Genetic Susceptibility Modifies Relationships Between Air Pollutants and Stroke Risk: A Large Cohort Study.

BACKGROUND: The extent to which genetic susceptibility modifies the associations between air pollutants and the risk of incident stroke is still unclear. This study was designed to investigate the separate and joint associations of long-term exposure to air pollutants and genetic susceptibility on stroke risk. METHODS: The participants of this study were recruited by the UK Biobank between 2006 and 2010. These participants were followed up from the enrollment until the occurrence of stroke events or censoring of data. Hazard ratios (HRs) and 95% CIs for stroke events associated with long-term exposure to air pollutants were estimated by fitting both crude and adjusted Cox proportional hazards models. Additionally, the polygenic risk score was calculated to estimate whether the polygenic risk score modifies the associations between exposure to air pollutants and incident stroke. RESULTS: A total of 502 480 subjects were included in this study. After exclusion, 452 196 participants were taken into the final analysis. During a median follow-up time of 11.7 years, 11 334 stroke events were observed, with a mean age of 61.60 years, and men accounted for 56.2% of the total cases. Long-term exposures to particulate matter with an aerodynamic diameter smaller than 2.5 µm (adjusted HR, 1.70 [95% CI, 1.43-2.03]) or particulate matter with an aerodynamic diameter smaller than 10 µm (adjusted HR, 1.50 [95% CI, 1.36-1.66]), nitrogen dioxide (adjusted HR, 1.10 [95% CI, 1.07-1.12]), and nitrogen oxide (adjusted HR, 1.04 [95% CI, 1.02-1.05]) were pronouncedly associated with increased risk of stroke. Meanwhile, participants with high genetic risk and exposure to high air pollutants had ≈45% (31%, 61%; particulate matter with an aerodynamic diameter smaller than 2.5 µm), 48% (33%, 65%; particulate matter with an aerodynamic diameter smaller than 10 µm), 51% (35%, 69%; nitrogen dioxide), and 39% (25%, 55%; nitrogen oxide) higher risk of stroke compared with those with low genetic risk and exposure to low air pollutants, respectively. Of note, we observed additive and multiplicative interactions between genetic susceptibility and air pollutants on stroke events. CONCLUSIONS: Chronic exposure to air pollutants was associated with an increased risk of stroke, especially in populations at high genetic risk.

The risk of drug overdose death among adults with select types of disabilities in the United States - A longitudinal study using nationally representative data.

BACKGROUND: Disability is associated with increased risk of drug overdose mortality, but previous studies use coarse and inconsistent methods to identify adults with disabilities. This investigation makes use of the U.S. Department of Health and Human Services disability questions to estimate the risk of drug overdose death among U.S. adults using seven established disability categories. METHODS: The longitudinal Mortality Disparities in American Communities study was used to determine disability status among a nationally representative sample of adults age ≥18 in 2008 (n = 3,324,000). Through linkage to the National Death Index, drug overdose deaths were identified through 2019. Adults in mutually-exclusive disability categories (hearing, vision, cognitive, mobility, complex activity, ≥2 limitations) were compared to adults with no reported disabilities using adjusted hazard ratios (aHRs) and controlling for demographic and socioeconomic covariates. RESULTS: The risk of drug overdose death varied considerably by disability type, as adults in some disability categories displayed only marginally significant risk, while adults in other disability categories displayed substantially elevated risk. Compared to non-disabled adults, the risk of drug overdose death was highest among adults with ≥2 limitations (aHR = 3.0, 95% CI = 2.8-3.3), cognitive limitation (aHR = 2.6, 95% CI = 2.3-2.9), mobility limitation (aHR = 2.6, 95% CI = 2.3-2.9), complex activity limitation (aHR = 2.3, 95% CI = 1.8-2.9), hearing limitation (aHR = 1.6, 95% CI = 1.3-1.9), and vision limitation (aHR = 1.3, 95% CI = 1.0-1.7). CONCLUSIONS: The examination of specific disability categories revealed unique associations that were not apparent in previous research. These findings can be used to focus overdose prevention efforts on the populations at greatest risk for drug-related mortality.

