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.

There is overwhelming evidence that social factors have profound influences on health. Children are particularly sensitive to social determinants, especially in the early years. Life course models view health as a developmental process, the product of multiple gene and environment interactions. Adverse early social exposures become programmed into biological systems, setting off chains of risk that can result in chronic illness in mid-life and beyond. Positive health-promoting influences can set in motion a more virtuous and health-affirming cycle, leading to more optimal health trajectories. Mounting an effective response to social determinants will involve both direct social policy initiatives designed to eliminate poverty and inequality, and indirect approaches focused on disrupting pathways between social risks and poor health outcomes. To be effective, these indirect strategies will require nothing short of a transformation of existing child health systems. Parents and professionals must work together from the ground up, raising public awareness about social determinants of health and implementing cross-sector place-based initiatives designed to promote positive health in childhood.

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Why social determinants

Lifecourse-informed models of health fundamentally challenge simple biomedical models, introducing new ways of thinking about how diseases develop. This paper considers the broad implications of lifecourse theory for the maternal and child health (MCH) research agenda. The Lifecourse Health Development model provides an organizing framework for a synthesis of the existing literature on lifecourse health and identification of gaps in knowledge. Priority areas identified for MCH research in order to close these knowledge gaps include: epigenetic mechanisms and their potential mutability; peri-conception as a critical and sensitive period for environmental exposures; maternal health prior to pregnancy; the role of the placenta as an important regulator of the intra-uterine environment; and ways to strengthen early mother–child interactions. Addressing knowledge gaps will require an emphasis on longitudinal rather than cross-sectional studies, long-term (lifetime) rather than short-term perspectives, datasets that include socio-demographic, biologic and genetic data on the same subjects rather than discipline-specific studies, measurement and study of positive health as well as disease states, and study of multi-rather than single generational cohorts. Adoption of a lifecourse-informed MCH research agenda requires a shift in focus from single cause-single disease epidemiologic inquiry to one that addresses multiple causes and outcomes. Investigators need additional training in effective interdisciplinary collaboration, advanced research methodology and higher-level statistical modeling. Advancing a life course health development research agenda in MCH will be foundational to the nation’s long-term health.

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A Lifecourse Approach to Health Development: Implications for the Maternal and Child Health Research Agenda

BACKGROUND: The list of recommended pediatric preventive services has grown considerably in the past decade, and clinician variability, clinician distribution, and other correlates of provision of these basic preventive services (BPS) are not known. OBJECTIVE: To describe the proportion of high-quality basic pediatric preventive services, exclusive of immunizations, reported by parents and to identify sociodemographic and health system predictors and health service correlates of provision of these services. STUDY DESIGN: The study used cross-sectional data on 2041 children, 4 to 35 months of age, in the 2000 National Survey of Early Childhood Health. OUTCOME MEASURES: The BPS measure assesses the receipt of (1) developmental assessment, (2) injury prevention counseling, (3) screening for parental smoking, (4) guidance on reading to the child, and (5) guidance on 14 other topics (assessed as a composite score). The BPS scale categorizes the receipt of services as excellent, good, fair, or poor. RESULTS: Most children received excellent (34.9%) or good (31.5%) care, but many received fair (24.9%) or poor (8.7%) care. Sociodemographic and health care factors such as race/ethnicity, insurance, and practice setting were not associated with BPS levels. Higher BPS scores were associated with parental reports of longer well-child visits, more counseling regarding family and community risk factors, lower rates of delayed or missed care, and greater satisfaction. CONCLUSIONS: Two thirds of children receive good or excellent basic preventive care, as determined with this composite, and no disparities according to race/ethnicity, income, or health insurance status of families (which are often found to be associated with health care access) were found. This equitable distribution of high-quality care suggests a high level of clinician professionalism. Duration of visits may be a key factor to improve quality of care. Because of its association with other services, processes, and outcomes of care, the BPS scale may serve as a useful construct for monitoring quality and stimulating efforts to improve national pediatric preventive care. Language: en

Prevalence and correlates of high-quality basic pediatric preventive care.

OBJECTIVES. Given that more than two thirds of uninsured children in California are eligible for public health insurance coverage, this study examined differences in primary care access and health status between uninsured but eligible (UBE) children and those who were insured. METHODS. Using data on 19485 children from the 2001 California Health Interview Survey, this study examined differences in primary care access and health status for UBE children versus those who were enrolled in public coverage. Results are stratified by profiles of other risk factors (RF) for poor access: nonwhite, low income, low parent education, and non–English speaking. RESULTS. UBE children were less likely than publicly enrolled children to have a physician visit in the past year, dental visit in the past year, and a regular source of care. On the basis of differences between the UBE children and enrollees in the prevalence of each dependent measure, UBE children with multiple RFs experienced greater disparities than UBE children with fewer RFs. For example, enrollees were more likely than UBE children to have a regular source of care among children with 2, 3, or 4 RFs (differences of 26, 26, and 25 percentage points, respectively) compared with 1 RF (19 percentage points) and 0 RFs (12 percentage points). A similar pattern was found for dental visits but not physician visits. Although there was no difference in health status between UBE children and enrollees overall, enrollees were more likely than UBE children to have excellent/very good health status among children with 2 RFs (difference of 9 percentage points), 3 RFs (12 percentage points), and 4 RFs (11 percentage points). CONCLUSIONS. This study demonstrates that UBE children in California have poorer access to care compared with enrollees, and those with the highest levels of risk have poorer health status. This suggests that providing insurance to these children (and particularly those with multiple RFs) may lead to improved access and health for these vulnerable children.

Enrolling Vulnerable, Uninsured but Eligible Children in Public Health Insurance: Association With Health Status and Primary Care Access

Using data from the 1981 Child Health Supplement to the National Health Interview Survey, we examined differences in access to ambulatory services for children of different family incomes. The results indicate that much progress has been made in equalizing access since the War on Poverty was initiated in the mid-1960s. Poor children with superior health status now generally see physicians at the same rates as children in similar health but from higher income families. However, children with substantial health problems from low-income families continue to lag behind their higher income counterparts in similar health. Medicaid was shown to substantially improve access to ambulatory services for economically disadvantaged children in poor health, but less than half of these children are covered by Medicaid. Recent changes in federal and state policies concerning Medicaid are discussed as well as policy options for addressing the needs of children afflicted by both poverty and ill health.

Neal Halfon

Papers

Why social determinants

A Lifecourse Approach to Health Development: Implications for the Maternal and Child Health Research Agenda

Prevalence and correlates of high-quality basic pediatric preventive care.

Enrolling Vulnerable, Uninsured but Eligible Children in Public Health Insurance: Association With Health Status and Primary Care Access

Access to ambulatory care services for economically disadvantaged children.