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BACKGROUND: While low sodium intake (40 years with stable blood pressure (BP), without heart failure or postural hypotension were randomised to intensive dietary counselling (target sodium intake

Introduction: Racial/ethnic differences in diagnostic and treatment services have been identified for a range of health conditions and outcomes. The current study aimed to analyze whether there are racial/ethnic differences in the timing of diagnostic testing and treatments for males with Duchenne Muscular Dystrophy (DMD). Methods: Diagnostic and clinical data for male individuals with DMD born during 1990-2010 were analyzed from eight sites (Arizona, Colorado, Georgia, Iowa, Piedmont Region of North Carolina, western New York, South Carolina, Utah) of the Muscular Dystrophy Surveillance Tracking and Research Network (MD STARnet). Seven milestones related to diagnosis/treatment experiences were selected as outcomes. Times to each milestone were estimated and compared by four racial/ethnic groups using Kaplan-Meier estimation and Cox proportional hazard models. Times between initial evaluation or diagnostic testing and later milestones were also compared by race/ethnicity. Results: We identified 682 males with definite or probable DMD of whom 61.7% were non-Hispanic White, 20.5% Hispanic, 10.6% other, and 7.2% non-Hispanic Black. Seven milestone events were studied (initial evaluation, first neurology/neuromuscular visit, diagnosis, corticosteroid treatment first offered, corticosteroid treatment started, first electrocardiogram or echocardiogram, and first pulmonary function testing). The first five milestone events occurred at an older age for non-Hispanic Black individuals compared to non-Hispanic White individuals. Time from diagnosis to first offering of corticosteroids and initiation of corticosteroid therapy was later for Hispanic individuals compared to non-Hispanic White individuals. When accounting for timing of initial evaluation/diagnosis, offering of corticosteroids continued to occur later, but first pulmonary testing occurred earlier, among Hispanic individuals compared to non-Hispanic Whites. No significant delays remained for non-Hispanic Black individuals after accounting for later initial evaluation/diagnosis. Conclusion: We described racial/ethnic differences in ages at selected diagnostic and treatment milestones. The most notable differences were significant delays for five of seven milestones in non-Hispanic Black individuals, which appeared to be attributable to later initial evaluation/diagnosis. Findings for Hispanic individuals were less consistent. Efforts to address barriers to early evaluation and diagnosis for non-Hispanic Black children with DMD may promote more timely initiation of recommended disease monitoring and interventions.

BackgroundIdentifying immune processes required for liver-stage sterilizing immunity to malaria remains an open problem. The IMRAS trial comprised 5x immunizations with radiation-attenuated sporozoites resulting in 55% protection from subsequent challenge.MethodsTo identify correlates of vaccination and protection, we performed detailed systems immunology longitudinal profiling of the entire trial time course including whole blood transcriptomics, detailed PBMC cell phenotyping and serum antigen array profiling of 11 IMRAS radiation-attenuated sporozoite (RAS) vaccinees at up to 21 timepoints each.ResultsRAS vaccination induced serum antibody responses to CSP, TRAP, and AMA1 in all vaccinees. We observed large numbers of differentially expressed genes associated with vaccination response and protection, with distinctly differing transcriptome responses elicited after each immunization. These included inflammatory and proliferative responses, as well as increased abundance of monocyte and DC subsets after each immunization. Increases in Vδ2 γδ; T cells and MAIT cells were observed in response to immunization over the course of study, and CD1c+ CD40+ DC abundance was significantly associated with protection. Interferon responses strongly differed between protected and non-protected individuals with high interferon responses after the 1st immunization, but not the 2nd-5th. Blood transcriptional interferon responses were correlated with abundances of different circulating classical and non-classical monocyte populations.ConclusionsThis study has revealed multiple coordinated immunological processes induced by vaccination and associated with protection. Our work represents the most detailed immunological profiling of a RAS vaccine trial performed to date and will guide the design and interpretation of future malaria vaccine trials.

