Despite the Canadian healthcare system's commitment to equity, evidence for disparate access to primary care (PC) providers exists across individual social identities/positions. Intersectionality ...allows us to reflect the realities of how social power shapes healthcare experiences at an individual's interdependent and intersecting social identities/positions. The objectives of this study were to determine: (1) the extent to which intersections can be used classify those who had/did not have a PC provider; (2) the degree to which each social identity/position contributes to the ability to classify individuals as having a PC provider; and (3) predicted probabilities of having a PC provider for each intersection.
Using national cross-sectional data from 241,445 individuals in Canada aged ≥18, we constructed 320 intersections along the dimensions of gender, age, immigration status, race, and income to examine the outcome of whether one had a PC provider. Multilevel analysis of individual heterogeneity and discriminatory accuracy, a multi-level model using individual-level data, was employed to address intersectional objectives. An intra-class correlation coefficient (ICC) of 23% (95%CI: 21-26%) suggests that these intersections could, to a very good extent, explain individual variation in the outcome, with age playing the largest role. Not all between-intersection variance in this outcome could be explained by additive effects of dimensions (remaining ICC: 6%; 95%CI: 2-16%). The highest intersectional predicted probability existed for established immigrant, older South Asian women with high income. The lowest intersectional predicted probability existed for recently immigrated, young, Black men with low income.
Despite a "universal" healthcare system, our analysis demonstrated a substantial amount of inequity in primary care across intersections of gender, age, immigration status, race, and income.
Maternal mortality is still a major risk for women of childbearing age in Nigeria. In 2008, Nigeria bore 14% of the global burden of maternal mortality. The national maternal mortality ratio has ...remained elevated despite efforts to reduce maternal deaths. Though health disparities exist between the North and South of Nigeria, there is a dearth of evidence on the estimates and determinants of maternal mortality for these regions.
This study aimed to assess differences in the levels and determinants of maternal mortality in women of childbearing age (15-49 years) in the North and South of Nigeria. The Nigeria Demographic and Health Surveys (2008 and 2013) were used. The association between maternal mortality (outcome) and relevant sociocultural, economic and health factors was tested using multivariable logistic regression in a sample of 51,492 living or deceased women who had given birth.
There were variations in the levels of maternal mortality between the two regions. Maternal mortality was more pronounced in the North and increased in 2013 compared to 2008. For the South, the levels slightly decreased. Media exposure and education were associated with maternal mortality in the North while contraceptive method, residence type and wealth index were associated with maternal death in the South. In both regions, age and community wealth were significantly associated with maternal mortality.
Differences in the levels and determinants of maternal mortality between the North and South of Nigeria stress the need for efforts to cut maternal deaths through new strategies that are relevant for each region. These should improve education of girls in the North and access to health information and services in the South. Overall, new policies to improve women's socioeconomic status should be adopted.
Abstract
Background
The prevalence of multimorbidity varies widely due to the lack of consensus in defining multimorbidity. This study aimed to measure the prevalence of multimorbidity in a primary ...care setting using two definitions of multimorbidity with two different lists of chronic conditions.
Methods
We conducted a cross-sectional study of 787,446 patients, aged 0 to 99 years, who consulted a family physician between July 2015 to June 2016. Multimorbidity was defined as ‘two or more’ (MM2+) or ‘three or more’ (MM3+) chronic conditions using the Fortin list and Chronic Disease Management Program (CDMP) list of chronic conditions. Crude and standardised prevalence rates were reported, and the corresponding age, sex or ethnic-stratified standardised prevalence rates were adjusted to the local population census.
Results
The number of patients with multimorbidity increased with age. Age-sex-ethnicity standardised prevalence rates of multimorbidity using MM2+ and MM3+ for Fortin list (25.9, 17.2%) were higher than those for CDMP list (22.0%; 12.4%). Sex-stratified, age-ethnicity standardised prevalence rates for MM2+ and MM3+ were consistently higher in males compared to females for both lists. Chinese and Indians have the highest standardised prevalence rates among the four ethnicities using MM2+ and MM3+ respectively.
Conclusions
MM3+ was better at identifying a smaller number of patients with multimorbidity requiring higher needs compared to MM2+. Using the Fortin list seemed more appropriate than the CDMP list because the chronic conditions in Fortin’s list were more commonly seen in primary care. A consistent definition of multimorbidity will help researchers and clinicians to understand the epidemiology of multimorbidity better.
