OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental psychology, epidemiology, sociology, and economics are catalyzing an important paradigm shift in our un- derstanding of health and disease across the lifespan. This converging, multidisciplinary science of human development has profound impli- cations for our ability to enhance the life prospects of children and to strengthen the social and economic fabric of society. Drawing on these multiple streams of investigation, this report presents an ecobiodeve- lopmental framework that illustrates how early experiences and envi- ronmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress, offering intriguing insights into causal mech- anisms that link early adversity to later impairments in learning, be- havior, and both physical and mental well-being. The implications of this framework for the practice of medicine, in general, and pediatrics, specifically, are potentially transformational. They suggest that many adultdiseasesshouldbeviewedasdevelopmentaldisordersthatbegin early in life and that persistent health disparities associated with pov- erty, discrimination, or maltreatment could be reduced by the allevi- ation of toxic stress in childhood. An ecobiodevelopmental framework alsounderscoresthe needfornewthinking aboutthe focus andbound- aries of pediatric practice. It calls for pediatricians to serve as both front-line guardians of healthy child development and strategically po- sitioned, community leaders to inform new science-based strategies that build strong foundations for educational achievement, economic productivity, responsible citizenship, and lifelong health. Pediatrics

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The Lifelong Effects of Early Childhood Adversity and Toxic Stress

Background
The literature on the prevalence of mental disorders affecting children and adolescents has expanded significantly over the last three decades around the world. Despite the field having matured significantly, there has been no meta-analysis to calculate a worldwide-pooled prevalence and to empirically assess the sources of heterogeneity of estimates.

Methods
We conducted a systematic review of the literature searching in PubMed, PsycINFO, and EMBASE for prevalence studies of mental disorders investigating probabilistic community samples of children and adolescents with standardized assessments methods that derive diagnoses according to the DSM or ICD. Meta-analytical techniques were used to estimate the prevalence rates of any mental disorder and individual diagnostic groups. A meta-regression analysis was performed to estimate the effect of population and sample characteristics, study methods, assessment procedures, and case definition in determining the heterogeneity of estimates.

Results
We included 41 studies conducted in 27 countries from every world region. The worldwide-pooled prevalence of mental disorders was 13.4% (CI 95% 11.3–15.9). The worldwide prevalence of any anxiety disorder was 6.5% (CI 95% 4.7–9.1), any depressive disorder was 2.6% (CI 95% 1.7–3.9), attention-deficit hyperactivity disorder was 3.4% (CI 95% 2.6–4.5), and any disruptive disorder was 5.7% (CI 95% 4.0–8.1). Significant heterogeneity was detected for all pooled estimates. The multivariate metaregression analyses indicated that sample representativeness, sample frame, and diagnostic interview were significant moderators of prevalence estimates. Estimates did not vary as a function of geographic location of studies and year of data collection. The multivariate model explained 88.89% of prevalence heterogeneity, but residual heterogeneity was still significant. Additional meta-analysis detected significant pooled difference in prevalence rates according to requirement of funcional impairment for the diagnosis of mental disorders.

Conclusions
Our findings suggest that mental disorders affect a significant number of children and adolescents worldwide. The pooled prevalence estimates and the identification of sources of heterogeneity have important implications to service, training, and research planning around the world.

Annual Research Review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents

www.mobilehealthmap.org 617‐442‐3200 New research shows that mobile health clinics improve health outcomes for hard to reach populations in cost‐effective and culturally competent ways . A Harvard Medical School study determined that for every dollar invested in a mobile health clinic, the US healthcare system saves $30 on average. Mobile health clinics, which offer a range of services from preventive screenings to asthma treatment, leverage their mobility to treat people in the convenience of their own communities. For example, a mobile health clinic in Baltimore, MD, has documented savings of $3,500 per child seen due to reduced asthma‐related hospitalizations. The estimated 2,000 mobile health clinics across the country are providing similarly cost‐effective access to healthcare for a wide range of populations. Many successful mobile health clinics cite their ability to foster trusting relationships. Qualitative research in such mobile health clinics has found that patients value the informal, familiar environment in a convenient location, with staff who “are easy to talk to,” and that the staff’s “marriage of professional and personal discourses” provides patients the space to disclose information themselves. A communications academic argued that mobile health clinics’ unique use of space is important in facilitating these relationships. Mobile health clinics park in the heart of the community in familiar spaces, like shopping centers or bus stations, which lend themselves to the local community atmosphere.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity.

