The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) addressed new initiatives and voted on several vaccine recommendations in their first 2024 meeting, held from February 28 to 29.
The ACIP discussed several vaccines during the 2-day meeting, including those for protection against COVID-19, Chikungunya, diphtheria and tetanus (DT), Hemophilus influenzae type b (Hib), polio, respiratory syncytial virus (RSV), meningococcal disease, and pneumococcal disease. The updated recommendations for vaccination against COVID-19, RSV, and pneumococcal disease are available here.
DT Vaccine
The DT vaccine, which was previously recommended for children younger than 7 years with a contraindication to pertussis-containing vaccines, has been discontinued in the United States. The ACIP now recommends the tetanus and diphtheria (Td) vaccine for this group, particularly in those who develop encephalopathy within 7 days of DT vaccination.1 Current guidelines indicate the diphtheria, tetanus, and pertussis (DTaP) vaccine as the first dose in the vaccination series. Children aged 7 years and older with contraindications may now receive Td for all remaining doses. Although it remains a viable option, the Td vaccine contains a lower dose of diphtheria toxoid, suggesting a decrease in its efficacy.
The ACIP approved the vaccines for children resolution for coverage of the Td vaccine in children younger than 7 years who have contraindications to pertussis-containing vaccines.2 This update is anticipated to be included in the recommended immunization schedule. Guidelines regarding the administration of a single booster dose of the Tdap vaccine among children aged between 11 and 12 years remain unchanged.
"
Revisions to the schedule should optimize protection against meningitis.
Meningococcal Vaccination
The meningococcal conjugate vaccine (MenABCWY), a pentavalent formulation from Pfizer®, was approved by the Food and Drug Administration (FDA) in October 2023. The ACIP now recommends the MenABCWY vaccine among children and adolescents for whom both the MenACWY and MenB vaccines are indicated at a single visit. The approval of the MenABCWY vaccine provides multiple options for revising the meningococcal vaccine schedule, including the elimination of a MenACWY vaccine dose in children aged 11 to 12 years and a change in the recommended age group for MenB vaccination to increase protection at the time of college entry.
Evidence suggests that college-aged students have a 3.5-fold higher risk for serogroup B disease than noncollege-aged students, with disease incidence peaking at 19 years of age and declining after 20 years of age.3 According to the ACIP, "Revisions to the schedule should optimize protection against meningitis." They also noted that the approval of a pentavalent formulation will serve to lower the number of injections needed for protection against meningococcal disease.
The ACIP proposed several options to consider for revising the recommended meningococcal vaccine schedule, as shown in the table:3
Option
ACWY Dose #1
ACWY Dose #2
B Dose #1
B Dose #2
Current Recommendation
11-12 years
16 years
16-23 years (preferred 16-18 years) *SCDM
16-23 years (preferred 16-18 years) *SCDM
1
11-12 years
16 years
16 years
17-18 years
2
11-12 years
16 years
16 years risk-based
17-18 years risk-based
3
No dose
16 years
16 years risk-based
17-18 years risk-based
4
15 years
17-18 years
17-18 years
17-18 years
*SCDM = shared clinical decision making
There is ongoing discussion regarding these 4 options as the ACIP noted that the existing vaccination platform took years to implement and any revisions to the schedule may affect school requirements.
Chikungunya Vaccination
Chikungunya is a viral disease transmitted to humans by infected mosquitoes. The Chikungunya vaccine (IXCHIQ) was licensed in the US by the FDA in November 2023 for use among individuals at risk for exposure to the virus, including travelers, laboratory workers, and those residing in areas with increased transmission risk. The vaccine is available as a single-dose primary schedule for individuals aged 18 years and older.4
The ACIP recommends the vaccine for adults traveling to a country or territory where there has been an outbreak of Chikungunya.2
However, the vaccine may be considered for the following individuals in the event of planned travel to a country or territory where there is no outbreak but where substantial evidence of transmission has occurred within the past 5 years:2
Individuals aged 65 years and older with underlying health conditions likely to have mosquito exposure
Individuals scheduled to remain abroad an extended period (≥6 months)
In regard to laboratory workers, the ACIP recommends Chikungunya vaccination for those whose research or diagnostic work involves the use of live viruses. The ACIP noted that the virus is primarily transmitted through aerosol, as well as percutaneous and possibly mucosal routes.2
Individuals who are pregnant should avoid exposure to Chikungunya.6 The ACIP noted that Chikungunya vaccination should be deferred until after delivery but may be considered for individuals at increased risk for exposure. However, they recommend against vaccination during the first trimester as well as after 36 weeks’ gestation.