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care–sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5–24.7]), and psychiatric conditions (RRs = 5.8–15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care– sensitive conditions and to manage chronic medical and mental health conditions.

Introduction: Previous studies indicated variability in the prevalence of Duchenne and Becker muscular dystrophies (DBMD) by racial/ethnic groups. The Centers for Disease Control and Prevention’s (CDC) Muscular Dystrophy Surveillance, Tracking, and Research network (MD STARnet) conducts muscular dystrophy surveillance in multiple geographic areas of the USA and continues to enroll new cases. This provides an opportunity to continue investigating differences in DBMD prevalence by race and ethnicity and to compare the impact of using varying approaches for estimating prevalence. Objective: To estimate overall and race/ethnicity-specific prevalence of DBMD among males aged 5–9 years and compare the performance of three prevalence estimation methods. Methods: The overall and race/ethnicity-specific 5-year period prevalence rates were estimated with MD STARnet data using three methods. Method 1 used the median of 5-year prevalence, and methods 2 and 3 calculated prevalence directly with different birth cohorts. To compare prevalence between racial/ethnic groups, Poisson modeling was used to estimate prevalence ratios (PRs) with non-Hispanic (NH) whites as the referent group. Comparison between methods was also conducted. Results: In the final population-based sample of 1,164 DBMD males, the overall 5-year prevalence for DBMD among 5–9 years of age ranged from 1.92 to 2.48 per 10,000 males, 0.74–1.26 for NH blacks, 1.78–2.26 for NH whites, 2.24–4.02 for Hispanics, and 0.61–1.83 for NH American Indian or Alaska Native and Asian or Native Hawaiian or Pacific Islander (AIAN/API). The PRs for NH blacks/NH whites, Hispanics/NH whites, and NH AIAN/API/NH whites were 0.46 (95% CI: 0.36–0.59), 1.37 (1.17–1.61), and 0.61 (0.40–0.93), respectively. Conclusions: In males aged 5–9 years, compared to the prevalence of DBMD in NH whites, prevalence in NH blacks and NH AIAN/API was lower and higher in Hispanics. All methods produced similar prevalence estimates; however, method 1 produced narrower confidence intervals and method 2 produced fewer zero prevalence estimates than the other two methods.

There are variants of prescription drug monitoring programs (PDMPs) and different groups of patients who are prescribed opioids. Patients with disabilities and those with chronic conditions might have different experiences in physician prescribing practices for opioids, when compared to a comparison group without these conditions. To determine differences in opioid prescriptions related to PDMPs for people without cancer-related pain and with disability conditions compared to other adult opioid users without cancer, using a national database. Opioid users were identified from the US Medical Expenditure Panel Survey. Disability groups were defined by diagnosis codes related to longstanding physical disability and inflammatory conditions. Our analyses used an event study framework and a difference-in-differences approach. During a two-year panel period, PDMPs did not reduce opioid prescriptions for individuals with disabilities who use opioids. Our data show that individuals with disabilities who use opioids, on average, have a higher incidence of continuous opioid use and significantly greater amounts prescribed compared to other adults who have opioid prescriptions. PDMPs do not appear to affect prescribers’ initial or ongoing use of opioids for individuals with longstanding physical disabilities and those with inflammatory conditions. Thus, these adults have greater exposure to opioids, compared to other adults who were prescribed opioids.

Environmental exposures to chemicals can disrupt gene expression, and the effects could be mediated by methylation. This investigation focused on methylation of genes associated with exposure to metals. Mother-child pairs from three locations in Montana were recruited, and buccal cells were collected for genome-wide methylation assay. Four pairs were from Butte, where there is mining and a Superfund site, four pairs were from Anaconda with a Superfund site, and four pairs were from Missoula with neither a mine nor a Superfund site. Principal component analysis, linear mixed models, hierarchical clustering and heatmap, and gene set enrichment analysis were used to visualize the profiles, identify the top associated methylation loci, and investigate the involved pathways. Distinctly higher or lower methylation in samples from Butte were found at the top differentially methylated loci. The 200 genes harboring the most hypermethylated loci were significantly enriched in genes involved in actin cytoskeleton regulation, ABC transporters, leukocyte transendothelial migration, focal adhesion, and adherens junction, which plays a role in pathogenesis of disease, including autism spectrum disorders. This study lays a foundation for inquiry about genetic changes associated with environmental exposure to metals for people living in proximity to Superfund and open pit mining.

