Lena E. Winestone

Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: A qualitative provider interview study

Abstract The aim of this study was to explore the perspectives of healthcare providers on the advantages and disadvantages of integrating HIV care services, including highly active antiretroviral therapy (HAART), into antenatal care (ANC) clinics in rural Kenya. We conducted a qualitative study using in-depth interviews and thematic analysis; 36 healthcare providers from six health centres in Nyanza Province, Kenya participated. Effects on service providers included increased workload due to the incorporation of specialised HIV services into ANC clinics. Providers observed that integration results in decreased patient time spent at the health facility, increased efficiency and closer provider-patient relationships; all leading to increased patient satisfaction. Providers also said that women would be more likely to receive HAART and adhere to their treatment as a result of improved confidentiality and decreased stigma. However, a minority of providers noted that integration could result in longer appointment times for HIV-positive women at ANC clinics leading to inadvertent disclosure. Integration could lead to strengthened ANC, postpartum care, prevention of mother-to-child transmission and HIV care for women and their families. However, integration efforts need to take into account potential negative effects on ANC provider workload, disclosure and the quality of care.

Increased utilization of pediatric specialty care: a population study of pediatric oncology inpatients in California.

Objective: To examine inpatient utilization of pediatric cancer specialty centers (PCSCs) by pediatric oncology patients. Study Design: We performed a retrospective (1999 to 2010) population-based analysis of oncology hospitalizations for pediatric patients aged 0 through 18 years using the California Office of Statewide Health Planning and Development database. Logistic regression examined hospitalization at 29 PCSCs and variables of age, sex, tumor type, payer, race, income, and distance to admission site. Results: Analysis of 103,961 pediatric oncology discharges revealed that 93% occurred at PCSCs. These sites experienced a 20% increase in pediatric oncology discharges, conversely non-PCSCs exhibited a 70% decrease (P<0.0001). Multivariate analyses revealed increased utilization with young age (odds ratio [OR], 4.58; 95% CI, 3.88-5.42), African American (OR, 1.26; 95% CI, 1.11-1.43), and middle income (OR, 1.36; 95% CI, 1.29-1.45). Decreased utilization was seen for females (OR, 0.88; 95% CI, 0.84-0.93) and Hispanics (OR, 0.72; 95% CI, 0.68-0.77). Payer and proximity were not significantly associated with change in utilization. Tumor types less likely to utilize a PCSC included germ cell, solid, and central nervous system tumors. Adolescents were >3 times less likely to be treated at a PCSC. Conclusions: Inpatient pediatric oncology care in California has become increasingly regionalized with the vast majority of patients accessing PCSCs. However, variability in hospitalizations of adolescent patients and children not treated in PCSCs deserve further evaluation.

The Role of Acuity of Illness at Presentation in Early Mortality in Black Children with Acute Myeloid Leukemia.

Black patients with acute myeloid leukemia (AML) experience higher mortality than White patients. We compared induction mortality, acuity of illness prior to chemotherapy, and insurance type between Black and White patients to assess whether acuity of presentation mediates the disparity. Within a retrospective cohort of 1,122 children with AML treated with two courses of standard induction chemotherapy between 2004 and 2014 in the Pediatric Health Information System (PHIS) database, the association between race (Black versus White) and inpatient mortality during induction was examined. Intensive Care Unit (ICU)‐level resource utilization during the first 72 hours following admission for initial AML chemotherapy was evaluated as a potential mediator. The total effect of race on mortality during Induction I revealed a strong association (unadjusted HR 2.75, CI: 1.18, 6.41). Black patients had a significantly higher unadjusted risk of requiring ICU‐level resources within the first 72 hours after initial presentation (17% versus 11%; RR 1.52, CI: 1.04, 2.24). Mediation analyses revealed the indirect effect of race through acuity accounted for 61% of the relative excess mortality during Induction I. Publicly insured patients experienced greater induction mortality than privately insured patients regardless of race. Black patients with AML have significantly greater risk of induction mortality and are at increased risk for requiring ICU‐level resources soon after presentation. Higher acuity amongst Black patients accounts for a substantial portion of the relative excess mortality during Induction I. Targeting factors affecting acuity of illness at presentation may lessen racial disparities in AML induction mortality.

Recurrent Donath-Landsteiner hemolytic anemia: a pediatric case report

Paroxysmal cold hemoglobinuria (PCH) is a form of autoimmune hemolytic anemia caused by the Donath‐Landsteiner antibody (D‐L antibody). In children, this is typically a transient immune‐mediated hemolysis that follows a viral illness and does not recur. Recurrent acute or chronic PCH due to D‐L antibody is very rare.

High human herpesvirus 6 viral load in pediatric allogeneic hematopoietic stem cell transplant patients is associated with detection in end organs and high mortality

Human Herpes Virus 6 (HHV‐6) reactivation occurs in approximately half of patients following allogeneic hematopoietic stem cell transplant (HSCT). While encephalitis and delayed engraftment are well‐documented complications of HHV‐6 following HSCT, the extent to which HHV‐6 viremia causes disease in children is controversial. We performed a retrospective review of HHV‐6 reactivation and possible manifestations in pediatric allogeneic HSCT patients at a single institution. Of 89 children and young adults who underwent allogeneic HSCT over a three‐and‐a‐half‐year period, 34 patients reactivated HHV‐6 early post‐transplant. Unrelated donor stem cell source and lack of antiviral prophylaxis were risk factors for the development of HHV‐6 viremia. Viremia correlated with the presence of acute graft‐versus‐host disease, but not chronic graft‐versus‐host disease. We identified two subgroups within the viremic patients—a high‐risk viremic and tissue‐positive group that reactivated HHV‐6 and had suspected end‐organ disease and a low‐risk viremic but asymptomatic group that reactivated HHV‐6 but did not exhibit symptoms or signs of end‐organ disease. Peak viral load was found to be strongly associated with mortality. Prospective studies in larger numbers of patients are needed to further investigate the role of HHV‐6 in causing symptomatic end‐organ disease as well as the association of viral load with mortality.

Renal Complications Associated with HSCT

Acute kidney injury and CKD remain significant complications of hematopoietic stem cell transplantation (HSCT) and are associated with morbidity and mortality. Careful assessment of kidney function, e.g., glomerular filtration rate (GFR), blood pressure, and proteinuria, is a critical first step in the detection of kidney disease and the prevention of further injury, when possible. While kidney injury can be multifactorial after HSCT, the most common causes include medications, infections, thrombotic microangiopathy, and perhaps GvHD. Close collaboration between HSCT providers, nephrologists, infectious disease experts, and, when needed, critical care teams is essential to the prevention and management of kidney injury in this high-risk population. This chapter discusses the prevalence and diagnosis of renal dysfunction post-HSCT. It also addresses common causes of kidney injury post-HSCT. Hemorrhagic cystitis is discussed in greater detail elsewhere (see Chap. 16).

Complications preceding early deaths in Black and White children with acute myeloid leukemia

Black patients have a twofold increased risk of induction mortality compared to White patients with acute myeloid leukemia (AML). We reviewed diagnosis and billing data from Pediatric Health Information System for 28 AML Induction I deaths to investigate conditions preceding death in White and Black patients. Half of deaths occurred within 10 days of initial diagnostic admission. Respiratory, cardiac, renal, and infectious complications were common prior to both White and Black deaths. Deaths in White patients were more commonly preceded by intracranial hemorrhage compared to deaths in Black patients. Future studies should assess management approaches of complications by race to identify modifiable processes that reduce mortality.