Polio Vaccination
The ACIP considered modifying the polio vaccine schedule for US children who have been vaccinated against polio in other countries. Six countries (Bangladesh, Cuba, Ecuador, India, Nepal, and Sri Lanka) include fractional inactivated polio virus (fIPV) vaccination in recommended routine childhood immunization schedules.8
According to the ACIP, 2 fIPV doses are considered valid and counted as one full intramuscular dose of IPV with respect to the US schedule. However, 1 fIPV dose is not considered a viable alternative to 1 IPV dose.8
Guidelines regarding children who have been vaccinated against polio in the US remain unchanged.
Hib Vaccination
There are ongoing discussions regarding the expansion of Hib vaccine recommendations for American Indian and Alaska Native (AI/AN) infants. Guidelines suggest the use of PedvaxHIB® (Hemophilus b conjugate vaccine) for AI/AN infants. However, the emergence of combination vaccines, such as Vaxelis®, may expand options for this population.
Vaxelis, initially licensed by the FDA in December 2018, is a hexavalent vaccine comprising DTaP, inactivated polio, Hemophilus influenzae type B conjugate, and hepatitis B virus vaccine formulations. Similar to PedvaxHIB, Vaxelis contains Hib conjugate at a lower dose.7 Combination vaccines provide an opportunity for fewer shots, reduce the risk for missed doses, and lower the burden of vaccine administration. Results of a phase 4 trial conducted among AI/AN infants (N=333) showed that Vaxelis was noninferior to PedvaxHIB with respect to Hib antibody levels 30 days following receipt of the first vaccine dose.8
Members of the ACIP will vote on additional vaccine recommendations at their next scheduled meeting in June of 2024.
"
["post_title"]=>
string(86) "CDC Vaccine Update: Meningococcal Disease, Polio, Chikungunya, and H influenzae"
["post_excerpt"]=>
string(136) "The CDC’s Advisory Committee on Immunization Practices convened to vote on new vaccine recommendations at their first meeting of 2024."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(59) "cdc-acip-recommends-updates-pediatric-immunization-schedule"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-18 15:05:35"
["post_modified_gmt"]=>
string(19) "2024-04-18 19:05:35"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(41) "https://www.clinicaladvisor.com/?p=183230"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[1]=>
object(WP_Post)#7049 (24) {
["ID"]=>
int(183205)
["post_author"]=>
string(5) "45391"
["post_date"]=>
string(19) "2024-04-18 11:15:47"
["post_date_gmt"]=>
string(19) "2024-04-18 15:15:47"
["post_content"]=>
string(459) "
A 50-year-old woman requests removal of a growth on her nose that began as a small bump approximately 2 years ago and has slowly enlarged. The patient has no history of skin cancer, warts, or similar lesions elsewhere on the body and has no family history of genodermatoses. The lesion has never bled. Physical examination reveals a 0.4 cm dome-shaped, smooth, firm, flesh-colored papule of her right nares.