The occurrence of multiple co-occurring chronic health conditions, known as multimorbidity, is associated with decreases in quality of life for patients and poses unique challenges for healthcare ...systems. Since people with psychotic disorders have an excess of physical health conditions compared to the general population, they may also be at a higher risk for multimorbidity. We conducted a systematic review and meta-analysis to quantify the prevalence and excess risk of multimorbidity among people with psychotic disorders, relative to those without psychosis.
We searched the MEDLINE, EMBASE, and PsycINFO databases, and conducted forward and backward citation tracing of included studies. Studies published after 1990 were included if they reported the prevalence of multiple chronic physical health conditions among people with psychotic disorders. Data on the prevalence and relative risk of multimorbidity were meta-analyzed using random effects models.
Fourteen studies met the inclusion criteria, and eight were included in the meta-analysis. Each study used a different operational definition of multimorbidity, both for the number and types of chronic conditions, which resulted in a wide range in prevalence estimates (16% to 91%). People with psychotic disorders had an increased risk of multimorbidity (RR = 1.69, 95%CI = 1.37,2.08), relative to those without psychosis.
People with psychotic disorders are more likely to experience multimorbidity than those without psychotic disorders. Clinicians treating people with psychosis should closely monitor for a range of physical health conditions. Future research examining multimorbidity among people with psychiatric illness should employ consistent definitions to better enable cross-study comparisons.
•The occurrence of multiple co-occurring chronic conditions is called multimorbidity•People with psychotic disorders have a 69% increased risk of multimorbidity•Clinicians should monitor patients with psychosis for physical health conditions
With Bangladesh's adoption of the third Sustainable Development Goal to reduce maternal mortality, the impetus for Bangladesh to continue to improve uptake of maternal healthcare is strong.
Using a ...propensity-score matched analysis, the present study utilized data from the 2014 Bangladesh Demographic Health survey to examine the impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery.
The results revealed a significant and positive impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery after matching treated and untreated mothers on included socio-demographic characteristics.
Implementation of policies to provide at least four antenatal care visits may serve as an effective strategy to increase SBA use and institutional delivery in Bangladesh, which could contribute to the reduction of maternal mortality.
Abstract
The life of RNA polymerase II (RNAPII) transcripts is shaped by the dynamic formation of mutually exclusive ribonucleoprotein complexes (RNPs) that direct transcript biogenesis and turnover. ...A key regulator of RNA metabolism in the nucleus is the scaffold protein ARS2 (arsenic resistance protein 2), bound to the cap binding complex (CBC). We report here that alternative splicing of ARS2′s intron 5, generates cytoplasmic isoforms that lack 270 amino acids from the N-terminal of the protein and are functionally distinct from nuclear ARS2. Switching of ARS2 isoforms within the CBC in the cytoplasm has dramatic functional consequences, changing ARS2 from a NMD inhibitor to a NMD promoter that enhances the binding of UPF1 to NCBP1 and ERF1, favouring SURF complex formation, SMG7 recruitment and transcript degradation. ARS2 isoform exchange is also relevant during arsenic stress, where cytoplasmic ARS2 promotes a global response to arsenic in a CBC-independent manner. We propose that ARS2 isoform switching promotes the proper recruitment of RNP complexes during NMD and the cellular response to arsenic stress. The existence of non-redundant ARS2 isoforms is relevant for cell homeostasis, and stress response.
Graphical Abstract
Graphical Abstract
ARS2 isoforms regulate RNA metabolism in the nucleus and cytoplasm under physiological and stress conditions.