Psychometric characteristics of a questionnaire to assess perceived disability in people with epilepsy.

It has been determined that quality of life in epilepsy is closely related to the perceived disability experienced by individuals with the diagnosis. However, this measure is seldom considered in healthcare processes. The objective of the present study is to establish the psychometric properties of the Perceived Disability Questionnaire in individuals diagnosed with epilepsy within a Latin American context. A cross-sectional, analytical study was conducted involving 325 participants, aged 12 years and older (M 40.42 years), individuals diagnosed with epilepsy in Colombia. The main psychometric properties of the instrument were explored to account for its factorial validity and reliability. The Perceived Disability Questionnaire exhibits high reliability (α = 0.878) and the three subscales comprising the final version of the questionnaire (Dissatisfaction, Pessimism, and Self-Disdain) explain 45.393 % of the total variance in relation to beliefs of disability associated with the diagnosis of epilepsy; the questionnaire significantly correlates with the Quality of Life in Epilepsy Inventory (QOLIE-10). Adequate psychometric properties of the instrument are found, which allows for its proposal as a tool in epilepsy care processes within the Colombian context.

What is fair? Ethical analysis of triage criteria and disability rights during the COVID-19 pandemic and the German legislation.

This essay discusses the ethical challenges and dilemmas in allocating scarce medical resources during the COVID-19 pandemic, using the German legislative process as a starting point. It is guided by the right to non-discrimination of people with disability and generally contrasts utilitarian and rights-based principles of allocation. Three approaches that were suggested in the German discussion, are presented, the lottery principle, the first come first served principle and the probability to survive principle. Arguments in favour and against each principle are discussed. The focus is on the utilitarian probability to survive principle, which was adopted in German legislation in 2022, and its discriminatory potential against people with disability. The essay suggests ways to mitigate the concerns of discrimination related to the probability to survive principle. It concludes that resolving the triage dilemma requires a balanced approach between utilitarian and rights-based concerns, which promotes both maximising the number of patients surviving and the right not to be discriminated against and be treated equally. It calls for a further debate on how many ethical values such as equity, fairness and non-discrimination we are willing to sacrifice for a higher number of survivors and when we are willing to sacrifice survivors to secure ethical values.

Discrimination against the dying.

The purpose of this paper is to identify a kind of discrimination that has hitherto gone unrecognised. 'Terminalism' is discrimination against the dying, or treating the terminally ill worse than they would expect to be treated if they were not dying. I provide four examples from healthcare settings of this kind of discrimination: hospice eligibility requirements, allocation protocols for scarce medical resources, right to try laws and right to die laws. I conclude by offering some reflections on why discrimination against the dying has been hard to identify, how it differs from ageism and ableism, and its significance for end-of-life care.

Extending patient-centred communication to non-speaking intellectually disabled persons.

Patient-centred communication is widely regarded as a best practice in contemporary medical care, both in terms of maximising health outcomes and respecting persons. However, not all patients communicate in ways that are easily understood by clinicians and other healthcare professionals. This is especially so for patients with non-speaking intellectual disabilities. We argue that assumptions about intellectual disability-including those in diagnostic criteria, providers' implicit attitudes and master narratives of disability-negatively affect communicative approaches towards intellectually disabled patients. Non-speaking intellectually disabled patients may also be taken to lack decision-making capacity and resultingly, may be given very little role in determining their care. But, given evidence of the heterogeneous communicative practices available to non-speaking patients, efforts should be made to extend patient-centred communication to them. We offer four suggestions for doing so: (1) treating those with non-speaking intellectual disabilities as potential communicators; (2) lengthening appointment times to develop relationships necessary for communication; (3) disentangling capacity from communication in concept and in practice; and (4) recognising the bidirectional connection between supported decision-making and patient-centred communication.

Epistemic injustice, healthcare disparities and the missing pipeline: reflections on the exclusion of disabled scholars from health research.