"
["post_title"]=>
string(31) "DermDx: Papule on Right Nostril"
["post_excerpt"]=>
string(138) "A 50-year-old woman requests removal of a growth on her nose that began as a small bump approximately 2 years ago and has slowly enlarged."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(27) "dermdx-papule-right-nostril"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-18 11:25:13"
["post_modified_gmt"]=>
string(19) "2024-04-18 15:25:13"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(69) "https://www.clinicaladvisor.com/?post_type=hm-slideshow&p=183205"
["menu_order"]=>
int(0)
["post_type"]=>
string(12) "hm-slideshow"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[2]=>
object(WP_Post)#7046 (24) {
["ID"]=>
int(183131)
["post_author"]=>
string(5) "45459"
["post_date"]=>
string(19) "2024-04-17 09:30:04"
["post_date_gmt"]=>
string(19) "2024-04-17 13:30:04"
["post_content"]=>
string(15175) "
Now that spring in the air, so is allergic rhinitis, with many affected patients streaming into clinician offices for relief. Yet for some patients, that need for relief goes beyond alleviating sneezes, itchy eyes, and stuffed noses. A growing body of research indicates a significant connection between allergies and mental health,1 especially among women.2
Not only do allergies potentially worsen mood disorders, but the stress and anxiety from mood disorders can, in turn, amp up allergic responses. "Depression in and of itself is thought to be a pro-inflammatory state,” says David Gudis, MD, chief of the division of rhinology and anterior skull base surgery at New York-Presbyterian/Columbia University Irving Medical Center, New York City. “If your inflammatory mechanisms are already firing, and then you throw an allergic reaction on top of it, you're propelling that allergic reaction to an even greater degree. Dealing with these challenges can deplete your resilience, leaving you less equipped to handle the ways in which allergies might worsen your condition."
Seasonal allergies, in particular, have been linked to generalized anxiety.1 This is “no surprise to most practicing allergists,” says Ron Saff, MD, a practicing allergist and assistant professor of medicine at Florida State University College of Medicine in Tallahassee, FL. Allergy season typically worsens allergy-related conditions, such as asthma and urticaria, he notes, which adds to patients’ stress levels. “Many patients usually do well with their allergic rhinitis symptoms throughout the rest of the year, but when the spring rolls around and the trees start pollinating, they come in with sneezing and runny noses and watery eyes, and many of them just don't feel well. It seems like I see more of everything in the spring,” says Dr Saff.
Clinicians and patients alike need to be more aware of the potential for connection between seasonal allergies and mental health, so that patients’ needs can be fully addressed, Drs Saff and Gudis both stress. This is especially true given that allergy seasons are not only starting earlier but are also lasting longer and hitting harder; a 2020 study highlighted a 21% rise in pollen levels across North America between 1990 and 2018.3
"
Not only do allergies potentially worsen mood disorders, but the stress and anxiety from mood disorders can, in turn, amp up allergic responses.
Inflammatory Response as a Common Denominator
“For at least 75 years, doctors have identified and written about the association between depression and anxiety and allergic rhinitis,” says Dr Gudis. “It's been studied in different ways, using different scientific methodologies of investigation around the world. The reason that's important is that allergens are different in different parts of the world — meaning this is not unique to a reaction to a specific allergen. It's related more to the cascade of the inflammatory pathways that occur in the body during the allergic reaction.”4
Research delving into how our bodies react to allergens, such as tree pollen, shows a complex inflammatory response that transcends the initial point of contact. Upon encountering tree pollen, for instance, the nasal membranes react to these perceived microscopic invaders, fueling a reaction that travels through the airways and spreads through the body and brain.5
At the heart of this inflammatory response are cytokines, crucial chemical messengers that orchestrate the response.6 Pro-inflammatory cytokines can penetrate the central nervous system (CNS) and interact with critical neurological processes, thus influencing important brain functions, including how brain cells communicate, hormone regulation, and behaviors associated with mental health conditions like depression and anxiety.7
Allergy Symptoms and Mood
In severe allergic rhinitis, many of the physical symptoms that cause physical misery can also have a major effect on a patient’s mood. “Any illness or disorder, if it detracts from the enjoyment of the world around us, is a psychological stressor, and allergic rhinitis8 is no different,” says Dr Gudis. “Basically, the whole middle of their head is inflamed, impacting memory, attention, and fatigue," Dr Gudis adds.
The nasal congestion of allergic rhinitis in itself can have a major impact on mood, he stresses. “We don't even realize it but our sense of smell helps us connect to people around us,” Dr Gudis says. “When people have olfactory dysfunction, as a result of their noses being swollen and inflamed, they are more likely to feel depressed9and isolated,” he says.