Concepts of what constitutes health, and theories about how health is produced and optimized, are constantly evolving in response to myriad social and cultural expectations shaped by our contemporary worldview, scientific advances, improvements in health interventions, and the changing capacity of the health system. Stimulated originally by a series of studies demonstrating how growth during early life is related to chronic health conditions that emerge many decades later, new research is demonstrating how complex developmental processes integrate a range of biological, behavioral, social, and environmental influences that modify gene expression, modulate physiologic and behavioral function, and dynamically shape different pathways of health production. These empirical findings are highlighting the limitations of the more mechanistic biomedical and biopsychosocial models of health, which fail to offer comprehensive explanations about such phenomena as the developmental origins of health, how stress affects current and future health, and the consequences of dynamic interactions between individuals and their environments over time. The comfort and certainty of simple, linear, and deterministic causal pathways are giving way to the uncomfortable uncertainty of nonlinear causal clusters that are networked together into complex, multilevel, interactive, and relational systems. Informed by new theoretical perspectives emerging from such fields of study as developmental psychology, systems biology, epigenetics, the developmental origins of chronic disease, and evolutionary developmental biology, a coherent transdisciplinary framework is emerging which we call Life Course Health Development (LCHD) and which is presented in this chapter as a set of seven principles: (1) health development, (2) unfolding, (3) complexity, (4) timing, (5) plasticity, (6) thriving, and (7) harmony. LCHD offers a new perspective that will guide future scientific inquiry on health development and facilitate synthesis of medicine and public health that links treatment, prevention, and health promotion and catalyzes more integrated and networked strategies for designing, organizing, and implementing multilevel health interventions that transcend individual and population dichotomies. We hope that the LCHD framework presented here, coupled with our explanatory narrative, will encourage theory building and testing, inspire innovative transdisciplinary research, and mature the framework into a scientific model with descriptive, explanatory, and predictive utility. Furthermore, we hope that LCHD will shine a light on the conundrum of how little attributable risk is explained in many studies of chronic disease, how early experience conditions future biological response patterns, and how these early experiences play through complex, environmentally influenced, and developmentally plastic health development pathways.

/pdf/the-emerging-theoretical-framework-of-life-course-health-42ok1hv930.pdf

The Emerging Theoretical Framework of Life Course Health Development

Associations between media use and health in US children.

Primary care is a cornerstone of the U.S. child health system (Donaldson et al. 1996; Starfield 1998). While many definitions of primary care exist, there is a general consensus on at least four defining features to assess its performance: accessibility, continuity, comprehensiveness, and coordination (Starfield 1994). As the receipt of high quality primary care has been associated with improved health (e.g., lower morbidity and mortality) (Lurie et al. 1984; Franks and Fiscella 1988; Shi 1994; Chande and Kinnane 1996; Safran et al. 1998; Shi, Green, and Kazakova 2004), and lower health care costs (e.g., fewer hospitalizations and emergency visits) (Bindman et al. 1995; Blumenthal, Mort, and Edwards 1995; Forrest and Starfield 1996; Gill, Mainous, and Nsereko 2000; Christakis et al. 2001), it is a major focus of national aims to reduce disparities and improve child health outcomes (U.S. Department of Health and Human Services 2000).

Despite its value, many children do not receive adequate primary care. Children in lower socioeconomic status (SES) families, the uninsured, and racial/ethnic minorities frequently have been reported to have poorer primary care experiences (Newacheck, Hughes, and Stoddard 1996; Ortega et al. 2000; Weech-Maldonado et al. 2001; Newacheck et al. 1998, 2002; Stevens and Shi 2002; Elster et al. 2003; Lurie et al. 2003; Seid, Stevens, and Varni 2003), and poorer health status (Montgomery, Kiely, and Pappas 1996; Brooks-Gunn and Duncan 1997; Lave et al. 1998; Goodman 1999; Flores et al. 1999; DiLiberti 2000; Holl et al. 2000; Bradley and Corwyn 2002; Wood et al. 2002; Fox et al. 2003; Newacheck et al. 2003). Given weakening state budgets across the nation, access to needed high quality primary care for these vulnerable children may be further compromised. Public health insurance and public health care delivery programs that provide essential primary care services to many children—and account for nearly one-third of the state budget in California—continue to teeter on the edge of the political chopping block, threatening the viability of these safety-net programs for children. Children in noncitizen families and those residing in rural areas (both prominent issues in California) are at even higher risk for poor primary care, as even safety-net delivery programs often overlook rural areas and noncitizens are generally excluded from state insurance programs (Inkelas et al. 2003).

Children served by public programs are considered vulnerable because they frequently have multiple risk factors for poor health status and poor primary care (e.g., living in poverty and not having health insurance) (Aday 2001). Previous research on child health and health care disparities has primarily focused on identifying and delineating the individual effects of these risk factors. Such an approach is important to identify new relationships and derive causal mechanisms, and forms the basis of most of our understanding of child health disparities.

Since risk factors often cluster together, however, e.g., parents who did not graduate high school (one risk), are more likely to work in low-wage jobs (a second risk) and not have health insurance (a third risk)—understanding how multiple risk factors combine to influence primary care is an important next step. One alternate approach builds on existing knowledge to describe individuals according to risk profiles that allow the reader to explore the influence of multiple risk factors in a more explicit and interpretable way (Shi and Stevens 2005).

