CONTEXT: Integrated care models may improve health care for children and young people (CYP) with ongoing conditions. OBJECTIVE: To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions. DATA SOURCES: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996–2018). STUDY SELECTION: Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0–18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome. DATA EXTRACTION: Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care. RESULTS: Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03–0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57–1.37; P = .57). LIMITATIONS: Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist. CONCLUSIONS: Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear.

The high-risk types of human papillomavirus (HPV) have been found to be associated with most cervical cancers and play an essential role in the pathogenesis of the disease. Despite recent advances in preventive HPV vaccine development, such preventive vaccines are unlikely to reduce the prevalence of HPV infections within the next few years, due to their cost and limited availability in developing countries. Furthermore, preventive HPV vaccines may not be capable of treating established HPV infections and HPV-associated lesions, which account for high morbidity and mortality worldwide. Thus, it is important to develop therapeutic HPV vaccines for the control of existing HPV infection and associated malignancies. Therapeutic vaccines are quite different from preventive vaccines in that they require the generation of cell-mediated immunity, particularly T cell-mediated immunity, instead of the generation of neutralizing antibodies. The HPV-encoded early proteins, E6 and E7 oncoproteins, form ideal targets for therapeutic HPV vaccines since they are consistently expressed in HPV-associated cervical cancer and its precursor lesions and thus play crucial roles in the generation and maintenance of HPV-associated disease. Our review will cover the various therapeutic HPV vaccines for cervical cancer, including live vector-based, peptide or protein-based, nucleic acid-based, and cell-based vaccines targeting the HPV E6 and/or E7 antigens. Furthermore, we will review the studies using therapeutic HPV vaccines in combination with other therapeutic modalities and review the latest clinical trials on therapeutic HPV vaccines.

Central nervous system (CNS) manifestations of chronic hepatitis C virus (HCV) and chronic human immune deficiency virus-1 (HIV-1) infections have been reported, but the impact of acute HCV infection on the CNS is unknown. A total of 10 individuals with chronic stable HIV-1 with documented acute HCV (HCV-RNA polymerase chain reaction positive and HCV antibody negative, group 1) underwent cerebral proton magnetic resonance spectroscopy (MRS) using acquisition parameters to quantify myo-inositol/creatine (mI/Cr) ratio in the right basal ganglia (RBG). Two matched control groups also underwent MRS; group 2: ten with chronic HIV-1 and no evidence of HCV, and group 3: ten with no evidence of HIV or HCV. Subjects also underwent computerized neurocognitive assessments (CogState). RBG mI/Cr ratio in group 1 (acute HCV in a background of HIV) was significantly lower than that in groups 2 and 3 [2.90 (+/-0.7) vs 3.34 (+/-0.4) and 3.43 (+/-0.4), mean (SD) for group 1 vs 2 and 3 respectively, P = 0.049], with 50% of subjects in group 1 having a mI/Cr ratio below the lowest observed ratio in either of the other groups. On neurocognitive testing, significant defects in the monitoring domain were observed in group-1, compared with matched controls (P = 0.021). Acute HCV in HIV-1 infected subjects is associated with CNS involvement. Clinicians should be vigilant of early CNS involvement when assessing subjects with acute HCV.

Introduction: Half of all children will experience an episode of wheezing by their sixth birthday and acute episodes of wheezing in preschool children account for the majority of all childhood hospital admissions for wheeze. Recurrent preschool wheezing associates with early loss of lung function and a life-long impact on lung health. Areas covered: We reviewed the literature on PubMed from August 2010-2020 focussing on factors associated with wheeze inception and persistence, paying specific attention to mechanistic studies that have investigated the impact of early life exposures in shaping immune responses in children with underlying susceptibility to wheezing. In particular, the role of early allergen sensitization, respiratory infections, and the impact of the environment on shaping the airway microbiome and resulting immune responses are discussed. Expert opinion: There is an abundance of associative data showing the role of in utero and postnatal factors influencing wheeze onset and persistence. However, mechanistic and stratified, biomarkerbased interventional studies that confirm these associations are now needed if we are to impact the significant healthcare burden resulting from preschool wheezing disorders.