This relationship was underlined by a 2016 study revealing a strong link between compromised olfactory function and depression.10 Of note, people who are depressed frequently have a diminished sense of smell compared to those who aren’t depressed. Moreover, individuals with a weaker sense of smell tend to be more prone to depression, especially if they've completely lost their ability to smell.
Allergies, Sleep Quality, and Mental Health
A growing body of research points to how inflammation from seasonal allergies can disrupt sleep,11 a major factor connecting allergic suffering to mood disorders, adds Dr Gudis.
A 2020 meta-analysis on the association between allergic rhinitis and sleep patterns found that although there is not a significant difference in sleep duration between people with and without allergic rhinitis, the condition was linked to poorer sleep quality, increased sleep disturbances, longer sleep latency, heightened usage of sleep medications, and lower sleep efficiency.11 Moreover, hay fever sufferers experience other sleep ailments, including insomnia, restless sleep, and obstructive sleep apnea, alongside daytime dysfunction, such as difficulty waking up and daytime sleepiness.
"When people have allergic rhinitis, one thing they experience is sleep dysfunction,” says Dr Gudis. "Allergic rhinitis, fundamentally, is defined by its underlying mechanism — its pathophysiology.” The inflammatory cytokines involved can disrupt normal and healthy sleep and increase fatigue, he explains.
“There's a shorter sleep duration... [and] a disruption of the normal sleep function and architecture.” Adequate sleep is critical to mental health, notes Dr Gudis, adding that research indicates that poor sleep “exacerbates symptoms of depression and anxiety.”
Allergy Medications and Mental Health
Some commonly used allergy medications can potentially worsen mental health conditions as well, says Dr Saff. While allergists are well-aware of this, patients and primary care providers often are not.
Older-generation decongestants present in antihistamines like those found in doxylamine or diphenhydramine can induce sedation12 and a feeling of disorientation. Pseudoephedrine and phenylephrine can cause anxiety, nervousness and insomnia13 without effectively treating allergic rhinitis.
Additionally, research suggests a connection between anticholinergics12 — such as Benadryl — and an increased risk of dementia in older adults.
“Benadryl [diphenhydramine] is frequently utilized in the emergency department,” says Saff. “And patients are frequently sent home on Benadryl, so I think there's certainly a lack of knowledge about the side effects of first-generation antihistamines.”
Additionally, Dr Saff notes that many patients resort to self-medication with these drugs before seeing him, often reporting adverse effects like drowsiness or ineffectiveness.
Dr Saff recommends that patients who wish to self-medicate use over-the-counter nasal steroids and antihistamines as safer alternatives, citing their minimal systemic absorption14 and fewer side effects. A protocol can be started before allergy season15 for more effective symptom management. Allergy eye drops also provide targeted relief without the systemic side effects associated with oral medications.16
Second-generation antihistamines in pill form, such as cetirizine, fexofenadine, and loratadine, are still a good choice for many, says Dr Gudis, as they cause less drowsiness than the first-generation drugs and last longer. Allegra is considered the least sedating of this group.17
Moreover, decongestants like oxymetazoline are useful for symptom relief but can have a rebound effect over a prolonged time. After a few days of using decongestants, the blood vessels in the nose become less responsive to the medication, reducing their effectiveness.
For patients seeking a medication-free option, Dr Saff suggests nasal irrigation — a time-tested, research-backed method using a saline solution to clear nasal passages.18 He recommends intranasal sodium chloride products over traditional neti pots for their ease of use and effectiveness.
Discussing the Allergy-Mental Health Connection With Patients
Many patients suffering with allergies who are also experiencing mood disorders may not be aware that the 2 problems could be connected, said Dr Gudis. "Patients might not realize they should mention changes in their mood to their ear nose and throat specialist, allergist, or pulmonologist," he notes. Given that, clinicians seeing allergy patients may want to open up this line of communication.
Dr Saff agrees. Although it is commonly assumed that depression screening is the responsibility of primary care providers, many patients — especially those without a regular primary care physician or detailed medical records — might miss crucial mental health screenings.