People with disabilities are subject to multiple forms of health-related and wider social disparities; carefully focused research is required to inform more inclusive, safe and effective healthcare practice and policy. Through lived experience, disabled people are well positioned to identify and persistently pursue problems and opportunities within existing health provisions that may be overlooked by a largely non-disabled research community. Thus, the academy can play an important role in shining a light on the perspectives and insights from within the disability community, and combined with policy decisions, these perspectives and insights have a better opportunity to become integrated into the fabric of public life, within healthcare and beyond. However, despite the potential benefits that could be yielded by greater inclusivity, in this paper we describe barriers within the UK academy confronting disabled people who wish to embark on health research. We do this by drawing on published findings, and via the lived experience of the first author, who has struggled for over 3 years to find an accessible PhD programme as a person with energy limiting conditions who is largely confined to the home in the UK. First, we situate the discussion in the wider perspective of epistemic injustice in health research. Second, we consider evidence of epistemic injustice among disabled researchers, focusing primarily on what philosophers Kidd and Carel (2017, p 184) describe as 'strategies of exclusion'. Third, we offer recommendations for overcoming these barriers to improve the pipeline of researchers with disabilities in the academy.

A comparison of factors associated with unmet healthcare needs in people with disabilities before and after COVID-19: a nationally representative population-based study.

BACKGROUND: People with disabilities, who require numerous healthcare services, are vulnerable to unmet healthcare needs. This study aimed to investigate and identify the factors that influence unmet healthcare needs among people with disabilities and to compare these factors before and after the COVID-19 pandemic in South Korea. METHODS: A propensity score matching analysis was conducted using two datasets from the National Survey of Disabled Persons collected in 2017 and 2020. The participants were matched based on variables known to influence healthcare utilization. Based on the Andersen model, logistic regression was performed to analyze the key characteristics of the factors associated with unmet healthcare needs, including predisposing, enabling, and need factors. RESULTS: Propensity score matching resulted in the inclusion of 1,884 participants in each group: an experimental group and control group. Before COVID-19, factors associated with unmet healthcare needs included sex, age, marital status, and education level (predisposing factors), instrumental activities of daily living dependency, satisfaction with medical staff's understanding of disability, satisfaction with medical institutional facilities and equipment (enabling factors), subjective health status, and depressive symptoms (need factors). After COVID-19, factors included physical disability, instrumental activities of daily living dependency, and discrimination (enabling factors), and subjective health status, chronic diseases, depressive symptoms, and regular medical care (need factors). No significant predisposing factors affecting unmet healthcare needs were identified after COVID-19. CONCLUSIONS: This study compared the factors affecting unmet healthcare needs among people with disabilities before and after COVID-19. Recognizing the different factors associated with unmet healthcare needs before and after COVID-19, (e.g., sex, type of disability, satisfaction with medical staff's understanding of disabilities, medical institutional facilities and equipment considering the disabled, discrimination, chronic diseases, and regular medical care) may help governments and policymakers establish strategies to reduce and prevent unmet healthcare needs during and a future crisis.

Contextual factors of financial capability and financial well-being for adults living with brain injury: a qualitative photovoice study.

OBJECTIVE: To identify the contextual factors related to financial capability and financial well-being for adults living with acquired brain injury (ABI). DESIGN & METHOD: We conducted a qualitative descriptive study using photovoice and included 17 adults who live with ABI in Manitoba, Canada. Over 3-to-5 weeks, participants took photos of their financial capability (i.e. knowledge, skills, and behaviors related to managing finances) or their financial well-being (i.e. subjective and objective financial outcomes). Participants were interviewed about their photos. Five researchers iteratively and thematically analyzed interview transcripts. MAIN OUTCOMES/RESULTS: Analysis identified the importance of the economic, social, technology, and physical or sensory context. Subthemes related to: (i) hard times finding financial resources; (ii) processes not making sense; (iii) getting help from the right person; and (iv) invisible disability bias and stigma. CONCLUSIONS: There is decreased literature about financial capability or financial well-being after ABI. The results of this study highlight the salience of finance to living with ABI and the importance of the context to addressing financial-related life participation for people living with ABI. Information about contextual factors related to finance can improve rehabilitation assessment and intervention practice as well as emphasize needed accessibility changes to financial environments.

Evaluating workforce needs: an investigation of healthcare professionals' attitudes, beliefs and preparedness towards the management of Para athlete mental health at the Tokyo 2020 and Beijing 2022 Paralympic Games.