Purpose We assessed an educational intervention to reduce the number of emergency department (ED) and inpatient stays for cardiovascular diagnoses, among South Carolina adult Medicaid Members with intellectual and developmental disability and hypertension (Members). Design This Randomized Controlled Trial (RCT) included Members or the person who helped them with their medications (Helpers). Participants, who included Members and/or their Helpers, were randomly assigned to an Intervention or Control group. Setting South Carolina Department of Health and Human Services, which administers Medicaid, identified eligible Members. Sample 412 Medicaid Members - 214 Intervention (54 Members participating directly; 160 Helpers participating in lieu of Members) who received the messages about hypertension and surveys about knowledge and behavior and 198 Controls (62 Members; 136 Helpers) who only received surveys of knowledge and behavior. Intervention Educational intervention about hypertension included a flyer and monthly text or phone messages for one year. Measures Input measures - characteristics of the Members; Outcome measures - hospital emergency department (ED) and inpatient visits for cardiovascular conditions. Analysis Quantile regression tested the association of Intervention/Control group status with ED and inpatient visits. We also estimated models using Zero-inflated Poisson (ZIP) models for sensitivity analysis. Results Participants in the Intervention group with highest baseline hospital use (top 20% ED; top 15% Inpatient) had significant reductions in Year 1 (.57 fewer ED and 2 fewer inpatient days) compared to the Control group. For ED visits, improvement continued in year two. Conclusion The intervention reduced the frequency of cardiovascular disease-related ED visits and Inpatient days for participants in the Intervention group in the highest quantiles of hospital use, and the improvement was better for those who had a Helper.

Metals and metalloids are ubiquitous and persistent in urban areas and are generally released into the environment as mixtures.The purpose of this study was to establish baseline concentrations of selected elements in meconium samples among a large urban population in the US and understand the spatial variability in concentrations. The association of metal mixtures on birth weight was also assessed.This cross-sectional study was conducted across five public hospitals located in New York City, NY (NYC) in four boroughs. We collected meconium sample from 116 infants during the first 24 h after delivery and quantified 11 metals using ICP-MS. Principal component analysis was used to determine metal mixtures and their association with birth weight. Spatial hot spots of each metal were calculated using the Getis-Ord (GI*).Essential elements were detected in all samples with Zn in the greatest abundance (median = 274.5 μg/g) and Mo in the least (median = 0.1845 μg/g). Pb was detected in all but two samples (median = 0.0222 μg/g), while Cd levels were detected in approximately half of the samples (median = 0.0019 μg/g). Co-located hot spots were detected for Cu, Zn, and Fe in southeast Brooklyn; Cd, Cr, and Ni in eastern Queens; and Al and Mo in south Queens. There was a significant inverse relationship between Pb concentrations (beta = -1935.7; p = 0.006) and the mixture of Cr, Cu, Mo, Zn (beta = -157.7; p = 0.045) and birth weight.Our findings indicate that meconium is an effective biomarker for measuring metal exposures among an urban population. We were able to quantify detectable levels of ten of the eleven metals measured in the study and characterize nutritionally necessary trace elements and metals derived from anthropogenic sources without biologic need in a cohort of NYC newborns. Further research needs to establish the change point from necessary to toxic, for the essential elements.

