Pediatrics
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Comparative Study
Low blood CD8+ T-lymphocytes and high circulating monocytes are predictors of HIV-1-associated progressive encephalopathy in children.
Human immunodeficiency virus type 1 (HIV-1)-associated progressive encephalopathy (PE) is a common and devastating complication of HIV-1 infection in children, whose risk factors have not yet been clearly defined. Regardless of the age of presentation, PE shortens life expectancy. Paradoxically, as survival of patients has been prolonged as a result of the use of antiretroviral therapy, the prevalence of PE has increased. Therefore, a predictive marker of PE emergence is critical. The objective of this study was to determine in an observational study whether any immunologic (CD4(+) and CD8(+) T-lymphocyte counts, monocyte counts) or virologic (viral load [VL], biological characteristics of viral isolates) marker might be predictive of PE and whether any particular marker may be involved in the timing of clinical onset of PE. ⋯ HIV-1 infection of the central nervous system (CNS) remains an important clinical concern. The first step toward PE prevention in HIV-1-infected children should be directed at predicting risk of PE and thus the prompt and reliable identification of infants who are at risk for CNS disease progression. Low blood CD8(+) T-lymphocytes is a strong early predictive marker of PE emergence in vertical HIV-1 infection. Indeed, among all of the immunologic and virologic variables assessed in this observational study, the only significant difference during the first months of life are the CD8(+) T-lymphocytes. A peak of significantly higher peripheral monocytes before the onset of PE with respect to established PE has not been previously described, and strengthens the growing evidence that an increased traffic of monocytes to the brain may be a key factor in triggering neurologic symptoms. The suppression of HIV-1 replication is dependent on the presence of a relatively small number of HIV-1-specifof HIV-1-specific CD8(+) T-lymphocytes, and it is possible that the duration of the neurologically asymptomatic phase for any given child may depend mostly on the magnitude of specific CD8(+) T-lymphocyte responses. Thus, a decrease of CD8(+) T-lymphocytes would diminish the host capacity to control viral infection, as reported in animal models, enabling infected macrophages to cross the blood-brain barrier. Our results advocate the use of CD8(+) T-lymphocyte and monocyte counts to follow-up HIV-1-infected children. We suggest that CD8(+) T-lymphocytes may be the nexus for many different aspects of the disease, namely loss of control of HIV-1 replication determining higher VL, increased traffic of activated and/or infected monocytes, spread of infection to immune sanctuaries, and finally clinical neurologic emergence of PE. Moreover, we suggest that CD8(+) T-lymphocytes or/and monocytes may be used as putative biological markers of neuropathogenicity. This might suggest their use in decision making of when to start more effective antiretroviral regimens for HIV-1 infection of the CNS and the need of new therapies either to preserve or to augment an adequate CD8(+) T-lymphocyte immune response. Early detection of children who are at risk for developing PE is particularly important because aggressive highly active antiretroviral therapy improves neurologic symptoms, allows possible use of neuroprotective treatment to prevent further development of encephalopathy, and emphasizes the relevance of developing therapies aimed to enhance CD8(+) T-lymphocyte function. In conclusion, the surrogate markers routinely used in clinical practice for HIV-1 infection (ie, CD4(+) T-lymphocyte counts and VL) seem to be insufficient to evaluate the clinical involvement of the CNS. Other systemic markers, as the recent proposed markers for PE evolution (cerebrospinal fluid VL by lumbar puncture and brain atrophy by cerebral magnetic resonance imaging) are undoubtedly more invasive than measuring CD8(+) T-lymphocyte and monocyte counts, when the neurologic manifestations of PE are still preventable.
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Multicenter Study
Examination of the communication practices between state newborn screening programs and the medical home.
