Impairment Types and Combinations Among Adolescents and Young Adults with Disabilities: Colorado 2014-2018.

OBJECTIVE: Understanding the types of functional challenges faced by adolescents and young adults with disabilities (AYA-WD) can help payers, clinicians, community-based service providers, and policymakers recognize and meet needs. This paper describes state-level prevalence rates for 1) AYA-WD overall and for 2) impairment types singly and in combinations; and 3) examines how rates may differ between those insured by Medicaid versus commercial insurance. METHODS: This descriptive study uses Colorado's All Payer Claims Dataset 2014-2018 to identify insured 10- to 26-year-olds (Medicaid only: 333,931; commercially only: 392,444). It then applies the previously validated Children with Disabilities Algorithm (CWDA) and its companion, the Diagnosis-to-Impairment-Type Algorithm (DITA), to compare state-level prevalence rates by insurance source for disability overall and for each of five impairment types singly and in combination. RESULTS: Disability prevalence was greater among the Medicaid-insured AYA-WD by +7.6% points (pp)-Medicaid: 11.9% (47,654/333,931), commercial: 4.3% (16,907/392,444). Most AYA-WD had a single impairment, but the prevalence of AYA-WD with two or more impairments was greater among the Medicaid-insured than the commercially insured (+9.9 pp; Medicaid: 33.5% [15,963/47,654], commercial: 23.7% [3992/16, 907]), as was the prevalence of impairment types that were physical (+6.7 pp; Medicaid: 54.7% [26,054/47,654], commercial: 48.0% [8121/16,907]); developmental (+4.1 pp; Medicaid: 35.4% [16,874/47,654], commercial: 31.3% [5290/16,907]); psychiatric (+6.7 pp; Medicaid 21.3% [10,175/47,654], commercial: 14.6% [2470/16,907]), and intellectual (+9.3 pp; Medicaid: 26.2% [12,501/47,654], commercial: 16.9% [2858/16,907]). CONCLUSIONS: CWDA and DITA can be used to understand the rates at which impairment types and combinations occur in a population with childhood-onset disabilities.

I don't know what type of arthritis I have: A population-based comparison of people with arthritis who knew their specific type and those who didn't.

OBJECTIVE: To understand differences between people with arthritis who do not know their type (DK) compared to those reporting osteoarthritis (OA) or inflammatory and autoimmune types of arthritis (IAA), including the receipt of appropriate health care, information, and services. METHODS: Analysis of the Survey on Living with Chronic Disease in Canada-Arthritis Component. Respondents aged ≥20 years with health professional-diagnosed arthritis (n = 4,385) were characterized as reporting DK, OA or IAA. Variables: arthritis characteristics (duration, number and site of joints affected), arthritis impact (current pain and fatigue, difficulty in sleeping and daily activities, impact on life), health (self-rated general and mental health, life stress), arthritis management strategies (seeing health professionals, medication use, assistive devices, receipt of arthritis information, self-management activities). Multinomial logistic and log-Poisson regressions were used, as appropriate, to compare the DK to the OA and IAA groups. RESULTS: In this arthritis sample, 44.2% were in the DK group, 38.3% reported OA and 17.5% reported IAA. Those in the DK group were more likely to be younger, have low income, low education, and be of non-white cultural background compared to those with OA. There were no significant differences in arthritis impact, but the DK group was less likely to have received information on, or have used, arthritis management strategies. CONCLUSIONS: The sociodemographic characteristics of the DK group suggest they likely have lower health literacy. They were less likely to have accessed health care and other support services, indicating this is an important group for health education, both for individuals with arthritis and health care providers.

Eye care utilisation in Newfoundland and Labrador: access barriers and vision health outcomes.

