Managed Care Network for the assessment of cardiac problems in children in a district general hospital: a working model

Aim

To assess a model for cardiology assessments in children with suspected heart disease by a general paediatrician with special expertise in paediatric cardiology (PsePC) in a district general hospital.

Methods

A new monthly “screening” clinic was established in May 2004 by the PsePC to reduce the burden of new referrals on outreach tertiary paediatric cardiology services. All patients were to have echocardiograms as part of their referral for cardiac assessment. Over a one year period (May 2004–April 2005), through audit, details of referrers, indications for referral, echocardiography assessments, and subsequent management were recorded. This was compared with the pattern of patients seen in the joint paediatric cardiology outreach clinics over a two year period (May 2003–April 2005).

Results

In the “screening” clinic, there were 75 appointments for 65 patients seen in 12 months. Fifty five of these patients had normal echocardiographic studies. Of the 47 referrals with heart murmurs in asymptomatic children, four had structurally abnormal hearts on echocardiographic assessment. Between May–October 2003 and November 2003–April 2004, the number of new patients with normal echocardiographic studies seen in the paediatric cardiology outreach clinic was 33/106 (31%) and 28/110 (25.4%) respectively. Following the introduction of the “screening” clinic, the number decreased to 21/99 (21%) during May–October 2004, and 10/102 (9.8%) during November 2004–April 2005.

Conclusion

This model can work effectively in order to identify pathology requiring input of a paediatric cardiologist more appropriately. Paediatricians with specific training in paediatric cardiology are potentially well equipped to provide this basic screening service.     

Infections and other causes of death in HIV-infected children in Africa

The human immunodeficiency virus (HIV) pandemic has dramatically reversed improvements in infant mortality and child survival in sub-Saharan Africa. However, accurate information on the specific causes of HIV-related morbidity and mortality arising from vertical transmission is infrequent and is constrained in resource-poor settings by infrastructure and local access to health care. Such knowledge is essential to improve clinical management of HIV-infected children in Africa. In this review, a global overview of the clinical aspects of HIV infection in children is given. Factors influencing HIV disease progression, morbidity and mortality are discussed from studies on a cohort of HIV-infected children that were followed at an orphanage in Nairobi between 1999 and 2001. These parameters are contrasted with available data on HIV-infected children residing in community settings in Africa.     

Managed Care Network for the assessment of cardiac problems in children in a district general hospital: a working model.

AIM: To assess a model for cardiology assessments in children with suspected heart disease by a general paediatrician with special expertise in paediatric cardiology (PsePC) in a district general hospital. METHODS: A new monthly "screening" clinic was established in May 2004 by the PsePC to reduce the burden of new referrals on outreach tertiary paediatric cardiology services. All patients were to have echocardiograms as part of their referral for cardiac assessment. Over a one year period (May 2004-April 2005), through audit, details of referrers, indications for referral, echocardiography assessments, and subsequent management were recorded. This was compared with the pattern of patients seen in the joint paediatric cardiology outreach clinics over a two year period (May 2003-April 2005). RESULTS: In the "screening" clinic, there were 75 appointments for 65 patients seen in 12 months. Fifty five of these patients had normal echocardiographic studies. Of the 47 referrals with heart murmurs in asymptomatic children, four had structurally abnormal hearts on echocardiographic assessment. Between May-October 2003 and November 2003-April 2004, the number of new patients with normal echocardiographic studies seen in the paediatric cardiology outreach clinic was 33/106 (31%) and 28/110 (25.4%) respectively. Following the introduction of the "screening" clinic, the number decreased to 21/99 (21%) during May-October 2004, and 10/102 (9.8%) during November 2004-April 2005. CONCLUSION: This model can work effectively in order to identify pathology requiring input of a paediatric cardiologist more appropriately. Paediatricians with specific training in paediatric cardiology are potentially well equipped to provide this basic screening service.     

Pertinent issues in diagnosis and management of wheezing in under-five children at community level

Wheezing in acute respiratory infections is a rule rather than exception. A large proportion of children (up to 75%) having ‘pneumonia’ or ‘severe pneumonia’ as per WHO definitions have associated wheezing. The current strategies to diagnose and manage wheeze in the community need to be updated, as audible wheeze is present in only less than one-third of wheezy children, and can not be relied upon solely. A history of previous episodes of respiratory distress has a high sensitivity to diagnose wheezy disorders. In a significant proportion of children, the respiratory rate comes back to normal and the chest indrawing disappear after two to three cycles of inhaled bronchodilator medications. Operational research is needed to evaluate the feasibility of including management of wheezing in the community based ARI management programs.     

