematically altered enrollment of children into the study based on the treatment of that day. These 2 issues—lack of randomization and concealed allocation—could invalidate the results of the study. The majority of subjects were black. Asthma prevalence, morbidity, and mortality are higher among black children, especially those in urban settings.¹ There is also some evidence of physiologic predisposition in this population, namely, higher serum immunoglobulin E levels and increased airway responsiveness.² However, no literature suggests that there is a difference in asthma treatment response between black children and children of other races or ethnicities.

OUTCOMES MEASURED: The primary outcome was rate of relapse within 10 days of discharge from the ED. Secondary outcomes were rate of hospitalization, frequency of vomiting, medication compliance, persistence of symptoms, and work or school days missed.

RESULTS: By evaluating the children who completed the study, the authors determined that the relapse rates were similar between the 2 groups, 7.4% in the dexamethasone group and 6.9% in the prednisone group (P = NS). Intention-to-treat analysis also found no difference between treatments. The number of admissions after relapse and the prevalence of persistent symptoms was also similar between the 2 groups. More children in the prednisone group missed 2 or more school days (P =.05), and more parents in this group reported not giving the medication at home (P =.004).

BACKGROUND: Prostate cancer is the second leading cause of death due to cancer in men, but substantial controversy surrounds the role of PSA in screening asymptomatic patients. Although the test can help detect prostate cancer earlier, we currently lack evidence that this early detection will increase length or quality of life. The issues involved in the controversy include frequent false-positive results, potential for complications from treatment, and the frequency of slow-growing tumors that may never become clinically significant. In recognition of this complexity, the American Cancer Society and the American Urological Association revised their recommendations for men older than 50 years, calling for shared decision making in which the patient and physician discuss options and together make a decision that agrees with the patient’s individual health preferences. Of note, most other major organizations do not advocate routine PSA tests for screening. Previous research has shown that the way information about PSA testing is presented can influence the outcome of shared decision making. This study compared the effect of either a scripted discussion or videotape on men’s opinions about taking the PSA test.

POPULATION STUDIED: The investigators approached all men older than 50 years who were presenting for an annual preventive care evaluation at a large health maintenance organization (HMO). The participants (n=176) were sequentially assigned to 1 of 4 interventions: usual care, a discussion about risks and benefits of PSA, a shared decision-making video, or the video plus discussion. Baseline characteristics including age, education, marital status, ethnicity (more than 70% white), history of friend or family member with prostate cancer, and previous PSA testing did not differ among groups. Approximately 40% of those contacted to participate in 1 of the 3 interventions refused, but recruitment rates did not differ among the intervention groups.

STUDY DESIGN AND VALIDITY: The investigators used a nonrandomized unblinded 2x2 factorial comparison of the discussion and video formats that yielded the 4 groups described above. A previous study evaluated and described the 25-minute video, and the lecture-format discussion closely followed the content of the video.

OUTCOMES MEASURED: Measured responses in all groups included whether they wanted PSA testing, their level of confidence in their decision, and levels of knowledge and concern about prostate cancer. Those in the intervention groups also rated the amount, clarity, and perceived balance and fairness of the presentations. The study did not measure the actual incidence of subsequent PSA testing.

RESULTS: Almost all (97%) in the usual care group opted for testing. Discussion decreased the testing rate to 82% (P <.05), and members of the video (63%) and video/discussion (50%) groups chose testing even less frequently (P <.05 for difference between the discussion-only and either video group). All of the interventions (other than usual care) significantly increased knowledge about prostate cancer (3.4-3.9 correct responses to 5 questions vs 1.6, P <.001) and decreased confidence in the decision regarding PSA. Subjects in the usual care group expressed more concern about prostate cancer than those in the intervention groups. Less than 1% of subjects felt negative about participating in the interventions. Eighty-two percent considered the presentation balanced; 8% felt it was slanted in favor of screening; and 11% felt it was slanted against having PSA testing.

BACKGROUND: Prostate cancer is the second leading cause of death due to cancer in men, but substantial controversy surrounds the role of PSA in screening asymptomatic patients. Although the test can help detect prostate cancer earlier, we currently lack evidence that this early detection will increase length or quality of life. The issues involved in the controversy include frequent false-positive results, potential for complications from treatment, and the frequency of slow-growing tumors that may never become clinically significant. In recognition of this complexity, the American Cancer Society and the American Urological Association revised their recommendations for men older than 50 years, calling for shared decision making in which the patient and physician discuss options and together make a decision that agrees with the patient’s individual health preferences. Of note, most other major organizations do not advocate routine PSA tests for screening. Previous research has shown that the way information about PSA testing is presented can influence the outcome of shared decision making. This study compared the effect of either a scripted discussion or videotape on men’s opinions about taking the PSA test.