OBJECTIVE: Our prior study revealed significantly lower use of eye care providers in Newfoundland and Labrador (NFLD). This study reports factors associated with this low use and related vision health outcomes. DESIGN: Cross-sectional survey. PARTICIPANTS: A total of 14 925 Caucasian respondents to the Canadian Community Health Survey - Healthy Aging 2008/2009 aged ≥65 years. METHODS: Univariate and multivariate analyses were performed using self-reported survey data. RESULTS: NFLD, along with 3 other provinces, does not insure seniors for routine eye examinations. Among seniors without self-reported glaucoma, cataracts, and diabetes, the use of eye care providers in NFLD (36.3%) is the lowest compared with provinces with (50.7%, p < 0.05) and without (42.2%, p > 0.05) government-insured eye examinations. Among seniors with known eye disease insured for eye care in all provinces, eye care utilisation in NFLD (63.1%) is still the lowest across all provinces (69.4%-71.3%, p > 0.05). Compared with the national average, NFLD seniors have significantly higher proportions of low income (61.7% vs 47.4%), no postsecondary education (53.6% vs 42.2%), and rural residency (40.6% vs 18.9%). These factors are all associated with low levels of eye care utilisation. Compared with insured provinces, NFLD has a significantly lower prevalence of self-reported cataracts (16.7% vs 23.1) and glaucoma (3.8% vs 7.0%), and a slightly higher prevalence of presenting visual impairment (4.0% vs 3.5%). CONCLUSIONS: Lack of government insurance, low socioeconomic status, and living in nonurbanised areas all contribute to the underutilisation of eye care providers in NFLD. This underutilisation appears to be associated with reduced detection of eye diseases.

Real-time Functional Analysis of Inertial Microfluidic Devices via Spectral Domain Optical Coherence Tomography.

We report the application of spectral-domain optical coherence tomography (SD-OCT) technology that enables real-time functional analysis of sorting microparticles and cells in an inertial microfluidic device. We demonstrated high-speed, high-resolution acquisition of cross-sectional images at a frame rate of 350 Hz, with a lateral resolution of 3 µm and an axial resolution of 1 µm within the microfluidic channel filled with water. We analyzed the temporal sequence of cross-sectional SD-OCT images to determine the position and diameter of microspheres in a spiral microfluidic channel under various flow rates. We used microspheres with known diameters to validate the sub-micrometer precision of the particle size analysis based on a scattering model of spherical microparticles. An additional investigation of sorting live HT-29 cells in the spiral microfluidic channel indicated that the distribution of cells within in the microchannel has a close correspondence with the cells' size distribution. The label-free real-time imaging and analysis of microscale particles in flow offers robustness for practical applications with live cells and allows us to better understand the mechanisms of particle separations in microfluidic sorting systems.

The impact of lack of government-insured routine eye examinations on the incidence of self-reported glaucoma, cataracts, and vision loss.

PURPOSE: We determined the impact of lack of government insured routine eye examinations on the incidence of self-reported glaucoma, cataracts and vision loss. METHODS: We analyzed data from the Canadian longitudinal National Population Health Survey (1994-2011). White respondents aged 65+ in 1994/1995 were included (n = 2618). Three cohorts were established at baseline: those free of glaucoma, cataracts, and vision loss (i.e., unable to see close or distance when wearing glasses or contact lenses). Incident cases were identified through self-reporting of these conditions during the follow-up period. RESULTS: The incidence (per 1000 person-years) of glaucoma was lower in uninsured provinces (8.1; 95% confidence interval [CI], 5.5-10.7) than in insured provinces (12.8; 95% CI, 10.5-15.1). The incidence of cataracts was also lower in the uninsured (67.2; 95% CI, 55.7-78.6) versus insured provinces (75.7; 95% CI, 69.2-82.2). The incidence of vision loss was higher in the uninsured (26.6; 95% CI, 20.2-33.0) versus insured provinces (22.5; 95% CI, 20.0-25.5). Adjusting for confounders, seniors in insured provinces had a 59% increased risk of glaucoma (incidence rate ratio [IRR], 1.59; 95% CI, 1.07-2.37), a 13% greater risk of cataracts (IRR, 1.13; 95% CI, 0.93-1.37), and a 12% reduced risk of vision loss (IRR, 0.88; 95% CI, 0.67-1.16). CONCLUSIONS: Lack of government-funded routine eye examinations is associated with a reduced incidence of self-reported glaucoma and cataracts, likely due to reduced detection. Lack of insurance also is associated with a higher incidence of self-reported vision loss, likely due to poorer access to eye care and late treatment.