The US Preventive Services Task Force (USPSTF) mental health screening recommendations are useful guidelines for identifying and addressing depression, says Dr Saff, who advocates for their broader use across specialties. Dr Saff says he employs a holistic approach for those struggling with anxiety and depression, recommending reading materials, counseling, and exercise. When appropriate, he may also prescribe medications such as selective serotonin reuptake inhibitors.18
As a practicing allergist in a college town, Dr. Saff often sees students who are under stress, separated from their usual support networks, and who don’t have a local primary care physician. Getting an appointment with a mental health professional sometimes can take months for these students, he notes. “They need help and I'm happy to offer them the medication,” he adds. “Many take me up on the offer.” When they do, he has them come back for reassessment after a month. Many students will instead choose to contact their primary care physician in their hometown, consult another provider, or to just live with the stress. “It's always the patient's choice,” says Dr Saff.
"
["post_title"]=>
string(73) "Seasonal Allergies Often Accompanied by Mental Health and Sleep Disorders"
["post_excerpt"]=>
string(146) "Seasonal allergies and mental health conditions can influence and augment each other, unbeknownst to many patients and some health care providers."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(52) "seasonal-allergies-and-mental-health-sleep-disorders"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-17 09:30:14"
["post_modified_gmt"]=>
string(19) "2024-04-17 13:30:14"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(41) "https://www.clinicaladvisor.com/?p=183131"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[3]=>
object(WP_Post)#7037 (24) {
["ID"]=>
int(183115)
["post_author"]=>
string(5) "45391"
["post_date"]=>
string(19) "2024-04-17 08:14:49"
["post_date_gmt"]=>
string(19) "2024-04-17 12:14:49"
["post_content"]=>
string(10493) "
Meet Daniel Crawford, DNP, ARNP, CPNP-PC, CNE, FAANP, Associate Dean for Graduate Practice Programs and Associate Professor at the University of Iowa College of Nursing, in Iowa City. He is president-elect of the National Association of Pediatric Nurse Practitioners (NAPNAP), which recently help their 2024 annual meeting in Denver, Colorado. Dr Crawford also maintains a clinical practice at the University of Iowa Stead Family Children’s Hospital, Division of Pediatric Neurology. The Clinical Advisor met with Dr Crawford to discuss the challenges facing the field of pediatric nurse practitioners.
Q: What do you see as the biggest challenge facing pediatric nurse practitioners in 2024?
Dr Crawford: The biggest challenges facing NAPNAP are tied to the biggest challenges facing pediatric health care. From NAPNAP’s origins over 50 years ago, pediatric nurse practitioners (PNP) have had a unique mission to meet the needs of underserved and rural populations by delivering the highest quality of health care possible. To deliver high-quality health care that is equitably available continues to be an important challenge and I believe that PNPs serve a unique role in meeting that demand in our communities.
Daniel Crawford, DNP
We are now recognized as providing quality, efficiency, and advocacy for our patients. We are seeing new roles, new ideas, and new ways that we're contributing to make a difference and move the needle on quality health outcomes for children.
My goal as NAPNAP president will be to combine these. Over the past year, I was able to co-lead our strategic planning task force. In creating a strategic plan, we realized where we are and where we need to be as an organization. We saw that there was a lot that we had to envision, which took us back to re-writing our mission statement and vision for the organization.
The vision statement says: “All infants, children, adolescents, and young adults receive equitable, high-quality pediatric health care.” Our mission is “to optimize the health and wellbeing of all infants, children, adolescents, and young adults, and empower our community of pediatric experts.”
My goal is to transition towards this new strategic plan and work with our staff and our leadership to continue to do the things we're doing well, but also areas that maybe we need to allocate our time, effort, and resources to advance what we hope to be in the future as an organization.
"
My graduate program can admit twice the number of NPs but we lack the [Federal] funding to pay for extra trainers.
Q: It has been estimated that 77 million Americans are living without a primary care clinician. What can be done to increase the number of primary care providers?
Dr Crawford: The shortage [of primary care providers] cuts across all types of patients, including pediatric patients. In my state of Iowa, a significant amount of primary care services are provided by nurse practitioners and we are not the only state where that is the case.