Care by parents of their children in hospital.

A care by parent option was introduced into a general paediatric ward without any additional finance or facilities. Most parents coped successfully and were grateful for the opportunity of caring for their children. All believed that their children benefited from their active involvement. The nurses believed that their role was enhanced and their job satisfaction increased. This system offers advantages and could become more generally used in paediatric wards in Britain.     

Pediatric trauma care in Africa: the evolution and challenges

Childhood trauma is one of the major health problems in the world. Although pediatric trauma is a global phenomenon in low- and middle-income countries, sub-Saharan countries are disproportionally affected. We reviewed the available literature relevant to pediatric trauma in Africa using the MEDLINE database, local libraries, and personal contacts. A critical review of all cited sources was performed with an emphasis on the progress made over the past decades as well as the ongoing challenges in the prevention and management of childhood trauma. After discussing the epidemiology and spectrum of pediatric trauma, we focus on the way forward to reduce the burden of childhood injuries and improve the management and outcome of injured children in Africa.     

The use of antibiotics in the treatment and prevention of infection in HIV-infected children

Children with HIV infection have an unusual susceptibility to bacterial infection, related to several immune abnormalities. Selection of initial antibiotic therapy must be individualized in these children. Patients with community-acquired disease are most likely to have infection by polysaccharide-encapsulated bacterial organism, most commonly Streptococcus pneumoniae and less frequently by Haemophilus influenzae type b. If it is possible to treat the patients at home, the use of amoxicillin-clavulanic acid might be appropriate. Other authors propose management with parenteral ceftriaxone because of the better compliance and the malabsorption. In hospitalized patients, concern for Gram-negative enteric pathogens other than polysaccharide-encapsulated organisms requires initial therapy with a third-generation cephalosporine in combination with an aminoglycoside. Trimethoprim-sulfamethizole is the most common drug used in HIV-infected children because it is recommended for the initial therapy and for prophylaxis of Pneumocystis carinii pneumonia, which occurs in as many as 42% of these children.     

Management of HIV-infected children in the home and institutional settings. Care of children and infections control in schools, day care, hospital settings, home, foster care, and adoption

The likelihood of high-risk pediatric exposure to HIV infection, other than perinatal exposure, has been shown to be low in most cases, and HIV PEP should be considered on a case-by-case basis. Generic considerations in the management of children who have become HIV infected emphasizes the principles of inclusion, maintaining confidentiality of a child's HIV status, and notifying those who need to know about the HIV status to care properly for the child or adolescent. Although appropriate infection-control precautions are applicable for all children and for many pathogens, children especially HIV-infected children, exposed to such pathogens, must be managed in a timely fashion. In many cases, recommendations that are applicable in one setting are applicable in others. Some exceptions apply, including infection-control precautions in hospitals versus other settings. A few additional considerations have been made for special settings and activities, including adoption, foster care, athletics, summer camp, and other recreational activities.     

Asthma at the interface: bridging the gap between general practice and a district general hospital

A clinic supervised by a nurse, using principles originally developed in general practice, was established in the paediatric department of a district general hospital. A randomised controlled study was conducted comparing children admitted with asthma or attending outpatients who were given a patient education programme and self management plan (intervention group) with a control group. The study comprised 91 patients aged 3-14 years admitted for asthma or attending a hospital outpatient department from November 1989 to November 1990. Seventy seven patients completed the study and kept diaries for a median of 283 days. Patients in the intervention group had significantly less restriction of activity (95% confidence interval (CI) -0.27 to -0.01) and fewer episodes of peak flow below 30% of best (95% CI 0.03 to 1.17). Patients in the intervention group were more likely to make the correct response to an acute exacerbation of their asthma than the control group (71% v 47%, 95% CI 9.51 to 39.1). The intervention group had fewer school absences and fewer home visits by a general practitioner. There was an increase in the readmission rate for the intervention group. A subgroup of patients who self managed by doubling their use of inhaled steroids during an exacerbation performed better than those patients who only increased their bronchodilator or were managed on salbutamol or sodium cromoglycate alone. Improvements in patient follow up and the structure of the self management plans used, particularly changing the peak flow level at which inhaled steroids are doubled, may further improve the outcome of patients attending the asthma clinic.     