Background Recent evidence suggests that many adults with intellectual and developmental disabilities (IDD) do not adequately manage hypertension (HTN) medication. Known risk factors for insufficient prescription filling include age, residential placement, and lack of caregiver support. This is a first report of a randomized intervention trial designed to analyze the relationship of a brief educational intervention with increased knowledge about HTN and improvement in prescription filling for anti-hypertensive medication. Objective/hypothesis The objective was to test whether an educational flyer and regular messages about HTN and the importance of refilling medication would improve scores on knowledge surveys. Participants were Medicaid members with HTN and IDD (Member) or caregivers (Helpers) who chose to participate on behalf of a Member. Methods Recruitment letters explained that either the Member or their Helper could participate (not both). Participants were randomly assigned to the Case or Comparison group, and both were comprised of Members and Helpers. Only Case participants received a flyer and monthly HTN education messages for one year, but all participants completed knowledge surveys at baseline, six, and 12 months. Linear regression and log-binomial models were used to compare responses between groups. Results Case Helpers had statistically significant improvements on HTN knowledge from baseline through the first year, compared to Comparison Members and Comparison Helpers. Regardless of group assignment, Helpers scored better on surveys than did Members. Conclusions This study suggests that it is beneficial to explicitly include Helpers in health care instruction and in management of chronic disease for adults with IDD.

Nationally, individuals with disability have higher rates of opioid use and misuse and are prescribed higher doses than those without disability. Opioid prescriptions during pregnancy are associated with adverse birth outcomes.To understand the difference in opioid prescribing during pregnancy over time by disability status among Medicaid beneficiaries who gave birth from 2008 to 2017 in South Carolina.Data from hospital discharges, vital records, and pharmacy were linked to determine the mother's disability status, opioid prescriptions filled during pregnancy, and other maternal characteristics. Disability status was characterized into physical disability, inflammatory conditions, intellectual and developmental disabilities (IDD), and psychiatric conditions. Bivariate analyses and negative binomial regression were utilized to obtain adjusted rate ratios for total opioid prescriptions and total morphine milligram equivalents (MME) during pregnancy per live birth. Models were adjusted for chronic pain status. The final analytic sample included 319,752 births to 224,838 mothers.Almost 7% of the births were to mothers with at least one type of disability. Overall, those with disability had a significantly higher adjusted rate ratio of total opioid prescriptions (aRR: 2.36; 95% CI: 2.21-2.52) and total MME (aRR: 2.29; 95% CI: 2.07-2.52) during pregnancy per live birth than those without disability. These findings were seen across all the diagnostic groups, except IDD, where there were no significant differences.The current study found that women with physical, inflammatory, and psychiatric disability were prescribed more opioids and at higher dosages during pregnancy than their counterparts without disability, after adjusting for chronic pain status.

Adults with intellectual or developmental disabilities often have hypertension and mental illness, and are prescribed medications for treatment. This study examined psychotropic medication adherence as a mediator between the association of residence type and antihypertensive medication adherence for adults with intellectual or developmental disabilities. We used Medicaid data of adults with intellectual or developmental disabilities who had hypertension and prescribed antihypertensive medication (N = 1,201) to measure the direct effect, indirect effect, and total effect of residence type (home vs. supervised setting) and antihypertensive medication adherence, with a mediator of psychotropic medication adherence. The indirect effect of psychotropic medication adherence on antihypertensive medication adherence was 1.26 (OR = 1.26, CI: 1.08–1.52), holding residency constant. The direct effect of residential type on antihypertensive medication adherence was 3.75 (OR = 3.75, CI: 1.61–8.75). This association may be due to some features of having a mental illness or maybe the result of being prescribed more than one medication.