Previous studies that have used this risk profile technique have shown that vulnerability to poor health is not defined by a single demographic, social, behavioral, or financial risk. In many instances, poor health outcomes have been associated with the multiplicity of risk factors a child or adolescent has. Sameroff et al. (1987) have shown an additive association between the number of family risk factors (e.g., minority status, low maternal education, poor maternal mental health) and child social-emotional health and IQ. Furstenberg et al. (1999) has demonstrated that family factors (e.g., single-parenting), community risks (e.g., neighborhood safety), and peer influences (e.g., antisocial peers) combine to influence adolescent social health and performance in school. More recent studies by Starfield, Robertson, and Riley have also combined both parent education and employment status to reveal an association between higher social class and child health status (Starfield, Robertson, and Riley 2002; Starfield et al. 2002).

Single risk factor focused assessments have some limitations in informing interventions, since they may tend to lead to more narrowly focused approaches to resolving disparities rather than more integrated, multisector interventions to improving child health. Understanding how risk factors combine to influence child health status and primary care and how such risk profiles are distributed in the population may provide better guidance in where to intervene to achieve the greatest results. Few studies assess how combinations of risk factors are distributed in the child population, and those few studies mentioned do not explicitly examine the combined influences of risk factors on disparities in child health status or primary care (Shi and Stevens 2005).

Understanding vulnerability in terms of multiple, overlapping risk factors for inadequate primary care is an important next step. Policy makers and those charged with monitoring access to care for vulnerable children might benefit from using this multiple risk factor approach to identify children who have the greatest health care needs and are least likely to obtain care. Even though more complex statistical techniques are available to describe the combined influences of multiple risk factors (i.e., multiple interaction terms), they create challenges in interpretation for policymakers. A more straightforward assessment of child vulnerability using risk profiles, particularly when combined with detailed analyses of the various common combinations, may help to better guide the allocation of resources, interventions, or outreach to improve the delivery of primary care at the population, health plan, or individual clinic level.

This study uses data on children and adolescents ages 0–19 from the 2001 California Health Interview Survey (CHIS) to construct a vulnerability risk profile for each child based on five factors: child race/ethnicity, household poverty status, parent education, health insurance coverage, and primary language. The prevalence of these profiles is presented overall and then according to two family factors (immigration status and geographic residence) that have been the focus of recent policy debates about access to care in California, including new legislation to cover all children regardless of immigration status through expansions of county-based health insurance programs into geographic areas with high rates of uninsurance. The profiles are used to examine disparities in child health status and three aspects of primary care (i.e., access, continuity, and comprehensiveness of care). To provide the most policy-relevant results, the relationship of risk profiles with primary care access is examined by child health status (i.e., health need).

/pdf/disparities-in-primary-care-for-vulnerable-children-the-2o8qp1e2rj.pdf

Disparities in Primary Care for Vulnerable Children: The Influence of Multiple Risk Factors

Use of ambulatory care services by children from low-income families has increased substantially since the early 1960s. However, in few studies have attempts been made to disaggregate physician visits according to type (eg, preventive upsilon diagnosis and treatment). In this study, receipt of preventive care (including physical, vision, and dental examinations), based on a sample of 16,838 children aged 5 to 16 years from the 1982 National Health Interview Survey, was examined. The results indicate that children in families with incomes below the poverty level, especially those without Medicaid insurance, are much less likely to receive routine preventive care on a timely basis. Poor school-aged children with Medicaid are much more likely to receive timely preventive care than their counterparts without Medicaid coverage. The effectiveness of preventive care for children is discussed and suggestions for improving access to routine preventive care are presented.

Preventive care use by school-aged children: differences by socioeconomic status.

The number of children in foster care in California doubled from 27 534 in 1980 to more than 62 419 in 1988, representing approximately 1% of the child population in the state. Past studies have domonstrated that children in foster care have high rates of medical and mental health problems. An examination of all Medi-Cal-paid claims was undertaken to describe the utilization of health services by children in foster care. Although children in foster care represent 4% of Medi-Cal-eligible children younger than 18 years of age, they account for approximately 5% of children using Medi-Cal services and 6.7% of expenditures, representing a 23% greater utilization rate and 41% greater expenditure rate than all children covered by Medi-Cal. Using the entire Medi-Cal population younger than 18 years of age as a comparison group, examination of inpatient and outpatient service utilization for specific condition categories showed few differences between children in foster care and the comparison group except for mental health service utilization, where children in foster care were much higher users of services.

Neal Halfon

Papers

The Emerging Theoretical Framework of Life Course Health Development

Associations between media use and health in US children.

Disparities in Primary Care for Vulnerable Children: The Influence of Multiple Risk Factors

Preventive care use by school-aged children: differences by socioeconomic status.

Children in foster care in California: an examination of Medicaid reimbursed health services utilization.