Legal basis of consent for health care and vaccination for adolescents

State law is generally the controlling authority for whether parental consent is required or minors may consent for their own health care, including vaccination. At the federal level, no vaccination consent law exists; however, federal law requires that vaccine information statements be given to the parent or another person who is qualified under state law to consent to vaccination of a minor. All states allow minors to consent for their own health care in some circumstances on the basis of either (1) their status (eg, age, emancipation, marriage) or (2) the kind of health care services they are seeking (eg, family planning services, treatment of sexually transmitted disease). In each state, a specific analysis of laws will be required to determine the circumstances under which a minor can consent for vaccination.

Sexual and reproductive health care for adolescents: legal rights and policy challenges

Laws developed over the past half century have significantly improved adolescents' access to essential sexual and reproductive health care. These laws allow many adolescent minors to give their own consent, protect confidentiality, and provide financial support for the care. The consent requirements for adolescents to receive health care are contained primarily in state court decisions and in statutes known as "state minor consent laws," which are based on either the minor's status or the services sought. Confidentiality protections for adolescents' health information are contained in these minor consent laws, in the federal medical privacy regulations known as the "HIPAA Privacy Rule," and in state medical privacy laws. Other significant laws include statutes providing for the emancipation of minors, court decisions delineating the mature minor doctrine, regulations protecting adolescents' access to confidential family planning services in publicly funded programs, and court decisions interpreting the constitutional right of privacy. Special considerations apply to consent and confidentiality questions pertaining to family planning, contraception, and pregnancy-related care for minors. In addition to the explicit provisions of state minor consent laws, many of the most important considerations are articulated in court decisions based on the constitutional right of privacy and the confidentiality requirements that are part of the federal Title X Family Planning Program and Medicaid.

A comparative assessment of cartilage and joint fat pad as a potential source of cells for autologous therapy development in knee osteoarthritis

OBJECTIVES

The utility of autologous chondrocytes for cartilage repair strategies in older subjects with osteoarthritis (OA) may be limited by both age-related and disease-associated decline in chondrogenesis. The aim of this work was to assess OA Hoffa's fat pad as an alternative source of autologous chondroprogenitor cells and to compare it with OA chondrocytes derived from different areas of cartilage.

METHODS

Cartilage and fat pad tissue digests were obtained from 26 subjects with knee OA and compared with normal bone marrow (BM) mesenchymal stem cells (MSCs) with respect to their in vitro colony-forming potential, growth kinetics, multipotentiality and clonogenicity. Flow cytometry was used to investigate their MSC marker phenotype.

RESULTS

Expanded cultures derived from eroded areas of cartilage were slightly more chondrogenic than those derived from macroscopically normal cartilage or chondro-osteophytes; however, all cartilage-derived cultures failed to maintain their chondrogenic potency following extended expansion. In contrast, OA fat pads contained highly clonogenic and multipotential cells with stable chondrogenic potency in vitro, even after 16 population doublings. Standard colony-forming assays failed to reflect the observed functional differences between the studied tissues whereas flow cytometry revealed higher levels of a putative MSC marker low-affinity growth factor receptor (LNGFR) on culture expanded fat pad-derived, but not cartilage-derived, MSCs.

CONCLUSIONS

In contrast to OA cartilage from three different sites, OA Hoffa's fat pad contains clonogenic cells that meet the criteria for MSCs and produce multipotential cultures that maintain their chondrogenesis long term. These findings have broad implications for future strategies aimed at cartilage repair in OA.

Abnormal T cell differentiation persists in patients with rheumatoid arthritis in clinical remission and predicts relapse

OBJECTIVES

An abnormal CD4+ T cell subset related to inflammation exposure (inflammation-related cells, IRC) has been identified in rheumatoid arthritis (RA). Patients with inflammatory and non-inflammatory diseases were used to examine the relationship between inflammation and this T cell subset in vivo.

METHODS

Blood was collected from healthy controls and patients with RA (active disease or in clinical remission), Crohn's disease and osteoarthritis. IRC and chemokine receptors were quantified by flow cytometry. Thymic activity and apoptotic factors were measured by real-time polymerase chain reaction. Circulating cytokines were measured by enzyme-linked immunosorbent assay. CXCR4 and SDF1 in synovial biopsies were measured using immunohistochemistry.

RESULTS

IRC were identified in patients with RA (p<0.0001) and Crohn's disease (p = 0.005), but not in those with osteoarthritis. In RA in remission, IRC persisted (p<0.001). In remission, hyperproliferation of IRC was lost, chemokine receptor expression was significantly lowered (p<0.007), Bax expression dropped significantly (p<0.001) and was inversely correlated with IRC (rho = -0.755, p = 0.03). High IRC frequency in remission was associated with relapse within 18 months (OR = 6.4, p<0.001) and a regression model predicted 72% of relapse.

CONCLUSIONS

These results suggest a model in which, despite the lack of systemic inflammation, IRC persist in remission, indicating that IRC are an acquired feature of RA. They have, however, lost their hyper-responsiveness, acquired a potential for survival, and no longer express chemokine receptors. IRC persistence in remission confirms their important role in chronic inflammation as circulating precursors of pathogenic cells. This was further demonstrated by much higher incidence of relapse in patients with high IRC frequency in remission.