Historical epidemiology of the second cholera pandemic: relevance to present day disease dynamics.

Despite nearly two centuries of study, the fundamental transmission dynamic properties of cholera remain incompletely characterized. We used historical time-series data on the spread of cholera in twelve European and North American cities during the second cholera pandemic, as reported in Amariah Brigham's 1832 A Treatise on Epidemic Cholera, to parameterize simple mathematical models of cholera transmission. Richards growth models were used to derive estimates of the basic reproductive number (R0) (median: 16.0, range: 1.9 to 550.9) and the proportion of unrecognized cases (mean: 96.3%, SD: 0.04%). Heterogeneity in model-generated R0 estimates was consistent with variability in cholera dynamics described by contemporary investigators and may represent differences in the nature of cholera spread. While subject to limitations associated with measurement and the absence of microbiological diagnosis, historical epidemic data are a potentially rich source for understanding pathogen dynamics in the absence of control measures, particularly when used in conjunction with simple and readily interpretable mathematical models.

Chronic back problems and labor force participation in a national population survey: impact of comorbid arthritis.

BACKGROUND: Back problems and arthritis are common chronic conditions, while having back problems is a frequent reason for lost work time. The objective of this study was to investigate employment status amongst individuals who report having both back problems and arthritis, compared to having either condition alone. METHODS: We analyzed data from the 2007/2008 Canadian Community Health Survey (ages 25-64, n = 79,719). Respondents who reported neither having worked in the past 12 months nor the past week were coded as not currently employed. Those reported being permanently unable to work were considered to be out of the labor force. Log-Poisson regressions, adjusting for socio-demographic and lifestyle factors, were used to estimate risks for being not currently employed or being out of the labor force for 5 mutually exclusive groups of chronic conditions: arthritis and back problems, back problems, arthritis, any other chronic conditions, and no chronic conditions. RESULTS: 12.7% of respondents reported being not currently employed and 2.9% being out of the labor force. 5.8% of respondents reported both arthritis and back problems, while 16.1% reported back problems and 7.3% arthritis. The back problems and arthritis group had the highest risk of not being currently employed. The risk was higher for men (PR = 1.90; 95% CI = 1.58, 2.29) than for women (PR = 1.31; 95% CI = 1.18, 1.46). Risks of being permanently unable to work were also the greatest for those with comorbid back problems and arthritis. CONCLUSIONS: There is a need for a reappraisal of back problems as a cause of work disability to account for the possibility of co-occurring arthritis.

Effectiveness and cost-effectiveness of pediatric rotavirus vaccination in British Columbia: a model-based evaluation.

BACKGROUND: Rotavirus gastroenteritis (RVGE) is associated with widespread morbidity and mortality in children worldwide. In high-income countries, including Canada, the burden of RVGE relates largely to morbidity and healthcare utilization. Two live rotavirus vaccines (RotaTeq(®) (Merck Frosst Canada Ltd.) and Rotarix™ (GlaxoSmithKline Inc.)), are now approved for use in Canada, but their economic attractiveness has not been evaluated in the Canadian context. METHODS: We performed a model-based economic analysis using a Markov chain Monte Carlo simulation of RVGE in populations of British Columbia children. Models were parameterized based on best available data on disease natural history and epidemiology, vaccine effectiveness and cost, and healthcare costs, and calibrated such that projections of healthcare utilization and vaccine coverage closely matched empirical estimates. Robustness of projections was evaluated in deterministic and probabilistic sensitivity analyses. RESULTS: Based on the best available data, childhood immunization against RVGE was projected to prevent 63-81 infections per 100 children vaccinated, and to prevent substantial numbers of outpatient medical visits. It was projected that either vaccine would prevent 1-2 hospitalizations per 100 children immunized. Vaccination was projected to increase healthcare costs: immunization with Rotarix™ would prevent incident infections at a cost of approximately $10 per infection prevented or $2400 per quality-adjusted life-year gained. Vaccination with RotaTeq™ would be more costly and less effective and would not be preferred. Projections were robust in the face of wide-ranging sensitivity analyses. INTERPRETATION: The use of currently available vaccines against RVGE in British Columbia children is projected to result in a substantial reduction in the burden of illness and healthcare utilization associated with RVGE, with a modest increase in healthcare costs. RVGE vaccination should be considered "highly cost-effective" relative to other commonly available health interventions.

