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Background: Nearly two decades ago, the Eight Americas study offered a novel lens for examining health inequities in the USA by partitioning the US population into eight groups based on geography, race, urbanicity, income per capita, and homicide rate. That study found gaps of 12·8 years for females and 15·4 years for males in life expectancy in 2001 across these eight groups. In this study, we aimed to update and expand the original Eight Americas study, examining trends in life expectancy from 2000 to 2021 for ten Americas (analogues to the original eight, plus two additional groups comprising the US Latino population), by year, sex, and age group., Methods: In this systematic analysis, we defined ten mutually exclusive and collectively exhaustive Americas comprising the entire US population, starting with all combinations of county and race and ethnicity, and assigning each to one of the ten Americas based on race and ethnicity and a variable combination of geographical location, metropolitan status, income, and Black-White residential segregation. We adjusted deaths from the National Vital Statistics System to account for misreporting of race and ethnicity on death certificates. We then tabulated deaths from the National Vital Statistics System and population estimates from the US Census Bureau and the National Center for Health Statistics from Jan 1, 2000, to Dec 31, 2021, by America, year, sex, and age, and calculated age-specific mortality rates in each of these strata. Finally, we constructed abridged life tables for each America, year, and sex, and extracted life expectancy at birth, partial life expectancy within five age groups (0-4, 5-24, 25-44, 45-64, and 65-84 years), and remaining life expectancy at age 85 years., Findings: We defined the ten Americas as: America 1-Asian individuals; America 2-Latino individuals in other counties; America 3-White (majority), Asian, and American Indian or Alaska Native (AIAN) individuals in other counties; America 4-White individuals in non-metropolitan and low-income Northlands; America 5-Latino individuals in the Southwest; America 6-Black individuals in other counties; America 7-Black individuals in highly segregated metropolitan areas; America 8-White individuals in low-income Appalachia and Lower Mississippi Valley; America 9-Black individuals in the non-metropolitan and low-income South; and America 10-AIAN individuals in the West. Large disparities in life expectancy between the Americas were apparent throughout the study period but grew more substantial over time, particularly during the first 2 years of the COVID-19 pandemic. In 2000, life expectancy ranged 12·6 years (95% uncertainty interval 12·2-13·1), from 70·5 years (70·3-70·7) for America 9 to 83·1 years (82·7-83·5) for America 1. The gap between Americas with the lowest and highest life expectancies increased to 13·9 years (12·6-15·2) in 2010, 15·8 years (14·4-17·1) in 2019, 18·9 years (17·7-20·2) in 2020, and 20·4 years (19·0-21·8) in 2021. The trends over time in life expectancy varied by America, leading to changes in the ordering of the Americas over this time period. America 10 was the only America to experience substantial declines in life expectancy from 2000 to 2019, and experienced the largest declines from 2019 to 2021. The three Black Americas (Americas 6, 7, and 9) all experienced relatively large increases in life expectancy before 2020, and thus all three had higher life expectancy than America 10 by 2006, despite starting at a lower level in 2000. By 2010, the increase in America 6 was sufficient to also overtake America 8, which had a relatively flat trend from 2000 to 2019. America 5 had relatively similar life expectancy to Americas 3 and 4 in 2000, but a faster rate of increase in life expectancy from 2000 to 2019, and thus higher life expectancy in 2019; however, America 5 experienced a much larger decline in 2020, reversing this advantage. In some cases, these trends varied substantially by sex and age group. There were also large differences in income and educational attainment among the ten Americas, but the patterns in these variables differed from each other and from the patterns in life expectancy in some notable ways. For example, America 3 had the highest income in most years, and the highest proportion of high-school graduates in all years, but was ranked fourth or fifth in life expectancy before 2020., Interpretation: Our analysis confirms the continued existence of different Americas within the USA. One's life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one's racial and ethnic identity. This gulf was large at the beginning of the century, only grew larger over the first two decades, and was dramatically exacerbated by the COVID-19 pandemic. These results underscore the vital need to reduce the massive inequity in longevity in the USA, as well as the benefits of detailed analyses of the interacting drivers of health disparities to fully understand the nature of the problem. Such analyses make targeted action possible-local planning and national prioritisation and resource allocation-to address the root causes of poor health