Background: While low sodium intake ( Methods: This is a protocol for two phase IIb randomised, two-group, parallel, open-label, controlled, single centre trials. Participants were aged >40 years with stable blood pressure, unchanged anti-hypertensive medications, willing to modify diet and provided written informed consent. Participants were excluded for abnormal sodium handling, heart failure, high dose diuretics, immunosuppression, pregnancy/lactation, postural hypotension, cognitive impairment, high or low body mass index (BMI) or inclusion in another trial. STICK participants had estimated glomerular filtration rate (eGFR) 30-60ml/min/1.73m2 and were excluded for acute kidney Injury, rapidly declining eGFR; known glomerular disease or current use of non-steroidal anti-inflammatory drugs. For COSIP, participants were excluded for known kidney or cardiovascular disease. Participants were randomized to usual care only (healthy eating) or an additional sodium lowering intervention (target Discussion: These Phase II trials will explore uncertainty about low sodium intake and cardiovascular and kidney biomarkers, and help determine the feasibility of low sodium intake. Trial results will also provide preliminary information to guide a future definitive clinical trial, if indicated. Trial registration: STICK: ClinicalTrials.gov NCT02738736 (04/04/2016); COSIP: ClinicalTrials.gov NCT02458248 (15/05/2016)

This study evaluated the effect of increased physical activity on annual medical expenditures among people with disability, as well as people without disability.We performed a cross-sectional study with linked national survey data from 2004 to 2013 Medical Expenditure Panel Survey and from 2002 to 2012 National Health Interview Study. We investigated the effect of physical activity on the annual medical expenditures in 2013 US dollars, among people with and without disability who were 18- to 64-year-old adults.For people with disability, we found a statistically significant effect (P .05) of physical activity on annual medical expenditures. Among people without disability, being inactive was associated with higher medical expenditures, compared with being sufficiently active. In our counterfactual analysis, among inactive people with disability, increasing activity to even a low level of activity could potentially save on average $2150.06 (95% confidence interval, 770.39 to 3529.72) annual medical costs.This analysis provides evidence that when an individual with a disability moves from inactive to active, the savings in medical expenditures are substantially larger than the savings for an individual without a disability ($2564.33 vs $393.34). Despite the challenge of participating in physical activity for people with disability, completing "some" activity may have large public health implications.

This project sought to identify Medicaid members with intellectual and developmental disabilities (IDD) in five states (Delaware, Iowa, Massachusetts, New York, and South Carolina) to develop a cohort for subsequent analyses of medical conditions and service utilization. We estimated that over 300,000 Medicaid members in these states had IDD. All members with diagnostic codes for IDD were identified and the three most frequent diagnoses were unspecified intellectual disability, autism or pervasive developmental disorder, and cerebral palsy. The percentage of Medicaid members with IDD ranged from 2.3% in New York to 4.2% in South Carolina. Identifying and characterizing people with IDD is a first step that could guide public health promotion efforts for this population.

Introduction Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions. Method To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied. Results There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings. Conclusion Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services.

Each year in the United States, about 4000 deaths are attributed to cervical cancer, and over 40,000 deaths are attributed to breast cancer (U.S. Cancer Statistics Working Group, 2015). The purpose of this study was to identify predictors of full, partial, and no screening for breast and cervical cancer among women with and without intellectual disability (ID) who are within the age group for screening recommended by the U.S. Preventive Service Task Force (USPSTF), while accounting for changes in recommendations over the study period. Women with ID and an age matched comparison group of women without ID were identified using merged South Carolina Medicaid and Medicare files from 2000 to 2010. The sample consisted of 9406 and 16,806 women for mammography screening and Papanicolaou (Pap) testing adherence, respectively. We estimated multinomial logistic regression models and determined that women with ID were significantly less likely than women without ID to be fully adherent compared to no screening with mammography recommendations (adjusted odds ratio [AOR]: 0.63, 95% confidence interval [CI] 0.55–0.72), and Pap testing recommendations (AOR: 0.17, 95% CI 0.16–0.19). For the 70% of women with ID for whom we had residential information, those who lived in a group home, medical facility, or supervised community living setting were more likely to be fully adherent with both preventive services than those living alone or with family members. For both outcomes, women residing in a supervised nonmedical community living setting had the highest odds of full adherence, adjusting for other covariates.