Core groups, antimicrobial resistance and rebound in gonorrhoea in North America.

BACKGROUND: Genital tract infections caused by Neisseria gonorrhoeae are a major cause of sexually transmitted disease worldwide. Surveillance data suggest that incidence has increased in recent years after initially falling in the face of intensified control efforts. OBJECTIVES: The authors sought to evaluate the potential contribution of antimicrobial resistance to such rebound and to identify optimal treatment strategies in the face of resistance using a mathematical model of gonorrhoea. METHODS: The authors built risk-structured 'susceptible-infectious-susceptible' models with and without the possibility of antibiotic resistance and used these models as a platform for the evaluation of competing plausible treatment strategies, including changing antimicrobial choice when resistance prevalence surpassed fixed thresholds, random assignment of treatment and use of combination antimicrobial therapy. RESULTS: Absent antimicrobial resistance, strategies that focus on treatment of highest risk individuals (the so-called core group) result in collapse of disease transmission. When antimicrobial resistance exists, a focus on the core group causes rebound in incidence, with maximal dissemination of antibiotic resistance. Random assignment of antimicrobial treatment class outperformed the use of fixed resistance thresholds with respect to sustained reduction in gonorrhoea prevalence. CONCLUSIONS: Gonorrhoea control is achievable only when core groups are treated, but treatment of core groups maximises dissemination of antimicrobial-resistant strains. This paradox poses a great dilemma to the control and prevention of gonorrhoea and underlines the need for gonococcal vaccines.

Cholera, canals, and contagion: Rediscovering Dr. Beck's report.

Cholera first appeared in North America (in Montreal and Quebec) in 1832 and spread rapidly across the eastern half of the continent. The dispatch of American disease control experts to Lower Canada in anticipation of cholera's spread implies that medical professionals expected spread, possibly from contagion, even though the notion that cholera was contagious was disparaged in medical writings of the time, and would be until John Snow's landmark work in London in the 1850s. Snow's insights derived largely from his observations on spatial and temporal patterns of cholera cases. We discuss a document from the 1832 epidemic, the report of Dr. Lewis Beck to New York's Governor Throop, which anticipates Snow in presenting geospatial data that imply cholera's contagiousness. Beck shows that the movements of immigrants along the newly completed New York state canal system resulted in sequential cholera outbreaks along the canal's path. Although aware of the degree to which this suggested contagion, Beck argues strenuously against the contagiousness of cholera. We explore the social context of early nineteenth-century medicine that probably led Beck to disbelieve his own observations, and to favor a medical model inconsistent with his data. Themes that emerge from our inquiry include belief in disease as a physical manifestation of defective morality, stigmatization of the poor and immigrant groups, and reluctance to overturn prevailing medical models that themselves reflected the economic position of medical practitioners. We show that these themes continue to serve as obstacles to innovation in medical and public health practice today.

Cholesterol-lowering ability of a phytostanol softgel supplement in adults with mild to moderate hypercholesterolemia.

Plant sterols, incorporated into spreads and other food sources, have been shown to lower serum cholesterol concentrations. The effect of phytostanol supplementation in softgel form has not been assessed. Our objective was to examine the effects of sitostanol as sitostanol ester in softgel form on serum lipid concentrations in hypercholesterolemic individuals. Thirty hypercholesterolemic adults were supplemented with 1.6 g of free phytostanol equivalents as phytostanol ester (2.7 g stanol esters) or placebo per day for 28 d in a randomized, double-blind, parallel study design. Phytostanol supplementation resulted in a significant decrease in total cholesterol (TC) (-8%) and LDL-cholesterol (-9%). There were no alterations in concentrations of HDL-cholesterol or TG. Nor were the ratios of LDL/HDL or TC/HDL altered significantly. Thus, use of phytostanol ester softgel supplements improved serum total and LDL-cholesterol concentrations in hypercholesterolemic individuals.