Child Health Supervision: Analytical Studies in the Financing, Delivery, and Cost-Effectiveness of Preventive and Health Promotion Services for Infants, Children, and Adolescents

Contents: Financing and Delivery of Child Health Supervision Services (An Overview of Health Insurance Coverage and Access to Child Health Supervision Services, Private Health Insurance Coverage of Preventive Benefits for Children, A 20-Year Retrospective of Child Health Supervision in Ambulatory Pediatric Settings, Ensuring Adequate Health Care Benefits for Children and Adolescents); Child Health Supervision Services and Medicaid (Informing State Medicaid Providers about EPSDT, Barriers to Full Participation in EPSDT and Possible Strategies for the Maternal and Child Bureau, Medicaid Managed Care: A Briefing Book on Issues for Children and Adolescents; State Implementation of OBRA \u2789 EPSDT Amendments within Medicaid Managed Care Arrangements)

The systematic guideline review: method, rationale, and test on chronic heart failure

Background: Evidence-based guidelines have the potential to improve healthcare. However, their de-novo-development requires substantial resources-especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development-the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF). Methods: A systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline. Results: Of 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 un-rateable (derived from a single guideline). Of the 25 consistencies, 14 were based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) - the majority was congruent. Incongruity was found where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer. Conclusion: The systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines

Systematic review of safety in paediatric drug trials published in 2007

Background: There is now greater involvement of children in drug trials to ensure that paediatric medicines are supported by sound scientific evidence. The safety of the participating children is of paramount importance. Previous research shows that these children can suffer moderate and severe adverse drug reactions (ADRs) in clinical trials, yet very few of the trials designated a data safety monitoring board (DSMB) to oversee the trial. Methods: Safety data from a systematic review of paediatric drug randomised controlled trials (RCTs) published in 2007 were analysed. All reported adverse events (AEs) were classified and assessed to determine whether an ADR had been experienced. ADRs were then categorised according to severity. Each trial report was examined as to whether an independent DSMB was in place. Results: Of the 582 paediatric drug RCTs analysed, 210 (36%) reported that a serious AE had occurred, and in 15% mortality was reported. ADRs were detected in more than half of the RCTs (305); 66 (11%) were severe, and 79 (14%) were moderate. Severe ADRs involved a wide range of organ systems and were frequently associated with cytotoxic drugs, antiparasitics, anticonvulsants and psychotropic drugs. Two RCTs reported significantly higher mortality rates in the treatment group. Only 69 (12%) of the RCTs stated there was a DSMB. DSMBs terminated five RCTs and changed the protocol in one. Conclusions: Children participating in drug RCTs experience a significant amount and a wide range of ADRs. DSMBs are needed to ensure the safety of paediatric participants in clinical drug trial

Progetto di costruzione del 4° tratto della provinciale Forno – Giffoni in contrada Siglia alla provinciale Umberto I° sponda destra del Picentino: lunghezza metri 1571.85: sezioni

In copertina: Consorzio dei comuni del mandamento di S. Cipriano Picentino con sede in S. Mango PiemonteIn copertina: Strada di accesso alla stazione ferroviaria di Pontecagnano sulla linea Salerno – BattipagliaIn copertina: Esecuzione della legge 8 luglio 1903 n° 312In copertina: Alligato n°.

Progetto di costruzione del 4° tratto della provinciale Forno – Giffoni in contrada Siglia alla provinciale Umberto I° sponda destra del Picentino: lunghezza metri 1571.85. Computo metrico: parte 3°: Distribuzione e trasporto delle terre

In copertina: Consorzio dei comuni del mandamento di S. Cipriano Picentino con sede in S. Mango PiemonteIn copertina: Strada di accesso alla stazione ferroviaria di Pontecagnano sulla linea Salerno – BattipagliaIn copertina: Esecuzione della legge 8 luglio 1903 n° 312In copertina: Alligato n°.