Objective To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs. Study design Medicaid administrative claims from 4 states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108 789 children (75 417 male; 33 372 female) under age 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of emergency department (ED) and inpatient hospital services were analyzed for 2012. Results Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153 348 562 and $76 654 361, respectively). Conclusions Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

Background Diabetes is one of the most common chronic conditions among adults. Little is known about the quality of diabetes care received by adults with intellectual and developmental disabilities (IDD). Objective To determine the extent to which the diabetes care needs are met for a population with both IDD and diabetes who are solely insured by Medicaid in five states (Iowa, Massachusetts, New York, Oregon and South Carolina). Methods Medicaid administrative data in 2012 were used to identify Medicaid members (excluding dual eligibles) with diabetes and IDD in five states. Four diabetes care measures were compared between members with and without IDD using bivariate analyses. For those with diabetes and IDD, a logistic regression model was fitted for each state with the following predictors: age, sex, IDD subgroup, and occurrence of a specialist visit in the current or past year. A meta-analysis was then conducted to synthesize cross-state results. Results Across the five states, 6229 (2%) of the 308,804 non-dual adult Medicaid members 18–64 years old with diabetes in 2012 also had IDD. Comparing those with IDD to their non-IDD peers on receipt of all four diabetes care measures showed differences by state, but state rates of overall adherence were very low, ranging from 16.6% to 28.5% of the population. Conclusions Meta-analysis results identified specialist visits as a strong predictor of adults with diabetes and IDD receiving all four components of diabetes care. This important information should be considered in efforts to improve quality care for this population.

Adults with intellectual and developmental disabilities (IDD) are known to experience significant health disparities; however, few studies have described anti-hypertensive medication adherence in this population. Using administrative data from South Carolina from 2000–2014, we evaluated the odds of adherence to anti-hypertensive medication among a cohort of adults with IDD and hypertension. Approximately half (49.5%) of the study cohort were adherent to anti-hypertensive medication. Those who lived in a supervised residence, had a Medicaid waiver, and had more frequent contact with a primary care provider were more likely to be adherent. Organizations that serve people with IDD have an opportunity to increase adherence by educating these individuals, their family members, and caregivers about the importance of adherence to anti-hypertensive medication.

Purpose Studies have shown that children with muscular dystrophy are at increased risk for falls, however there is insufficient information about what predicts the first and subsequent events. The purpose of this study was to describe the experience of injury with emphasis on identifying risk factors for fall-related injuries. Methods We studied 269 boys with muscular dystrophy describing their injury experience and identifying risk and protective factors associated with 281 non-simultaneous injuries and 127 falls that resulted in Emergency Department visits and/or inpatient hospitalization during the period 1998-2014. We used a Cox model to estimate the predictors of an initial fall and a zero-inflated Poisson model to identify the predictors for the number of falls. Results Falls accounted for the greatest number of injury occurrences; The most frequent injury type was contusion. The factors that were protective for falls were steroid use, wheelchair use, or having a heart condition. Baseline age was negatively associated with the risk of having any fall, but not significantly related to subsequent falls. Conclusion Wheelchair use and heart conditions associated with reduced risk of falls likely reflects decreased mobility. Clinicians should help families identify factors associated with falls among those who remain ambulatory.

Background: Knowledge of fecundity and infertility in women with a disability (WWD) is limited. This study aims to compare the fecundity and infertility experiences of women with a self-id...