OBJECTIVES: To examine healthcare professionals (HCPs) attitudes, beliefs and preparedness towards the management of Para athlete mental health during the Tokyo 2020 and Beijing 2022 Paralympic Games. METHODS: A cross-sectional observational study was conducted. National Paralympic Committee's HCPs (n=857) working at the Tokyo 2020 and Beijing 2022 Paralympic Games were invited to respond to an anonymous online survey regarding the management of Para athlete mental health in their team. Data were analysed using descriptive frequency statistics. RESULTS: The survey was completed by 256 HCPs (30% of respondents). Most HCPs agreed that mental health was a concern in Para athletes (n=210; 82%). However, half (n=122; 48%) agreed that they did not screen Para athletes for mental health symptoms, and half (n=130; 51%) agreed that there was increased stigma around disclosure of mental health symptoms among Para athletes, compared with athletes without disability. Most HCPs (n=221; 86%) agreed they wanted to improve their knowledge and skills surrounding athlete mental healthcare. Culturally sensitivite, non-discriminatory and contextual factors were highlighted as desired areas of education for HCPs and active information dissemination for Para athletes. CONCLUSION: HCPs working at the Paralympic Games considered Para athlete mental healthcare important and reported perceived stigma, yet indicated low rates of mental health screening. Most respondents expressed the need for mental health education. Culturally sensitive training and active education strategies should be implemented to optimally manage Para athlete mental health.

Injury incidence according to athlete impairment type during the 2012 and 2016 Summer Paralympic Games: a combined analysis of 101 108 athlete days.

OBJECTIVES: The relationship between sport-related injuries and Para athlete impairment type has not yet been comprehensively studied. This study aimed to describe injury incidence according to athlete impairment type during the London 2012 and Rio 2016 Summer Paralympic Games, by sex, age, Games period, chronicity and anatomical area. METHODS: A combined analysis of 7222 athletes was conducted comprising 101 108 athlete days, using pooled data. Internet sources were used to identify impairments of registered athletes. Impairment types: brain disorders (BD), limb deficiency, neuromuscular disorders (NMD), spinal cord-related disorders, visual impairment (VI) and 'all others' (OTH: impaired passive range of movement, intellectual impairment, leg length difference, short stature and unknown impairments). Results by impairment type are reported as univariate unadjusted incidences (injuries/1000 athlete days; 95% CIs). Statistical significance between impairment types was determined when 95% CIs did not overlap. RESULTS: The overall crude unadjusted incidence of injury was 11.1 (95% CI 10.4 to 11.9), significantly higher in VI (13.7 (95% CI 11.0 to 15.7)) and NMD (13.3 (95% CI 11.1 to 16.1)) compared with BD (9.1 (95% CI 7.7 to 10.8)). Acute (sudden onset) (8.6 (95% CI 7.3 to 10.1)) and lower limb (6.6 (95% CI 5.4 to 8.1)) injuries were higher among athletes with VI, while athletes with NMD had a higher incidence of repetitive (gradual onset) (5.9 (95% CI 4.3 to 8.0)) and upper limb (6.9 (95% CI 5.2 to 9.0)) injuries compared with other impairments. CONCLUSIONS: Incidence and type of injuries differed between athlete impairment types. Athletes with VI or NMD sustained the highest incidence of injury, and athletes with BD had the lowest. Findings of this study can inform the management of competition-related injuries in Para athletes.

Prevalence of urinary incontinence in Brazilian para athletes.