In the US, >90% of people with T2DM on oral antihyperglycemics use secretagogues. The present analysis is the first to quantify the real-world, US frequency of Level 3 severe hypoglycaemia (SH) in ...this population. Longitudinal, prospective data were leveraged from the iNPHORM study. Adults (≥18 years old) with secretagogue-treated T2DM (not on insulin) were recruited from a US-wide, probability-based internet panel. Data on participant characteristics and Level 3 SH occurrence were captured across a screener, baseline and 12 monthly follow-ups. Multivariable negative binomial regression with cluster bootstrapping for repeated measures modelled the annualized rate of SH for individuals completing ≥1 follow-up(s). A repeated lasso regression ‘voting’ procedure selected all risk factors. Multiple imputation addressed missingness. Of the 353 respondents (male: 51.1%; age: 54.6 SD: 13.2 years; diabetes duration: 10 IQR: 12 years; retention rate: 84.4%), the incidence proportion of SH over follow-up was 21.8 (95% CI: 17.8-26.3)%, and the rate was 3.8 (95% CI: 2.5-5.7) events per person-year. Our final model included age, continuous/flash glucose monitoring use, corticosteroid use, number of healthcare visits, fear of hypoglycemia, number of past-year SH requiring hospital care, retinopathy, and other diabetes complications. The rate of annualized Level 3 SH statistically increased with younger age, more frequent healthcare visits, greater fear of hypoglycemia, higher number of past-year healthcare-related SH, and presence of retinopathy. Our results indicate disturbingly high incidences of Level 3 SH among secretagogue users. Whenever logical and feasible, clinicians should prioritize one of the many other available antihyperglycemics that confer little to no hypoglycemia risk. Else, other hypoglycemia prevention strategies—risk-tailored to this ubiquitous T2DM population—are urgently warranted.
Disclosure
A.Ratzki-leewing: Consultant; Novo Nordisk, Eli Lilly and Company, Research Support; Sanofi. J.E.Black: None. G.Zou: None. B.L.Ryan: None. S.B.Harris: Advisory Panel; Bayer Inc., AstraZeneca, Eli Lilly and Company, Dexcom, Inc., Novo Nordisk A/S, Novo Nordisk Canada Inc., Sanofi, Consultant; Abbott Diabetes, Janssen Pharmaceuticals, Inc., Other Relationship; American Diabetes Association, Research Support; Abvance Therapeutics, Canadian Institutes of Health Research.
Funding
Sanofi Global
Despite an aging US diabetes population, little is known about the real-world frequency of iatrogenic severe hypoglycemia (SH) among older adults. We analyzed iNPHORM data to address this gap. People ...≥60-year-old with T1DM or T2DM on insulin and/or secretagogues were recruited from a probability-based internet panel. Data on SH were obtained via a screener, baseline, and 12 monthly follow-ups. Crude SH incidence rates (IRs) and proportions (IPs) were calculated overall, and by diabetes type, medication type, and mode of SH recovery. N=307 were analyzed (T1DM: 8.5%; age: 67.5 SD:5.5 years; male: 54.1%; retention rate: 81.8%). Among T2DM respondents, 39.9% used insulin without secretagogues, 50.2% secretagogues without insulin, and 10.0% insulin and secretagogues. The overall IP of SH was 19.9 (95%CI: 15.8-24.7)%, and the IR was 0.89 (95%CI: 0.62-1.27) events per person-year (EPPY). People with T1DM had a higher total IP (42.3 95%CI: 25.5-61.1%) and IR (2.07 95%CI: 0.98-4.38 EPPY) than those with T2DM (IP: 17.8 95%CI: 13.8-22.7%; IR: 0.78 95%CI: 0.52-1.15 EPPY), including insulin without secretagogue users (1.09 95%CI: 0.66-1.80 vs. 0.61 95%CI: 0.26 to 1.45 insulin with secretagogues and 0.50 95%CI: 0.23 to 1.05 secretagogues without insulin EPPY). Emergency care and hospitalization constituted 3.6% (T1DM: 0%; T2DM: 6.7%) and 1.8% (T1DM: 0%; T2DM: 2.2%) of SH (n=224), respectively. Paramedical/hospital-based SH was more common in T2DM (0.06 95%CI: 0.02-0.19) than T1DM (0 EPPY) with IRs highest among insulin without secretagogue users (0.11 95%CI: 0.03-0.47 EPPY). This is the first US prospective study on SH frequency in older adults with diabetes. Most (96.4%) events occurred at-home, underscoring the need for self-reported SH capture. Overall IPs and IRs were greater in T1DM than T2DM; but those with T2DM had more healthcare-based events. To mitigate undue health and economic costs, it is imperative clinicians remain vigilant to preventing SH in this vulnerable and growing population.
Disclosure
A.Ratzki-leewing: Consultant; Novo Nordisk, Eli Lilly and Company, Research Support; Sanofi. J.E.Black: None. G.Zou: None. B.L.Ryan: None. S.B.Harris: Advisory Panel; Bayer Inc., AstraZeneca, Eli Lilly and Company, Dexcom, Inc., Novo Nordisk A/S, Novo Nordisk Canada Inc., Sanofi, Consultant; Abbott Diabetes, Janssen Pharmaceuticals, Inc., Other Relationship; American Diabetes Association, Research Support; Abvance Therapeutics, Canadian Institutes of Health Research.