Primary care providers' willingness to see unaccompanied adolescents

PURPOSE

To describe primary care practitioners' office policies and willingness to provide medical care for unaccompanied adolescents aged 11-17 years.

METHODS

A unique 32-item survey was mailed in June and July, 2001 to 1979 office-based pediatricians and family practitioners randomly selected from the American Medical Association's physician database. The survey included questions regarding demographic information, number of adolescents seen in the practice, office policies regarding adolescents alone in the clinic, and 5-point Likert scales regarding their willingness to see patients in various situations, as well as to see patients in 12 brief clinical scenarios. Predictors of the willingness to see adolescents alone were identified and entered into binomial logistic regression models. Specific policies included on the surveys were coded into groups.

RESULTS

Survey responses (n = 710) represented a 36% response rate. This sample included 288 family practitioners and 368 pediatricians; 43.3% of physicians reported having a specific policy regarding seeing adolescents without their parents present. Family practitioners were more likely than pediatricians to report having such a policy (51.3% vs. 38.2%, p =.001,), yet pediatricians reported a higher percentage of adolescents in their practices than family practitioners (22.6% vs. 12.4%, p <.0005). Not having a policy was an independent predictor of "often" or "always" seeing an adolescent alone for routine health maintenance (OR = 2.84, 95% CI 1.91-4.24) and urgent care visits (OR = 3.01, 95% CI 1.90-4.77). Specific policies varied, and many physicians assessed each case on an individual basis.

CONCLUSIONS

Specific policies are associated with a decreased willingness of physicians to see adolescents who are unaccompanied by a parent. Carefully developed clinic policies that are consistent with legal guidelines should be implemented in order to maximize adolescents' abilities to access care.

Eligibility and enrollment of adolescents in Medicaid and SCHIP: recent progress, current challenges

PURPOSE

To examine the effect of recent federal and state policy changes on adolescents' eligibility and enrollment in Medicaid and the State Children's Health Insurance Program (SCHIP).

METHODS

By analyzing relevant provisions in federal and state laws, approved state plans and amendments, annual reports and evaluations, and enrollment data provided by states, this article explores the extent to which states have taken full advantage of opportunities to expand Medicaid and SCHIP eligibility for adolescents.

RESULTS

Between March 1997 and September 2001, states made significant progress toward expanding Medicaid and SCHIP coverage for adolescents. During that time, the number of states that provided Medicaid coverage to all poor adolescents aged younger than 19 years doubled, most states eliminated the disparities that previously existed in Medicaid eligibility levels for younger children and adolescents, and virtually every state raised the income level at which adolescents are eligible for public coverage in either Medicaid or SCHIP. These changes resulted in an increase in the number of adolescents who are enrolled in Medicaid and SCHIP. Nevertheless, many states implemented other policies that create barriers to adolescents' eligibility and enrollment.

CONCLUSIONS

Despite recent expansions of public insurance eligibility, millions of adolescents remain uninsured. Much work remains to address eligibility gaps and to ensure that eligible adolescents are actually enrolled and use services. The current political and economic environment threatens to undermine the ability of adolescents to access services through these important programs.

Access to health care for youth leaving foster care: Medicaid and SCHIP

PURPOSE

To examine how Medicaid and the State Children's Health Insurance Program (SCHIP) could improve health care access for youth aging out of foster care, a vulnerable population with multiple health concerns.

METHODS

On the basis of an analysis of state and federal laws, state plans and amendments, and a telephone survey of state officials, this article identifies options in Medicaid and SCHIP for states to provide health insurance coverage for these youth, examines states' use of available options, and highlights other relevant federal health care programs.

RESULTS

Numerous Medicaid and SCHIP eligibility categories could provide coverage for older adolescents leaving foster care. The federal Foster Care Independence Act of 1999 (FCIA) created a new Medicaid expansion option for this group and other opportunities for states to address their health care needs. Numerous other federal programs also finance health care that could serve this population.

CONCLUSIONS

The potential exists through Medicaid or SCHIP to ensure that nearly all former foster youth have health insurance as they leave state custody, but Medicaid and SCHIP cannot alone meet all health care needs of these youth. Financing available through other public programs is essential. A few states have adopted the new FCIA Medicaid expansion option for former foster youth, and a larger number have implemented other relevant Medicaid options. Additional states have used other innovative approaches to facilitate health care access. Most states could do much more. A major challenge is to find approaches that can be implemented during times of severe budgetary limitations.

The health of adolescent girls: does the law support it?

The law provides protection and creates many policy options that could and do support the health of adolescent girls. Current legal protection pertains to consent for care, confidentiality of information, and insurance coverage; gaps in protection and policy options also exist. The extent to which the protection and options will remain in place and the gaps will be filled is uncertain. Additional issues of current interest and debate include financing treatment for increasingly pressing health concerns, such as eating disorders, obesity, and depression; new challenges concerning statutory rape reporting and enforcement of the laws related to it; and girls' access to emergency contraception.

Nursing practice and statutory rape. Effects of reporting and enforcement on access to care for adolescents

Changes over the past decade in statutory rape laws and their enforcement have created anxiety and confusion for nurses and other health care providers in jurisdictions across the country. Mandated reporting of statutory rape as child abuse potentially has the unsought effect of deterring some of the adolescents most in need of confidential health care from seeking that care. Knowledge and advocacy on the part of nurses can help mitigate the harms of overly inclusive reporting and enforcement.