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

/pdf/the-lifelong-effects-of-early-childhood-adversity-and-toxic-49ejk1ikxi.pdf

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.

This article reports recommendations that were developed at the California Conference on Health Care for Children in Foster Care, organized to discuss implementation in the state of CWLA's Standards for Health Care Services for Children in Out-of-Home Care. Programs and legislation developed in the state are also discussed.

Implementing critical health services for children in foster care

In Reply. —We agree with the points made by Dr Sissman on the desirability of distinguishing barriers to access from barriers to utilization of available services. While access to adequate medical care is necessary to enable appropriate utilization, it is not sufficient. However, these two concepts are often difficult to distinguish. If a clinic is identified as a child's usual source of care, but the family does not have insurance, or the clinic is not located within a reasonable distance, or is not open at convenient hours, or does not provide services in a culturally sensitive manner, or waiting times are excessive, then the family may not appropriately utilize the available care. Does this represent lack of access or underutilization? Is this attributable to the family or to the system of medical care itself? The data from our study show clearly that poor children who do not have Medicaid are

Access to Care for Poor Children: Necessary but Not Sufficient-Reply

The unique health, legal, and social status of children in foster care* poses particular problems for the designers of any kind of health plan. Because many children in out-of-home care are highly mobile, moving from family to family, and from one geographic locale to another, the context of their lives challenges the assumptions that health insurance is based upon. This article attempts to highlight current access to health care services for this group of children, how the President's proposed Health Security Act would affect the delivery of health care services, and what special considerations are necessary to meet the needs of this particular group of children. We have focused on the President's plan partially because it provides the greatest amount of detail, and partially because it has the greatest likelihood of doing the most to improve the availability of appropriate health care services for children in general, and children in foster care in particular.** The analysis printed here is based upon the version of the American Health Security Act that was introduced in Congress by members of the House and Senate on November 22, 1993 (H.R. 3600/S. 1757). This most recent version of the Health Security Act has incorporated changes that greatly improve the extent of coverage and other considerations for children in foster care compared to earlier drafts of the plan.Studies have documented that while children in foster care experience high rates of serious health problems, they also face significant obstacles in their access to essential health care services. Although professional organizations such as the American Academy of Pediatrics and the Child Welfare League of America have developed excellent standards for health care services for children in foster care, the actual delivery of health care services to this needy population falls far short of these standards. The reasons for this failure relate to both the financing of services and the organization of care. President Clinton's proposed American Health Security Act of 1993 would have a major impact on the accessibility of health care services for children in foster care. In a number of important respects, the proposed plan would improve access, but in other critical areas it would limit essential care.HEALTH CARE ACCESS UNDER CURRENT LAW FOR CHILDREN IN FOSTER CAREWHO ARE THE CHILDREN IN FOSTER CARE?The population of children in foster care is growing rapidly. There were an estimated 460,000 children in foster care at the end of fiscal year 1993, with more than 659,000 served by the system during that year. In the wake of escalating and persistent poverty, family violence, mental illness, and the drug epidemic, the number of children in foster care has been increasing nationwide since 1985. It is projected that 500,000 to 600,000 children will be in foster care by 1995. The vast majority of these children live in family foster homes (70%); the remainder are in group homes, residential treatment centers, or institutional settings.WHAT ARE THE HEALTH CARE NEEDS OF CHILDREN IN FOSTER CARE?Children in foster care have high rates of serious health problems. Several studies have documented that children in foster care have high rates of chronic medical problems that require ongoing treatment. Approximately 60% of children in foster care have moderate to severe mental health problems. Children in foster care also experience high rates (40%) of physical health problems (e.g., asthma, growth disorders, neurological abnormalities). The high frequency of health and mental health problems is a result of the children's poor health prior to placement, the effects of abuse and neglect, the effects of separation and frequent moves, and the lack of access to appropriate health and mental health services. A particular concern is the increasing number of infants entering care with multiple health and developmental needs due in large part to maternal drug use and prenatal exposure to drugs. …

National Health Care Reform, Medicaid, and Children in Foster Care.

The Affordable Care Act (ACA) introduces enormous policy changes to the health care system with several anticipated benefits and a growing number of unanticipated challenges for child and adolescent health. Because the ACA gives each state and their payers substantial autonomy and discretion on implementation, understanding potential effects will require state-by-state monitoring of policies and their impact on children. The “voltage drop” framework is a useful interpretive guide for assessing the impact of insurance market change on the quality of care received. Using this framework we suggest a state-level checklist to examine ACA statewide implementation, assess its impact on health care delivery, and frame policy correctives to improve child health system performance. Although children’s health care is a small part of US health care spending, child health provides the foundation for adult health and must be protected in ACA implementation.

https://pediatrics.aappublications.org/content/pediatrics/134/4/794.full.pdf

Quality Health Care for Children and the Affordable Care Act: A Voltage Drop Checklist

THE HEALTH system reform debate is over how to organize, deliver, and finance personal health care services. At $1 trillion, the enormity of the health care sector warrants a healthy debate about its structure and the respective roles of the public and private sectors. Erosion of middle-class health insurance coverage and an insecure economic and employment future have mobilized a broad constituency for insurance market reforms.1,2Distributive justice issues raise concern for the 40 million Americans without health benefits. Lost, however, among discussions of health security, universal coverage, and competitive markets is the unstated principal mission that any health system must serve toimprovethe health of the entire population. Legislators know that increasing public interest in health reform is attributable to the emergence of health insurance coverage as a middle-class issue.2,3An increasing proportion of the voting public has become part See also pp 1276 and 1297.

Neal Halfon

Papers

Implementing critical health services for children in foster care

Access to Care for Poor Children: Necessary but Not Sufficient-Reply

National Health Care Reform, Medicaid, and Children in Foster Care.

Quality Health Care for Children and the Affordable Care Act: A Voltage Drop Checklist

Where Is the Health in Health System Reform