Assessment issues in the testing of children at school entry

The authors introduce readers to the research documenting racial and ethnic gaps in school readiness. They describe the key tests, including the Peabody Picture Vocabulary Test (PPVT), the Early Childhood Longitudinal Study (ECLS), and several intelligence tests, and describe how they have been administered to several important national samples of children. Next, the authors review the different estimates of the gaps and discuss how to interpret these differences. In interpreting test results, researchers use the statistical term "standard deviation" to compare scores across the tests. On average, the tests find a gap of about 1 standard deviation. The ECLS-K estimate is the lowest, about half a standard deviation. The PPVT estimate is the highest, sometimes more than 1 standard deviation. When researchers adjust those gaps statistically to take into account different outside factors that might affect children's test scores, such as family income or home environment, the gap narrows but does not disappear. Why such different estimates of the gap? The authors consider explanations such as differences in the samples, racial or ethnic bias in the tests, and whether the tests reflect different aspects of school "readiness," and conclude that none is likely to explain the varying estimates. Another possible explanation is the Spearman Hypothesis-that all tests are imperfect measures of a general ability construct, g; the more highly a given test correlates with g, the larger the gap will be. But the Spearman Hypothesis, too, leaves questions to be investigated. A gap of 1 standard deviation may not seem large, but the authors show clearly how it results in striking disparities in the performance of black and white students and why it should be of serious concern to policymakers.     

Experience of anti-retroviral treatment for HIV-infected children in Malawi: the 1st 12 months

INTRODUCTION: Malawi is a resource-poor country in central southern Africa with an estimated 91,000 HIV-infected children. A national public sector antiretroviral treatment (ART) scale-up programme was commenced in 2004. AIM: The experience and results of the 1st 12 months of free ART for HIV-infected children from a public sector hospital in Malawi is reported. METHODS: Demographic and clinical data were collected at the commencement of ART and during treatment of all children who attended the clinic at Queen Elizabeth Central Hospital, Blantyre from 1 August 2004 to 31 July 2005. RESULTS: ART was prescribed for 238 children during the 1st 12-month period. Of these, 196 were ART-na?ve and 42 had previously begun ART elsewhere. There were 128 (53.8%) males. Median age of the 196 ART-na?ve children was 87 months (range 7-212); 173 (88.3%) had WHO clinical stage III disease and 23 (11.7%) had WHO clinical stage I or II disease. Weight-for-age and weight-for-height Z-scores improved significantly with treatment. By 31 July 2005, 194 (81.5%) of the 238 children who attended the clinic were alive and on treatment, 20 (8.4%) had died, 19 (8.0%) were lost to follow-up and 5 (2.1%) had been transferred to other health facilities. CONCLUSIONS: In a resource-poor setting with only clinical monitoring available, children can feasibly and effectively be treated with ART. Lack of appropriate laboratory facilities, extra staff and paediatric drug formulations, although not ideal, should not prevent commencement of ART for children in such a setting.     

Maltreatment issues by level of adolescent substance abuse treatment: the extent of the problem at intake and relationship to early outcomes

Differences in self-reported victimization and outcomes for residential (n = 114) vs. outpatient (n = 73) substance abuse treatment samples were examined. Repeated measures MANOVAs for victimization level by level of care were performed on days of alcohol and marijuana use and substance-related problems. Residential treatment participants reported higher prevalence of victimization and higher levels of general victimization but did not differ on acute (high) victimization at intake. Analyses revealed a significant interaction between follow-up outcomes and level of care for adolescents with acute intake victimization. Adolescents placed in residential treatment were more likely to reduce their days of alcohol and marijuana use and past month substance-related problems at follow-up. Adolescents with low intake levels of victimization did not differ by level of care. Findings suggest that clinicians must carefully weigh placement recommendations for adolescents with maltreatment histories and that researchers should study ways to increase outpatient treatment effectiveness for these adolescents.