Women with spinal cord injury (SCI) may face barriers that result in disparities in receipt of recommended mammography and Papanicolaou testing.South Carolina.South Carolina women with SCI were identified using International Classification of Diseases codes in 2000-2010 Medicaid and Medicare billing data.Receipt of mammography and Pap testing was determined using procedure billing codes. Partial proportional odds models were estimated to examine the association between SCI and adherence with screening recommendations from the United States Preventive Services Task Force. Each individual's screening experience was classified as full adherence, partial adherence, or no screening.The cohort for mammography consisted of 3,173 women with SCI and 6,433 comparison women without SCI. The cohort for Pap testing consisted 5,025 women with SCI and 9,538 comparison women. Women with SCI were less likely to have full adherence with mammography recommendations (aOR = 0.69, 95% CI 0.64, 0.76) and Pap test recommendations (aOR = 0.53, 95% CI 0.49, 0.57). They were more likely to have no mammography screening (aOR = 1.44, 95% CI 1.33, 1.57) and no Pap testing (aOR = 1.89, 95% CI 1.77, 2.03) than women without SCI.Using longitudinal data with multiple outcome levels, women with SCI were less likely to be fully adherent with receipt of recommended breast and cervical cancer screenings and more likely to have no screenings during the eligible years when compared to women without SCI.

The broad categories of blindness, low vision, age-related macular degeneration, cataract, and glaucoma, as well as other visual impairments impact 3 to 4% of the U.S. population (Burrows, Hora, Li, & Saaddine, 2011; National Eye Institute, 2014). These impairments become more prevalent with age; an estimated 3% of all persons over the age of 40 are either blind or severely visually impaired (Centers for Disease Control and Prevention, 2014b). These figures do not include the substantial number of persons with the increased potential to develop vision problems because of already diagnosed diabetic retinopathy (2.5% of those over age 18), cataract (16% of those over the age of 40), or glaucoma (2% of those over the age of 40) (Centers for Disease Control and Prevention, 2014b). Visual impairment is associated with poorer quality of life, including lower perceived health, higher levels of functional limitations, higher rates of depression and anxiety, and higher ratings of emotional distress (Brody et al., 2001; Evans, Fletcher, & Wormald, 2007; Laforge, Spector, & Sternberg, 1992; Okoro et al., 2011; Scott, Schein, Feuer, Folstein, & Bandeen-Roche, 2001; Scott, Smiddy, Schiffman, Feuer, & Pappas, 1999; Slakter & Stur, 2005; Soubrane, Cruess, Lotery, et al., 2007; ZambelliWeiner, Crews, & Friedman, 2012). For people with such an impairment, there is also a link with greater dependence upon others, social isolation, and reduced access to health care (Reichard, Stolzle, & Fox, 2011; Smith, 2008; Varma, Wu, Chong, Azen, & Hays, 2006). There is a growing body of literature describing the receipt of clinical preventive services for individuals with disabilities, compared to those without. Results have been inconsistent in terms of whether people with one or more disability may be more or less likely to receive recommended preventive services (Andresen et al., 2013; Chevarley, Thierry, Gill, Ryerson, & Nosek, 2006; HornerJohnson, Dobbertin, Andresen, & Iezzoni, 2014; Smeltzer, 2006; Tezzoni, McCarthy, Davis, Harris-David, & O'Day, 2001). For example, one study using data from the Medical Expenditure Panel Survey (MEPS) found that women with disabilities were less likely to receive mammography and Pap testing but more likely to receive influenza immunization, cholesterol screening, and colorectal cancer screening (Wei, Findley, & Sambamoorthi, 2006). One possible explanation for these disparate findings across studies is that there are differences in study design, including who is included in the sample (for example, women only), or how a disability is identified (self-report, secondary data, or enrollment in disability services) or classified (functional status, medical diagnosis, level of severity) (Congdon, Friedman, & Lietman, 2003; Peterson-Besse et al., 2014). Regardless, there is evidence that patients with multiple chronic conditions require additional intervention for obtaining recommended services (Goodman et al., 2014). It is possible that people with visual impairments may be at risk of not receiving recommended preventive services at the same rate as the general population. There have been few studies investigating the receipt of preventive services specifically in people with visual impairments. A recent study, also using MEPS data, compared receipt of preventive services across different categories of disability, categorized according to self-reported functional limitation, and found that people with visual impairments were most likely (compared to those with hearing, physical, or cognitive impairments) to have no usual source of medical care, to have foregone medical or dental treatment, to have received no dental care within the prior year, and to have never had screening for colorectal cancer. People with vision impairments did not appear to be less likely than those with other types of disability to receive screening for breast or cervical cancer (Horner-Johnson et al. …