Funding
Sanofi Global
Aims
The higher prevalence of chronic physical health conditions among people with psychotic disorders may result in a reduced life expectancy as compared to the general population. More research is ...needed on the risk of multiple co-occurring chronic health conditions, known as multimorbidity, for people with psychotic disorders.
Methods
We conducted a matched retrospective cohort study to quantify the prevalence of multimorbidity and associated factors among people with psychotic disorders over the 10-year period following first diagnosis, relative to those without psychosis. Data from an early psychosis intervention program in London, Canada were linked to population-based health administrative data to identify patients with first-episode psychosis (
n
= 439), and a comparison group from the general population (
n
= 1759) matched on age, sex, and postal code. We followed the cohort for 10 years to ascertain the prevalence of multimorbidity. We compared people with and without psychosis using modified Poisson regression models, and explored risk factors for multimorbidity among those with psychotic disorders.
Results
People with psychotic disorders may have a 26% higher prevalence of multimorbidity 10 years following first diagnosis, although our findings include the possibility of a null effect (PR = 1.26, 95% CI 0.96–1.66). People with psychosis living in areas with the highest levels of material deprivation had a threefold higher prevalence of multimorbidity as compared to those in the lowest areas of material deprivation (PR = 3.09, 95% CI 1.21–7.90).
Conclusion
Multimorbidity is prevalent among those with psychosis, and assessment for chronic health conditions should be integrated into clinical care for younger populations with psychotic illness.
Most prediction models for diabetes-related iatrogenic severe hypoglycemia (SH) have derived from trial/administrative records subject to poor generalizability, ascertainment bias, and incomplete ...data capture. Redressing this gap, iNPHORM leveraged the clinical and methodological advantages of prospective self-report to develop and internally validate a 1-year SH prediction model for use in real-world clinical contexts.
Adults (18-90 years old) with insulin- and/or secretagogue-treated type 1 or 2 diabetes (T1D, T2D) were recruited from a US-wide probability-based internet panel and followed for one year. Monthly emailed questionnaires assessed SH incidence and related factors. To model recurrent 1-year SH (daytime + nocturnal) , Andersen-Gill Cox proportional hazards regression was performed on participants completing ≥1 follow-up. Missing data were multiply imputed with chained equations. Machine learning penalized regression with lasso was used to select clinically plausible predictors.
A total of 986 (T1D: 17%) participants were analyzed (retention rate: 86.2%) . The mean age was 51 (SD: 14.3) years, 49.6% were male, and the median duration of T1D/T2D was 12 (IQR: 14) years. Among T2D participants, 38% were on insulin (without secretagogues) , 38% on secretagogues (without insulin) , and 24% on insulin plus secretagogues. Across follow-up, 35.1% (95% CI: 32.2-38.1%) reported ≥1 SH, and the annual rate was 4.97 (95% CI: 4.13-5.99) . Combination insulin-secretagogue therapy; use of an insulin pump and continuous glucose monitoring; decreased age; increased previous SH requiring healthcare utilization; chronic kidney disease; and food insecurity predicted 1-year SH risk. The optimism adjusted c-statistic was 0.75.
iNPHORM is the first long-term, prospective study on SH prediction in the general US population with T1D and T2D. Our 7-variable model can be used to identify patients at high-risk of SH, leading to more valid, cost-effective prevention strategies in the real world.
Disclosure
A.Ratzki-leewing: Consultant; Eli Lilly and Company, Other Relationship; Sanofi. S.B.Harris: Consultant; Abbott, AstraZeneca, Eli Lilly and Company, Novo Nordisk, Sanofi, Other Relationship; Abbott, AstraZeneca, Bayer Inc., Dexcom, Eli Lilly and Company, HLS Therapeutics, Janssen Pharmaceuticals, Inc., Novo Nordisk, Sanofi, Research Support; Applied Therapeutics Inc., AstraZeneca, Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation (JDRF) , Novo Nordisk, Sanofi, The Lawson Foundation. J.E.Black: None. G.Zou: None. S.Webster-bogaert: None. B.L.Ryan: None.
Funding
Sanofi Global
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