for those most disadvantaged so that all Americans can live long, healthy lives, regardless of where they live and their race, ethnicity, or income., Funding: State of Washington, Bloomberg Philanthropies, Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The Human Development Index (HDI)-a composite metric encompassing a population's life expectancy, education, and income-is used widely for assessing and comparing human development and wellbeing at the country level, but does not account for within-country inequality. In this study of the USA, we aimed to adapt the HDI framework to measure the HDI at an individual level to examine disparities in the distribution of wellbeing by race and ethnicity, sex, age, and geographical location., Methods: We used individual-level data on adults aged 25 years and older from the 2008-21 American Community Survey (ACS) Public Use Microdata Sample. We extracted information on race and ethnicity, age, sex, location (Public Use Microdata Areas), educational attainment, and household income and size. We merged these data with estimated life tables by race and ethnicity, sex, age, location (county), and year, generated using Bayesian small-area estimation models applied to death certificate data from the National Vital Statistics System. For each individual in the ACS, we used these combined data to estimate years of education, household consumption, and expected lifespan; converted each of these three features into an index using a percentile score; and calculated the HDI as the geometric mean of these three indices. Finally, we grouped individuals into yearly HDI deciles., Findings: Years of education, household consumption, and expected lifespan-and thus the HDI-varied considerably among adults in the USA during the 2008-21 period. For most race and ethnicity and sex groups, the mean HDI increased gradually from 2008 to 2019, then declined in 2020 due to declines in expected lifespan, although there were systematic differences in the distribution of the HDI by race and ethnicity and sex. In the lowest HDI decile, there was over-representation (ie, >10% of the total population of a given race and ethnicity and sex group) of American Indian and Alaska Native (AIAN) males (50% [SE 0·2] in decile, mean annual population in decile 0·37 million [SE 0·002]), Black males (40% [<0·1], 4·67 million [0·006]), AIAN females (23% [0·1], 0·19 million [0·001]), Latino males (21% [<0·1], 3·27 million [0·006]), Black females (14% [<0·1], 1·86 million [0·004]), and Latina females (13% [<0·1], 2·07 million [0·006]). Given differences in total population size, however, White males were the largest population group in the lowest decile (27% [<0·1] of the lowest decile, 5·87 million [0·012]), followed by Black males (22% [<0·1]) and Latino males (15% [<0·1]). There were notable differences in these patterns by age group: for example, for the 25-44 years age group, the lowest HDI decile had even greater over-representation of AIAN males (66% [0·2] in decile, 0·22 million [0·001]) and Black males (46% [<0·1], 2·52 million [0·005]) than the 85 years and older age group (22% [1·1], <0·01 million [<0·001]; and 20% [0·3], 0·03 million [<0·001]). By contrast, the lowest decile had an under-representation of Asian females (2% [<0·1], 0·06 million [<0·001]) in the 25-44 years age group, but an over-representation in the 85 years and older age group (25% [0·3], 0·03 million [<0·001]). The lowest HDI decile for the 25-44 years age group was primarily male (76% [<0·1], 6·44 million [0·009]) whereas for age 85 years and older it was predominantly female (71% [0·1], 0·42 million [0·002]). In the highest HDI decile, shifts in the composition of the population by age were particularly large for White males, who made up 5% (0·1; 0·39 million [0·001]) of this decile in the 25-44 years age group, but 49% (0·2; 0·29 million [0·001]) in the 85 years and older age group. From 2012 to 2021, the proportion of the population living in the lowest HDI decile varied substantially by location, and a disproportionately high share of the population living in locations in much of the southern half of the USA, Appalachia, and Rust Belt states were in the lowest HDI decile., Interpretation: Substantial disparities in wellbeing exist within the USA and are heavily influenced by race and ethnicity (due to racism), sex, age, and geographical location. These disparities are not immutable, but improvement is not a given, and gains can be fleeting in the face of a crisis such as the COVID-19 pandemic. Sustained action to ensure that everyone has meaningful access to a high-quality education, the means to earn a sufficient income, and the opportunity to live a long and healthy life is needed to reduce these disparities and should focus on the populations and locations that are worst off., Funding: State of Washington and National Institute on Minority Health and Health Disparities., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes., Methods: We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access., Results: We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children., Conclusions: Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.