As outlined in the Newborn Screening Task Force report published in August 2000, the newborn screening system is more than just testing, but also involves follow-up, diagnosis, treatment, and evaluation. As such, multiple professional and public partners need to be adequately involved in the system to help ensure success. In addition, newborn screening programs are state-based; therefore, policies and procedures vary from state to state. Historically, there has been little uniformity between state newborn screening programs. ⋯ Newborn screening roles and responsibilities vary tremendously between states. Improvements in communication and better-defined protocols are needed, particularly between state newborn screening programs and the medical home. Many states identified the medical home as having significant responsibilities related to the short-term follow-up of screen-positive infants. Identification of the correct medical home before testing would help to reduce unnecessary time and frustration for state newborn screening programs, especially in the follow-up of infants that are difficult to locate. In addition, primary care physicians (ie, the medical home) need to have appropriate and ongoing involvement, including a mechanism to provide feedback to their state newborn screening program. This is particularly important given the adoption of tandem mass spectrometry by an increasing number of states, and the likely expansion of newborn screening in the future. Recommendations include the following: Primary care physicians should have appropriate and ongoing involvement in the newborn screening system and should be appropriately represented on state newborn screening advisory committees. States should develop protocols to identify the medical home before heelstick screening. States should work with families, primary care physicians, and prenatal health care professionals to develop well-defined systems for pretesting education of parents. All newborn screening results (both positive and negative) should be sent to the infant's medical home. If results are not received by the medical home, efforts should be made to obtain results. Medical homes and subspecialists should submit follow-up information on screen-positive infants and infants with confirmed diagnoses to the state newborn screening program, regardless of the existence of state requirements to do so, and efforts to build enhanced direct communication systems, linking state newborn screening programs to community-based medical homes, should continue.
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Colds accounted for 1.6 million emergency department (ED) visits and 25 million ambulatory visits by children and adults in 1998. Although most colds are caused by viruses and do not require medical intervention, many families seek health care for the treatment of colds. Parental misconceptions about the cause and appropriate treatment of colds may contribute to unnecessary health service utilization. The objective of this study was to determine predictors of reported ED use and ambulatory care use for colds among families with young children. ⋯ Misconceptions about the appropriate treatment of colds are predictive of increased health service utilization. Targeted educational interventions for families may reduce inappropriate antibiotic-seeking behavior and unnecessary health service utilization for colds.
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Comparative Study
Are hospital characteristics associated with parental views of pediatric inpatient care quality?
Patient assessments of care are increasingly being considered an important dimension of quality of care. Few studies have examined the types and extent of problems identified by parents in the care of hospitalized children and whether hospital characteristics are associated with some of these problems. The objective of this study was to describe the quality of pediatric inpatient care as perceived by parents of hospitalized children and test whether hospital characteristics (academic status, market competition, freestanding children's hospital) are associated with variations in quality. ⋯ Despite high subjective ratings of quality of care, measures of specific processes of care reveal significant variations among hospitals and identify areas with opportunities for improvement. Improving the quality of communication with the parent of a hospitalized child may have the most positive impact on a hospital's overall quality of care rating. AHCs and hospitals in more competitive markets may be more prone to problems. With wide variation in parental perceptions of hospital quality of care, a systems analysis of individual hospitals may provide strategies for hospitals to deliver higher quality care.
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Review Comparative Study
Scope of practice issues in the delivery of pediatric health care.
In recent years, there has been an increase in the number of nonphysician pediatric clinicians and an expansion in their respective scopes of practice. This raises critical public policy and child health advocacy concerns. The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a team-based approach with coordination by a physician leader, preferably a pediatrician. ⋯ The AAP also believes that nonphysician clinicians who provide health care services in underserved areas should be supported by consulting pediatricians and other physicians using technologies including telemedicine. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of practice conflicts outside state legislatures. The AAP affirms that as nonphysician clinicians seek to expand their scopes of practice as providers of pediatric care, standards of education, training, examination, regulation, and patient care are needed to ensure patient safety and quality health care for all infants, children, adolescents, and young adults.