OBJECTIVE: To describe the prevalence of urinary incontinence (UI) in para athletes in Brazil. METHODS: This is a cross-sectional study with Brazilian para athletes with physical impairments from all para sports. The data from 86 participants of both sexes (60 males and 26 females) were collected through an online survey that gathered sociodemographic data and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, from March to July 2023. RESULTS: The prevalence of UI was 45.3% (n=39), with the average impact on quality of life scored at 6.1±3.5 on a scale of 0-10. Most para athletes reported moderate (43.5%) or severe (38.4%) symptoms. The most common type was mixed UI (46.1%), with an average of 3±1.9 episodes of urinary loss per athlete in the last 4 weeks. Adjusted Poisson regression (controlling for sex, age and level of competition) revealed that para athletes with orthopaedic impairments had a 58% lower prevalence of UI (prevalence ratio=0.42; 95% CI 0.24, 0.83) compared with those with neurological impairments. Furthermore, ordinal regression indicated that para athletes with neurological impairments were 147% more likely to experience a progression from 'severe' to 'very severe' UI (OR=2.47; 95% CI 1.59, 3.93). CONCLUSIONS: UI is highly prevalent among para athletes, particularly those with neurological impairments, underscoring the need for specialised genitourinary healthcare and the need for further treatment and monitoring of the condition. There is a critical need to raise awareness among coaches, healthcare providers and the athletes themselves about UI and its impact to foster the comprehensive well-being of these athletes.

Self-Reported Disability Type and Risk of Alcohol-Induced Death - A Longitudinal Study Using Nationally Representative Data.

BACKGROUND: Disability is associated with alcohol misuse and drug overdose death, however, its association with alcohol-induced death remains understudied. OBJECTIVE: To quantify the risk of alcohol-induced death among adults with different types of disabilities in a nationally representative longitudinal sample of US adults. METHODS: Persons with disabilities were identified among participants ages 18 or older in the Mortality Disparities in American Communities (MDAC) study (n = 3,324,000). Baseline data were collected in 2008 and mortality outcomes were ascertained through 2019 using the National Death Index. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were estimated for the association between disability type and alcohol-induced death, controlling for demographic and socioeconomic covariates. RESULTS: During a maximum of 12 years of follow-up, 4000 alcohol-induced deaths occurred in the study population. In descending order, the following disability types displayed the greatest risk of alcohol-induced death (compared to adults without disability): complex activity limitation (aHR = 1.7; 95% CI = 1.3-2.3), vision limitation (aHR = 1.6; 95% CI = 1.2-2.0), mobility limitation (aHR = 1.4; 95% CI = 1.3-1.7), ≥2 limitations (aHR = 1.4; 95% CI = 1.3-1.6), cognitive limitation (aHR = 1.2; 95% CI = 1.0-1.4), and hearing limitation (aHR = 1.0; 95% CI = 0.9-1.3). CONCLUSIONS: The risk of alcohol-induced death varies considerably by disability type. Efforts to prevent alcohol-induced deaths should be tailored to meet the needs of the highest-risk groups, including adults with complex activity (i.e., activities of daily living - "ALDs"), vision, mobility, and ≥2 limitations. Early diagnosis and treatment of alcohol use disorder within these populations, and improved access to educational and occupational opportunities, should be considered as prevention strategies for alcohol-induced deaths.

A mixed methods evaluation of the effectiveness of an oral health training program for disability care workers in Burkina Faso.

BACKGROUND: While efforts to improve the oral health of vulnerable populations have received little attention in general, the situation of children with disabilities in low- income countries (LICs) remains especially challenging. The present study evaluated the effectiveness of an oral health training provided to disability care workers in Ouagadougou, Burkina Faso thereby contributing to closing the knowledge gap in disability research in relation to oral health in LICs. METHODS: This was a single-arm pre-post study following an embedded mixed methods design using the New World Kirkpatrick training effectiveness evaluation model. For the purposes of this study, three levels of the Kirkpatrick (KP) evaluation were considered: reaction, learning and behaviour. RESULTS: A total of 44 care workers from 6 disability centres participated in the study. Care worker post-training scores (Md = 17) were significantly higher compared to pre-training scores (Md = 13) [Wilcoxon signed-ranks test: Z= -5.53, p < .001, r = .59.] The median value for care worker confidence in applying training material in their everyday job was 7 out of 10 points (IQR = 3). At the 1-month training follow-up, 3 centres had implemented daily toothbrushing for people with disabilities. CONCLUSION: These findings suggest that tailored training led to an increase in care worker confidence and motivation to implement oral health activities, in knowledge about oral health and a partial implementation uptake of daily toothbrushing in disability centres. Further long-term evaluations with dental care provision in rural and urban settings are needed to lower the high oral disease burden of people with disabilities in Burkina Faso.