Lower respiratory infections (LRIs) are the leading cause of death in children under the age of 5, despite the existence of vaccines against many of their aetiologies. Furthermore, more than half of these deaths occur in Africa. Geospatial models can provide highly detailed estimates of trends subnationally, at the level where implementation of health policies has the greatest impact. We used Bayesian geostatistical modelling to estimate LRI incidence, prevalence and mortality in children under 5 subnationally in Africa for 2000-2017, using surveys covering 1.46 million children and 9,215,000 cases of LRI. Our model reveals large within-country variation in both health burden and its change over time. While reductions in childhood morbidity and mortality due to LRI were estimated for almost every country, we expose a cluster of residual high risk across seven countries, which averages 5.5 LRI deaths per 1,000 children per year. The preventable nature of the vast majority of LRI deaths mandates focused health system efforts in specific locations with the highest burden.

Objectives: To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population., Design: Cross-sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS., Setting: 270 Medicaid-certified nursing homes in 10 states., Participants: A total of 2014 nursing home residents 60 years or older (mean = 84.3 +/- 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size., Measurements: Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints)., Results: Forty-nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2,5.6), dementia (OR = 2.3;CI = 1.8,3.0), restraints-trunk (OR = 1.7; CI = 1.5,2.0), chair (OR = 1.4; CI = 1.2,1.6), bedrails (OR = 1.3; CI = 1.1,1.5), and use of antianxiety/hypnotic medications (OR = .7;CI = .5,1.0) (all P < .04)., Conclusions: Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.

Evaluation of 1 million incontinent American nursing home residents is hampered by both failure to detect incontinence and logistical barriers to diagnostic testing. The nationally mandated Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) were devised to address these deficiencies. Although both instruments are also used in at least 18 other countries, neither has been evaluated. Our goal was to determine the reliability of the MDS and the accuracy of the RAP in predicting the lower urinary tract cause of incontinence. We determined interrater reliability for the 13 MDS items related to urinary incontinence in 123 randomly selected residents of 13 nursing homes in 5 states; forms were completed blindly by 2 nurses from each facility who were trained for a day. The RAP was assessed in 102 representative institutionalized women by blinded evaluation of its diagnostic accuracy compared with the multichannel videourodynamic criterion standard. For the MDS, interrater reliability for incontinence of all grades was excellent (weighted kappa correlation coefficient = 0.90), although reliability was greater at the extremes of measurement than for incontinence of intermediate severity. With the exception of delirium, correlations for the 11 MDS items related to incontinence were 0.65-0.96; for 6 items, correlations were > or = 0.8. The diagnostic accuracy of the RAP, successfully administered to 80% of women, was 70%. The accuracy of the nearly identical algorithm that formed the basis for the RAP was 84%. Importantly, serious misclassifications were not observed for either the RAP or the algorithm. Although its definitions should be modified slightly, the MDS appears to be feasible and reliable when administered by trained staff. In women, the diagnostic accuracy and safety of the RAP are good-particularly when administered as instructed-but the original, sex-specific algorithm is preferable. Together, the MDS and modified RAP provide a useful, stepwise, and non-urodynamically based strategy to guide evaluation and therapy of incontinence in this setting.

Because of the high prevalence of detrusor hyperactivity with impaired contractility (DHIC) in incontinent institutionalized women, we postulated that: 1) single-channel cystometry, the most commonly used diagnostic test, would be inadequate when used alone but that 2) its accuracy could be greatly enhanced by combining it with a previously-performed stress test. To test the hypothesis, we used blinded comparison of a clinical stress test and single-channel cystometry with multichannel videourodynamic evaluation (criterion standard), a strategy designed a priori. Subjects were 97 incontinent women who were considered representative of incontinent nursing home women nationally. With cystometry alone, 9 of 37 women with DHIC (24%) were misdiagnosed as stress-incontinent vs. 1 of 25 with DH (P = .03). In each case, misdiagnosis was due to failure to recognize low-pressure involuntary bladder contractions. Combining cystometry with the stress test improved diagnostic accuracy markedly. Of the 77% of women in whom the results of both tests were congruent, all were correctly classified. When results of the two tests were discordant, neither was superior. Significantly, no woman with stress incontinence was missed by the two-test strategy, nor was anyone with detrusor hyperactivity misclassified. We conclude that in institutionalized elderly women, DHIC commonly mimics other types of urinary tract dysfunction. Thus, single-channel cystometry alone is an inadequate diagnostic test in this population. However, a strategy that combines cystometry with a clinical stress test can correctly classify the majority of such women and identify those in whom the diagnosis is less secure. Use of this simple strategy would facilitate correct diagnosis and initial treatment of most institutionalized women without referral, and also enrich the referred population with those most likely to benefit. Such an approach could significantly improve the approach to this costly and morbid condition.

In the following study, the basal joint of the thumb and its neighboring joints of 100 anatomical specimens were inspected radiologically and macroscopically for arthrotic alterations. The comparison of the radiological and macroscopic findings showed that early arthrotic joint alterations cannot be diagnosed by radiograms. Virtually half of the specimens examined demonstrated arthrotic lesions of the basal joint of the thumb, whereas the trapezio-scaphoidal and trapezoido-scaphoidal joints were only affected in one-third of the specimens. Two-thirds of the cases with manifest arthrosis of the metacarpophalangeal joint of the thumb demonstrated additional arthrotic changes in the joints between the scaphoid, trapezium, and trapezoideum. No macroscopic evidence of arthrotic alterations in the remaining radial carpal bones were observed. The architecture of the capsular and ligamentous apparatus as well as the individual variations in the scaphoid bone have both been discussed as possible causes of these phenomena, as were polyarthrotic or secondary arthrotic processes.

Prevalent, morbid, and costly, urinary incontinence in the nursing home poses a major problem for patient, caregiver, and administrator alike. In this article, the authors review the pathophysiology of incontinence in the frail elderly, and give guidelines for how to diagnose and treat this common condition.