Development of a Regionalized,Comprehensive Care Network for Pediatric Sickle Cell Disease to Improve Access to Care in a Rural State

Sickle cell disease (SCD), an inherited group of blood disorders, is a major public health problem worldwide. Patients experience severe anemia, increased risk of life-threatening infections, painful crisis, and chronic organ damage. Access to comprehensive care for SCD is known to improve outcomes; however, it is only reported from large urban centers serving one metropolitan area. Alabama, US, is a largely rural state with a significant number of children born each year with SCD. Prior to the development of our regional clinic network, the Children and Youth Sickle Network (CYSN^SM), 50% of patients identified by newborn screening were not enrolled in comprehensive sickle cell care. The majority of non-enrolled patients lived in southern Alabama. Rural areas in this region are particularly plagued by poverty and poor access to healthcare. Life expectancy is equivalent to residents of Sri Lanka. This area has 15.7 doctors/10 000 residents compared with the statewide ratio of 41.9 doctors/10 000 residents.To improve access to care, a regional clinic network, the CYSN^SM, was established in 1995. This paper reviews the impact of the CYSN^SM on pediatrie SCD in Alabama over the first 5 years of implementation.Since its inception in 1995, the CYSN^SM has provided care for 923 patients compared with 450 prior to the development of the clinic network. Currently, 90% of all cases identified by newborn screening are enrolled compared with 50% pre-CYSN^SM. Prior to the network, the average age of patients at their first clinic visit was 21 months. In the post-CYSN^SM period, the average age at first clinic visit decreased substantially to 5.3 months. Prior to the CYSN^SM, patients traveled on average 90 miles to a comprehensive clinic. Post-CYSN^SM, this distance has been cut in half to an average of 45 miles. A total of 70% of patients now live within 30 miles of a clinic. Most importantly, the infection death rate has decreased from 5.71 deaths/100 patient years to 1.94 deaths/100 patient years.The development, implementation, and evaluation of the CYSN^SM show that comprehensive care delivery in a rural setting is feasible and improves outcomes in pediatric SCD.     

Risk Adjustment for Measuring Health Care Outcomes, 3rd edition

Lisa I. Iezzoni (editor) Hardback, 508 pp, August 2003, ISBN 1-56793-207-X, $76.50, AcademyHealth/HAP(http://www.ache.org/hap.cfm) Lisa Iezzoni and colleagues produced the first edition of RiskAdjustment for Measuring Health Care Outcomes nearly 10 yearsago. At that time, payers and researchers were concerned withrisk adjustment primarily as a tool for hospital payment andfor assessing hospital performance. Although the Health CareFinancing Administration had ceased issuing Medicare risk-adjustedmortality rate reports, several other hospital performance reportingprojects were then underway, such as New York State’scoronary artery bypass grafting (CABG) surgery mortality project,Pennsylvania’s hospital outcomes reporting project, andthe Cleveland Health Quality     

Severe influenza B myocarditis and myositis.

OBJECTIVE: To report an influenza B infection with associated myocarditis and severe skeletal myositis. DESIGN: Case report. SETTING: Cardiac intensive care unit in a university-affiliated children's hospital. PATIENT: A 4-yr-old girl. RESULTS: The patient was successfully supported with extracorporeal membrane oxygenation for profound myocardial dysfunction and a combination of plasmapheresis and continuous venovenous hemodialysis for rhabdomyolysis and acute renal failure. CONCLUSIONS: This case provides a reminder that patients presenting with viral illness or myoglobinuria accompanied by renal failure, with or without associated myocarditis, may be demonstrating symptoms of influenza B.     

Seasonality and trend in blood lead levels of New York State children

Background  

Environmental exposure to lead remains a significant health problem for children. The costs of lead exposure in children are estimated to be considerably more than other childhood diseases of environmental origin. While long-term trends in blood lead levels (BLLs) among children are declining, seasonal variation persists. Cross-sectional studies have found a peak in summer months. Part of this variation may be due to increased exposure to lead paint on window sills and through increased contact with soils containing lead during the summer. The current study represents the largest published population-based study on seasonality and trends in the BLLs of children to date. In addition, the results offer a comparison of recent data on seasonality of BLLs in New York State children, to studies conducted over the past three decades.     

Distinctive gene expression profiles by cDNA microarrays in endometrioid and serous carcinomas of the endometrium.

Endometrial carcinomas are classified by their morphology into two major subtypes. Endometrioid carcinomas (type I) are generally estrogen dependent, well-differentiated, superficially invasive, and have a good outcome. Serous carcinomas (type II) are hormone independent, frequently deeply invasive and widely metastatic, and have a poor prognosis. Microarray technology and analysis allows us to determine if the global gene expression profiles of these two subtypes correlate with their morphologic phenotype. Fresh tissue from 18 endometrial carcinomas was studied: 7 well-, 2 moderately, and one poorly differentiated endometrioid, 4 serous carcinomas, and 4 high-grade mixed endometrioid-serous carcinomas. Labeled cDNA probes were synthesized (Cy5 for tumor, Cy3 for reference) and applied to microarrays containing 18,098 cDNA clones or ESTs. A pool of equal amounts of total RNA from each tumor served as the reference RNA. By unsupervised cluster analysis, the endometrioid carcinomas clustered together and were separate from the serous carcinomas. The high-grade mixed carcinomas clustered with the serous carcinomas. Using a statistical algorithm based on gene expression pattern and conducting a supervised analysis of the two defined groups, we have identified 315 genes that statistically differentiate type I from type II endometrial carcinomas. In addition to corroborating the predicted overexpression of known markers (e.g., ras and catenin in endometrioid carcinomas), the cDNA microarray technique has revealed novel alterations in gene expression relevant to cell cycle, cell adhesion, signal transduction, apoptosis, and tumor progression not previously implicated in endometrial carcinomas. For serous carcinomas, these include aldolase, desmoplakin, integrin-linked kinase, PKC, and metallopeptidase. In conclusion, the gene expression profiles of type I and type II endometrial carcinomas are different. Refinement of these profiles will permit more accurate diagnostic tumor classification and the development of prognosis assays.     