Background This pilot study was conducted to determine if we could identify intrauterine exposure to metals in meconium, as a measure of exposure for mother-child pairs living in proximity to a mining operation. Objectives We used meconium as a means to measure metal exposure in utero. We set out to quantify the exposure to selected metals that are currently being mined and also are found in the Superfund site in Butte, Montana, and to compare it to that of Columbia, South Carolina, US, where mining is not occurring. Methods This cross-sectional study was conducted between May and November 2018. We received Institutional Review Board approval and we consented women following the birth of their newborns, and collected meconium within 24 h of birth, without any identifiers. Each laboratory used the same protocol for collection, transport, and storage; and the same laboratory protocol was used for the analysis of all samples. Samples were digested using standard acid/peroxide digestion methods and measured by inductively coupled plasma mass spectroscopy. Results We collected meconium specimens from 17 infants in Columbia, South Carolina and 15 infants in Butte, Montana. The concentrations found in Columbia were in the low μg kg−1 range (or less) and were similar to the low levels that have been identified in other studies of meconium. The magnitude of the differences in concentrations found in Butte compared to Columbia was 1792 times higher for Cu, 1650 times higher for Mn, and 1883 times higher for Zn. Conclusion Using meconium to measure exposure of newborns has implications for risk assessment in a mining-exposed population. This approach was inexpensive and thorough. The magnitude of the differences in the metal levels identified from the two study sites suggests there is an urgent need for further research to learn if there are health consequences to these highly exposed infants.

Two counties in Montana, Deer Lodge and Silver Bow (DL/SB), have two Superfund sites, as well as an active copper and molybdenum mine in SB. The population living in proximity to these sites are exposed to additional metals and some have been shown to be neurotoxic, especially for children; thus, this study focused on the incidence of brain and other nervous system cancers. The Montana Central Tumor Registry data was used to identify the cases in DL/SB and the remaining 54 counties of Montana (comparison group). After controlling for sex, cancer stage, and year of diagnosis, we found an incidence rate ratio for DL/SB versus comparison group of 6.28 (95% CI: 2.32–17.02) for children ages birth to 4 years, and 3.95 (95% CI: 1.66–9.38) for adults age 30–34 years. The high incidence rate of the brain cancer in the two age groups requires public health action.

The health effects of living in proximity to Superfund sites with ongoing remediation were evaluated for residents of two contiguous Montana counties, Deer Lodge and Silver Bow. Deer Lodge and Silver Bow are home to the Anaconda Smelter and Silver Bow Creek/Butte Area Superfund sites, respectively. Established by the Environmental Protection Agency in 1983, both sites have had ongoing remediation for decades. Employing county level death certificate data obtained from the Centers for Disease Control and Prevention WONDER site, sex and age-adjusted standardized mortality ratios (SMRs) for composite targeted causes of death were calculated using observed versus expected mortality for both counties, and compared to the expected mortality from the remaining Montana counties. Cancers, cerebro- and cardiovascular diseases (CCVD), and organ failure were elevated for the two counties during the study period, 2000–2016, with SMRs of 1.19 (95% CI 1.10, 1.29); 1.36 (95% CI 1.29, 1.43); and 1.24 (95% CI 1.10, 1.38), respectively. Neurological conditions were not elevated for the two counties (SMR = 1.01; 95% CI 0.89, 1.14). Time trend analyses performed using Cox regression models indicate that deaths from cancers (HR = 0.97; p = 0.0004), CCVDs (HR = 0.95; p ≤ 0.0001), and neurological conditions (HR = 0.97; p = 0.01) decreased over the study period. While the ecological approach applied limits the interpretation of our results, our study suggests that while mortality is elevated, it is also decreasing over time for these two Superfund sites.