Health spillover studies of long-term care insurance in China: evidence from spousal caregivers from disabled families.

BACKGROUND: To alleviate the shortage of caregivers associated with disabled persons, China has implemented a pilot policy for long-term care insurance. This policy has the characteristics of "familialization" and "de-familialization" policy orientation, and it is indeed essential to clarify whether the policy has a positive spillover effect on the health of family caregivers, which is of great value to the pilot from local practice to national institutional arrangement. METHODS: Based on the China Health and Retirement Longitudinal Study microdata and time-varying DID method, our study used the implementation of the pilot policy as a "quasi-natural experiment" to assess the health spillover effects of the pilot policy on family spousal caregivers. RESULTS: This policy significantly improved the health of spousal caregivers, increasing self-rated health and life satisfaction, and reducing depression; Compared with female, urban and central-western spousal caregivers, male, rural and eastern spousal caregivers were "beneficiaries" in more dimensional health. CONCLUSIONS: Our research indicated that spousal caregivers of disabled people, particularly male, rural and eastern spousal caregivers, experienced positive health spillovers after implementing long-term care insurance. These results suggest that the imbalance between supply and demand of nursing staff could be solved in terms of de-familialization and familialization, spousal caregivers should be promoted to equally enjoy the policy benefits on gender, urban-rural and regions.

Health check-ups as interventions for work disability management: supervisors and occupational healthcare follow the recommendations to a great extent.

OBJECTIVES: Work disability management is a problem globally. This study was designed to find out whether the initiation, process and outcome of health check-ups (HCUs) follow the national legislation and whether supervisors and occupational healthcare (OHC) units act according to the legislation-based recommendations. METHODS: Data of 1092 employees with reduced work ability were collected during 2013-2018 in 15 OHC units across Finland. Nine reasons for HCUs, eight process activities and three recommendations were analysed. Cross-tabulation and multinomial logistic regression analysis were used in the analyses. RESULTS: Employees themselves initiated an HCU for early support more often (OR with 95% CI 2.37; 1.04 to 5.40) compared with supervisors. Personnel in OHC units initiated an HCU in musculoskeletal disorders more often (OR 1.58; 95% CI 1.05 to 2.37) and in mental disorders less often (OR 0.52; 95% CI 0.35 to 0.76) compared with supervisors. These findings were reflected in the recommendations after the HCU, where rehabilitation was recommended for employees with musculoskeletal disorders more often than for employees with mental disorders (ORs 5.48; 95% CI 1.91 to 15.67 and 1.59; 95% CI 0.74 to 3.43, respectively). CONCLUSION: Supervisors and OHC units followed the recommendations for management of work disability to a great extent. Employees were active in looking for help early when they had problems with work ability. This positive finding should be promoted even more. OHC units did not initiate HCUs or recommend rehabilitation in mental disorders as actively as they did in musculoskeletal disorders. Support of employees with mental disorders should be improved and studied more. Registration of the study The study protocol was approved and registered on 22 September 2017 by the Doctoral Program of Health Sciences, Faculty of Medicine, University of Eastern Finland, registration no. 189067.

Chronic Phase Survival Rate in Stroke Patients With Severe Functional Limitations According to the Frequency of Rehabilitation Treatment.

OBJECTIVE: To investigate the chronic phase survival rate according to the frequency of rehabilitation treatment in the acute and subacute phases in stroke patients with severe functional limitations. DESIGN: A retrospective longitudinal cohort study. SETTING: Population-based study using the Korean National Health Insurance Database from 2007 to 2018. PARTICIPANTS: We enrolled 593 patients who experienced stroke in 2009 with national disability registration (NDR) grade of 3 or less (N=593). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The frequencies of rehabilitation treatment within 24 months after stroke were categorized into none, 1-50, 51-200, 201-400, and >400 treatments based on requests made to the Health Insurance Review and Assessment Service. As a dependent variable, we assessed all-cause mortality from 24 to 120 months after stroke. RESULTS: The study enrolled 283 patients in NDR grade 1 (the most severe), 158 in grade 2, and 152 in grade 3. Groups with more severe functional limitations showed a lower chronic phase survival rate (P<.001). The groups with higher frequencies of rehabilitation treatment in the acute and subacute phases showed a higher chronic phase survival rate (P<.001). In the Cox regression analysis, a higher degree of functional limitation, lower frequency of rehabilitation treatment, older age, male sex, and chronic kidney disease were independent risk factors for chronic phase mortality in stroke patients with severe functional limitations. CONCLUSIONS: A high frequency of rehabilitation treatment in the acute and subacute phases was associated with the long-term survival of stroke patients with severe functional limitations.