<p>This review will outline an evidence-based approach for diagnosing and managing children with problematic severe asthma (PSA). Children with PSA have uncontrolled asthma symptoms, despite maximal prescribed asthma treatment. These children have high morbidity and mortality and should be referred for specialist respiratory assessment and management. The first step in the assessment of a child with PSA is confirming the diagnosis of asthma using objective evidence. Following this, an assess- ment of inhaled corticosteroid adherence and a multi-disciplinary team approach is essential for separating difficult asthma (DA) from severe therapy resistant asthma (STRA). The majority of children have DA which entails uncontrolled asthma symp- toms due to underlying modifiable factors including poor treatment adherence, poor inhaler technique, exposure to environ- mental allergens, co-morbid conditions and psycho-social factors.  Approximately 20% of children with PSA have STRA, and have persistent asthma symptoms despite good treatment adherence and correction of modifiable factors. Children with STRA typically have multiple and severe aeroallergen sensitization, eosinophilic airway inflammation and high fraction exhaled nitric oxide (FeNO). Further investigation of children with STRA includes an assessment of systemic steroid responsiveness, this is important for confirming the diagnosis of STRA and guiding the choice of additional treatment. Biologics are an add on (immune targeted) therapy for STRA. The current biologics used in children target the T2 helper (Th2) pathway mediating eosino- philic, allergic asthma.</p><p><strong>Conclusion. </strong>Future clinical trials of biologics in children will be essential to help identify childhood specific biomarkers and to decide which biologic is best for which individual child.</p>

Asthma is a chronic airways disease with both immediate and longterm health implications, including death and permanent disability.The burden of asthma, both clinical and financial, is considerable, with more than 100,000 annual hospital admissions in the United Kingdom and an overall cost of more than £1 billion per annum to the NHS. 1 A significant proportion of these costs can be attributed to children with asthma, in particular, those with severe asthma, who utilize up to 50% of healthcare resources for asthma. In addition, pediatric severe asthma has long-term health consequences into adulthood, with longitudinal studies suggesting it predisposes for adult chronic obstructive pulmonary disease. 2 If management of pediatric severe asthma can be optimized, then some of these health burdens may be mitigated.Problematic severe asthma (PSA) is an all-encompassing definition used for children aged 6-16 years with a confirmed diagnosis of asthma who have persistent symptoms despite maximal conventional therapy. 3 In order to optimize the management of children with PSA, a thorough assessment must be undertaken by the multidisciplinary team (MDT)

Introduction Improving efficiency in healthcare delivery while maintaining patient safety is central to providing high quality patient care, improved patient satisfaction and creates a culture of improved training for future paediatricians. Poor communication during patient handovers has been cited as being one of the most dangerous interventions that clinicians put patients through. The SBAR handover tool has been recognised by the WHO as well as the National Health Service Institute of Innovation and Improvement as a simple and standardised tool that encourages the clinicians to present patient information in a concise and focused fashion that has been shown to improve patient safety. SBAR is an acronym which stands for Situation, Background, Assessment and Recommendation. Aim To evaluate the impact of time spent by paediatric trainees on the morning patient handover before and after the introduction of SBAR within the department. Method The handovers involved discussing patients who were on the ward, the ED department, and ambulatory unit. An additional note was made of patients for whom there was a significant psycho-social element to their handover. Information on the time spent discussing each patient using a conventional, semi-structured handover process, was recorded for 7 days (over two consecutive weeks). This was followed by conducting the exercise again after the entire department had undergone SBAR training and a 2 month period of daily practise. Data was then gathered for a 14 day period over three consecutive weeks. Results Prior to commencing the use of SBAR, each handover was taking an average of 55.7 min (range 40 to 73) with 22 patients being discussed per handover on average. Post SBAR, it took an average of 32 min for each handover (range 19 to 49) with 21 patients being discussed per handover. Pre SBAR, it took an average of 2.57 min to handover a patient compared to 1.54 min post SBAR. This represents a 60% reduction in time using SBAR (p<0.0003). Conclusions This significant reduction in handover times using SBAR demonstrates improved efficiency. This has several benefits including enabling time to be generated for ‘micro-teach’ sessions and improved paediatric training or increasing departmental productivity.

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