There is not enough training capacity for nurse practitioners to meet the demand. There are a lot of plans underway and things that are being developed and designed to hopefully address this moving forward. We continue to turn out high-quality graduates in PNP programs across the country, and we know that our physician counterparts continue to do the same, but at the end of the day, there is still a shortage.
Q: What do you think contributes to this shortage? Is it a lack of federal funding for education?
Dr Crawford: We need to fix the Federal allocations for health care training so that we can increase the number of NPs in our programs but unfortunately things move slowly . When you look at pediatrics in particular, we know there is a shortfall in PNPs and this is a missed opportunity. My graduate program can admit twice the number of NPs but we lack the funding to pay for extra trainers; we don’t have the Federal funding needed for NP education.
We are also thinking about the undergraduate pipeline. We engage students early on their nursing pathway by meeting with incoming freshmen. I am presenting to high school students who have been admitted to the College of Nursing to discuss what an advanced practice nursing career looks like. This includes what the educational pathway looks like beyond nursing school, and what kind of things are going to help support them in that process. We encourage undergraduate students who are curious about graduate degrees to start building a mentorship relationship in nursing school.
We must realize the geographic diversity of our nurse practitioner programs and our institutions that are representative of the populations we serve. A school in Chicago will have a different makeup from a school in Iowa, which is a predominantly rural state.
Our student cohorts should be reflective of the communities in which they serve. There's a body of evidence that shows that outcomes are better when providers reflect their patient population. In Iowa, nurse practitioners who are from rural communities return to their communities at a high rate after graduation. We can graduate somebody to go back to that community and establish a pediatric primary care practice and become an individual who is uniquely positioned to affect the lives of the children in that community. At the end of the day, we are about providing high-quality pediatric outcomes for all children.
Q: How did you become a pediatric nurse practitioner specializing in epilepsy?
Dr. Crawford: After nursing school, I knew what I liked and what I did not like. I joined a practice and we created a pretty unique model that I would say rivals some of the fellowship models for transition to practice with nurse practitioners. I knew I liked neurology. I knew I liked the people in the practice, and I knew that this model sounded like a really good way for me to continue to grow professionally. I spent my first few years of practice in general neurology seeing the full spectrum of neurologic disorders.
Sometimes life throws you unexpected curveballs and around that time my daughter was diagnosed with epilepsy. I was then the parent with a child with epilepsy and I got to experience what that experience looks like from the parent side. That enabled me as a PNP to not only better meet the needs of the child with epilepsy but also the family. We know that the family unit is an important part of the overall health of the child. It was an opportunity to reflect and to grow in ways that I never anticipated professionally. Thankfully, my daughter's treatment was effective and she outgrew her seizures.
Q: You recently were named the new Associate Dean for Graduate Practice Programs. How do you balance your administrative/academic work with your clinical work?
Dr Crawford: When I was offered this position, I said that I would only take it as long as I could keep my practice. My practice and clinic hours are such an important part of me. My administrative role involves a lot of meetings and strategies about a lot of complicated topics. When I go to the clinic every Thursday morning, it's my time to spend with kids, play games, and have fun. I get to work with families on managing their child’s epilepsy and just see how life is going for them.
"
["post_title"]=>
string(79) "Daniel Crawford, DNP: Moving the Needle on Quality Health Outcomes for Children"
["post_excerpt"]=>
string(163) "Dr Crawford discusses the challenges facing pediatric nurse practitioners, including the shortages of primary care providers in rural and underserved urban areas. "
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(46) "moving-needle-quality-health-outcomes-children"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-17 08:14:57"
["post_modified_gmt"]=>
string(19) "2024-04-17 12:14:57"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(41) "https://www.clinicaladvisor.com/?p=183115"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
}
You’ve read {{metering-count}} of {{metering-total}} articles this month.
We want you to take advantage of everything Clinical Advisor has to offer. To view unlimited content, log in or register for free.
{{login-button}} {{register-button}}
Want to view more content from Clinical Advisor?
Register now at no charge to access unlimited clinical news with personalized daily picks for you, full-length features, case studies, conference coverage, and more.
{{login-button}} {{register-button}}
Want to read more?
Please login or register first to view this content.