Psychological and Cognitive Functioning Among Patients Receiving Outpatient Rehabilitation for Post-COVID Sequelae: An Observational Study.

OBJECTIVES: To describe the characteristics of individuals receiving outpatient rehabilitation for post-acute sequelae of SARS-CoV-2 infection (PASC). Further, to examine factors associated with variation in their psychological and cognitive functioning and health-related quality of life. DESIGN: Observational study. SETTING: Outpatient COVID-19 recovery clinic at a large, tertiary, urban health system in the US. PARTICIPANTS: COVID-19 survivors with persistent sequelae (N=324). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Multivariable logistic and linear regression models were used to examine factors associated with COVID survivors' experience of severe anxiety, severe depression, post-traumatic stress disorder (PTSD), cognitive impairment, and self-reported health-related quality of life. RESULTS: About 38% of survivors seeking care for their persistent COVID symptoms suffered from severe anxiety, 31.8% from severe depression, 43% experiencing moderate to severe PTSD symptomology, and 17.5% had cognitive impairment. Their health-related quality of life was substantially lower than that of the general population (-26%) and of persons with other chronic conditions. Poor and African American/Black individuals experienced worse psychological and cognitive sequelae after COVID19 infection, even after controlling for age, sex, initial severity of the acute infection, and time since diagnosis. CONCLUSIONS: Evidence of consistent disparities in outcomes by the patients' race and socioeconomic status, even among those with access to post-acute COVID rehabilitation care, are concerning and have significant implications for PASC policy and program development.

Delivering Rehabilitation Care Around the World: Voices From the Field.

OBJECTIVES: To identify the challenges and common issues that the rehabilitation health workforce experienced in delivering services in different practice settings across the world. These experiences could suggest approaches to improving rehabilitation care to people in need. DESIGN: A semi-structured interview protocol centering on 3 broad research questions was conducted to collect data. The data were analyzed to identify common themes across the cohort interviewed. SETTING: Interviews were conducted using Zoom. Interviewees not able to access Zoom provided written responses to the questions. PARTICIPANTS: Participants included 30 key rehabilitation opinion leaders from different disciplines from 24 countries, across world regions and income levels (N=30). INTERVENTIONS: NA. MAIN OUTCOME MEASURES: Although rehabilitation care deficiencies differ in severity, participants reported that the demand for services consistently outstrips available care, regardless of world region or income level. Access and social barriers, particularly in rural areas and remote regions, are common challenges for those delivering and receiving rehabilitation care. RESULTS: Individual voices from the field reported both challenges and hopeful changes in making rehabilitation services available and accessible. CONCLUSIONS: The descriptive approach undertaken has allowed individual voices, rarely included in studies, to be highlighted as meaningful data. Although the research findings are not generalizable beyond the convenience cohort included without further analysis and validation in specific local practice contexts, the authentic voices that spoke out on these issues demonstrated common themes of frustration with the current state of rehabilitation services delivery but also hopefulness that more solutions are on the horizon.

On Ageing and Maturing.

Räsänen draws a distinction between chronological age and biological age and argues that biological ageing is (sometimes) desirable. To demonstrate this, he asks us to consider the case of April, who like Karel Capek's Elina Makropulos, has stopped biologically ageing. Unlike Makropulos, though, April's biological ageing was halted before puberty, so she will never mature into adulthood. Räsänen contends this case shows ageing can be desirable, but this equivocates between maturing and ageing. Here I argue biological ageing, or the wear and tear normally associated with chronological ageing, is prima facie undesirable, but that maturing can be prima facie desirable.