A parallel algorithm for simulation of large neural networks

The simulation of biologically realistic neural networks requires the numerical solution of very large systems of differential equations. Variables within the system can be changing at rates that vary by orders of magnitude, not only at different times of the solution, but at the same time in different parts of the network. Therefore, an efficient implementation must be able to vary the solution step size, and do so independently in different subsystems. A single processor algorithm is presented in which each neuron can be solved with its own step size by using a priority queue to integrate them in the correct order. But this leaves the problem of how communication and synchronisation between neurons should be managed when executing in parallel. The proposed solution uses an algorithm based on waveform relaxation, which allows groups of neurons on different processors to be solved independently and hence in parallel, for substantial parts of the computation. Realistic test problems were run on a distributed memory parallel computer and results show that speedups of 10 using 16 processors are achievable, and indicate that further speedups may be possible.     

Alterations in respiratory behavior, brain neurochemistry and receptor density induced by pharmacologic suppression of sleep in the neonatal period

The present study examined if drug suppression of active sleep (AS) in the neonate affected the development and expression of respiratory behavior. Secondly, we assessed brain neurochemistry and receptor density in specific supra-medullary brain regions to identify coincident biochemical alterations. Sprague-Dawley newborn rat pups were randomized and divided among six rat mothers (n=10/mother/group), each mother housed separately. Two untreated control (UC) groups received either no interventions or were fed milk vehicle twice daily and were handled similarly to the drug intervention animals. Pharmacological disruption of sleep was achieved by administration (2 groups of each) of either clonidine (CLO) 100 microm/kg, or scopolamine (SCO) 800 microm/kg, given orally twice daily for the first 7 days of life. On postnatal (P) days P10 and P19 of life, pups were assessed for metabolism, minute ventilation (VE), tidal volume (Vt) and frequency (f). On P21 (14 days after the end of drug exposure), pups from each condition were sacrificed and punch biopsies of the frontal cortex, hypothalamus, and hippocampus were examined for hydroxytryptophan (5-HT), and norepinepherine (NE) by HPLC. An equal number of pups were sacrificed and brains examined for muscarinic acetylcholine (mAch), alpha2-adrenergic and I1-imidazoline receptor density. RESULTS: Both CLO and SCO exposed animals had a lower V(t) and respiratory quotient than UC animals (p<0.01). CLO animals exhibited a higher f (p<0.01) and both CLO and SCO exhibited a lower V(t) (p<0.05) than the UC groups; VE was reduced in the SCO groups, compared with CLO and UC groups (p<0.01). Pattern of breathing in response to brief hypoxia exposure was altered for CLO and SCO. The normal decline in VE during sleep was not observed in CLO rats. Both drug exposures resulted in a comparable reduction in hypothalamic NE and 5-HT levels (p<0.05), while in the frontal cortex, and the hippocampus variable changes in NE and 5-HT, occurred. In CLO and SCO rats mAch receptors were increased in cortex, and reduced in hypothalamus; I1-imidazoline receptors were increased in hypothalamus and decreased in hippocampus (p<0.05 for each). In contrast, alpha2-adrenergic receptors were increased in cortex for both CLO and SCO, decreased in hypothalamus for CLO, and decreased in hippocampus for SCO (p<0.05 for each). CONCLUSIONS: these data show that drug-induced neonatal sleep suppression will alter ventilatory pattern, metabolism, and site-specific concentrations of adrenergic neurotransmitters and in receptor density, perhaps as a result of suppression of neonatal AS.     

Does gastrostomy tube feeding in children with cerebral palsy increase the risk of respiratory morbidity?

BACKGROUND: Children with severe neurological impairment may have significant oral motor dysfunction and are at increased risk of nutritional deficiencies, poor growth, and aspiration pneumonia. Gastrostomy tube feeding is increasingly being used for nutritional support in these children. AIM: To examine the occurrence of respiratory morbidity before and after gastrostomy feeding tube insertion in children with severe neurological disabilities. METHODS: This study was nested in a longitudinal, prospective, uncontrolled, multicentre cohort study designed to investigate the outcomes of gastrostomy tube feeding in 57 children with severe neurological disabilities. Parents completed a questionnaire prior to (visit 1) and 6 and 12 months (visits 2 and 3) following the gastrostomy, detailing number of chest infections requiring antibiotics and/or hospital admission. RESULTS: Mean number of chest infections requiring antibiotics was 1.8 on visit 1 and 0.9 on visit 3. Hospital admissions for chest infections fell significantly from 0.5 to 0.09. CONCLUSION: This study provides no evidence for an increase in respiratory morbidity following insertion of a feeding gastrostomy in children with cerebral palsy.