POPULATION STUDIED: The investigators approached all men older than 50 years who were presenting for an annual preventive care evaluation at a large health maintenance organization (HMO). The participants (n=176) were sequentially assigned to 1 of 4 interventions: usual care, a discussion about risks and benefits of PSA, a shared decision-making video, or the video plus discussion. Baseline characteristics including age, education, marital status, ethnicity (more than 70% white), history of friend or family member with prostate cancer, and previous PSA testing did not differ among groups. Approximately 40% of those contacted to participate in 1 of the 3 interventions refused, but recruitment rates did not differ among the intervention groups.

STUDY DESIGN AND VALIDITY: The investigators used a nonrandomized unblinded 2x2 factorial comparison of the discussion and video formats that yielded the 4 groups described above. A previous study evaluated and described the 25-minute video, and the lecture-format discussion closely followed the content of the video.

OUTCOMES MEASURED: Measured responses in all groups included whether they wanted PSA testing, their level of confidence in their decision, and levels of knowledge and concern about prostate cancer. Those in the intervention groups also rated the amount, clarity, and perceived balance and fairness of the presentations. The study did not measure the actual incidence of subsequent PSA testing.

RESULTS: Almost all (97%) in the usual care group opted for testing. Discussion decreased the testing rate to 82% (P <.05), and members of the video (63%) and video/discussion (50%) groups chose testing even less frequently (P <.05 for difference between the discussion-only and either video group). All of the interventions (other than usual care) significantly increased knowledge about prostate cancer (3.4-3.9 correct responses to 5 questions vs 1.6, P <.001) and decreased confidence in the decision regarding PSA. Subjects in the usual care group expressed more concern about prostate cancer than those in the intervention groups. Less than 1% of subjects felt negative about participating in the interventions. Eighty-two percent considered the presentation balanced; 8% felt it was slanted in favor of screening; and 11% felt it was slanted against having PSA testing.

BACKGROUND: Prostate cancer is the second leading cause of death due to cancer in men, but substantial controversy surrounds the role of PSA in screening asymptomatic patients. Although the test can help detect prostate cancer earlier, we currently lack evidence that this early detection will increase length or quality of life. The issues involved in the controversy include frequent false-positive results, potential for complications from treatment, and the frequency of slow-growing tumors that may never become clinically significant. In recognition of this complexity, the American Cancer Society and the American Urological Association revised their recommendations for men older than 50 years, calling for shared decision making in which the patient and physician discuss options and together make a decision that agrees with the patient’s individual health preferences. Of note, most other major organizations do not advocate routine PSA tests for screening. Previous research has shown that the way information about PSA testing is presented can influence the outcome of shared decision making. This study compared the effect of either a scripted discussion or videotape on men’s opinions about taking the PSA test.

POPULATION STUDIED: The investigators approached all men older than 50 years who were presenting for an annual preventive care evaluation at a large health maintenance organization (HMO). The participants (n=176) were sequentially assigned to 1 of 4 interventions: usual care, a discussion about risks and benefits of PSA, a shared decision-making video, or the video plus discussion. Baseline characteristics including age, education, marital status, ethnicity (more than 70% white), history of friend or family member with prostate cancer, and previous PSA testing did not differ among groups. Approximately 40% of those contacted to participate in 1 of the 3 interventions refused, but recruitment rates did not differ among the intervention groups.

STUDY DESIGN AND VALIDITY: The investigators used a nonrandomized unblinded 2x2 factorial comparison of the discussion and video formats that yielded the 4 groups described above. A previous study evaluated and described the 25-minute video, and the lecture-format discussion closely followed the content of the video.

OUTCOMES MEASURED: Measured responses in all groups included whether they wanted PSA testing, their level of confidence in their decision, and levels of knowledge and concern about prostate cancer. Those in the intervention groups also rated the amount, clarity, and perceived balance and fairness of the presentations. The study did not measure the actual incidence of subsequent PSA testing.

RESULTS: Almost all (97%) in the usual care group opted for testing. Discussion decreased the testing rate to 82% (P <.05), and members of the video (63%) and video/discussion (50%) groups chose testing even less frequently (P <.05 for difference between the discussion-only and either video group). All of the interventions (other than usual care) significantly increased knowledge about prostate cancer (3.4-3.9 correct responses to 5 questions vs 1.6, P <.001) and decreased confidence in the decision regarding PSA. Subjects in the usual care group expressed more concern about prostate cancer than those in the intervention groups. Less than 1% of subjects felt negative about participating in the interventions. Eighty-two percent considered the presentation balanced; 8% felt it was slanted in favor of screening; and 11% felt it was slanted against having PSA testing.