The impact of Medicaid on children's healthcare and health

PURPOSE OF REVIEW: This article reviews the impact of the Medicaid program, including the proportion of children in America insured by Medicaid; the extent to which Medicaid-enrolled children have access to care; the use of services and the quality of care received by Medicaid enrollees, including evidence for disease reduction; and family satisfaction with the program. RECENT FINDINGS: More than a quarter of all children in the United States were insured through public programs, primarily Medicaid, in 2002. Public insurance programs are even more critical for low-income children: 69.5% of children in families with incomes below 100% of the federal poverty level are covered by public programs. The reach of Medicaid is extensive, although substantial numbers of eligible children remain uninsured. Although Medicaid-insured children still face access barriers, particularly for certain types of specialty care, parents of children with public insurance report high levels of satisfaction with their experience with well-child care. While the study findings are mixed, several recent studies show very favorable comparisons between the experience of privately insured children and that of publicly insured children. SUMMARY: Medicaid plays a critical role in providing health insurance coverage for children, particularly for very low-income families. Additional efforts are needed to fully enroll all eligible families and to assure full access to high-quality care.     

Neutrophilic eccrine hidradenitis in two neutropaenic patients

We describe two patients, who presented with erythematous facial plaques, in keeping with neutrophilic eccrine hidradenitis, during chemotherapy for acute myeloid leukaemia. Both patients were neutropaenic and febrile. Histology showed a dermal neutrophilic infiltrate around the eccrine glands with gland destruction. The importance of recognizing this disorder is to prevent the inappropriate use of antibiotics as it is self limiting.     

Regulation of T cell function by NK cell receptors for classical MHC class I molecules

Inhibitory receptors for MHC class I molecules were initially characterised on NK cells. Human and mouse NK cell receptors (NKRs) are also expressed on T cells, predominantly on a subset of memory-phenotype CD8(+) T cells. This review focuses on the precise determination of interactions between NKRs and MHC class I, as well as on the unexpected in vivo function of NKRs on T cells.     

A mechanism-based model for the population pharmacokinetics of free and bound aflibercept in healthy subjects

AIM

Aflibercept (VEGF-Trap), a novel anti-angiogenic agent that binds to VEGF, has been investigated for the treatment of cancer. The aim of this study was to develop a mechanism-based pharmacokinetic (PK) model for aflibercept to characterize its binding to VEGF and its PK properties in healthy subjects.

METHODS

Data from two phase I clinical studies with aflibercept administered as a single intravenous infusion were included in the analysis. Free and bound aflibercept concentration−time data were analysed using a nonlinear mixed-effects modelling approach with MONOLIX 3.1.

RESULTS

The best structural model involved two compartments for free aflibercept and one for bound aflibercept, with a Michaelis–Menten type binding of free aflibercept to VEGF from the peripheral compartment. The typical estimated clearances for free and bound aflibercept were 0.88 l day⁻¹ and 0.14 l day⁻¹, respectively. The central volume of distribution of free aflibercept was 4.94 l. The maximum binding capacity was 0.99 mg day⁻¹ and the concentration of aflibercept corresponding to half of maximum binding capacity was 2.91 µg ml⁻¹. Interindividual variability of model parameters was moderate, ranging from 13.6% (V_max) to 49.8% (Q).

CONCLUSION

The present PK model for aflibercept adequately characterizes the underlying mechanism of disposition of aflibercept and its nonlinear binding to VEGF.     

Effectiveness of pediatric practice consultation on missed opportunities for immunization

Objective To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines. Design The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed. Results The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions. Conclusions There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities. This study was funded by the Centers for Disease Control and Prevention, contract number 200-90-0850.     

The 'T-cell-ness' of NK cells: unexpected similarities between NK cells and T cells

NK cells are considered as prototypical innate immune cells. However, recent discoveries have tended to refine the dogmatic concepts of innate and adaptive immunity. In many ways, NK cells are highly related to T cells and represent the closest innate immune cell lineage to adaptive immune cell populations. Here, we review the relationships between NK cells and T cells and discuss the recently described cell-intrinsic-adaptive features of NK cells.