Access to general health care among people with disabilities in Latin America and the Caribbean: a systematic review of quantitative research

In Latin America and the Caribbean (LAC), there are 85 million people with disabilities (PwD). They often experience barriers accessing healthcare and die, on average, 10-20 years earlier than those without disabilities. This study aimed to systematically review the quantitative literature on access to general healthcare among PwD, compared to those without disabilities, in LAC. A systematic review and narrative synthesis was conducted. We searched in EMBASE, MEDLINE, LILACS, MedCarib, PsycINFO, SciELO, CINAHL, and Web of Science. Eligible articles were peer-reviewed, published between January 2000 and April 2023, and compared healthcare access (utilization, coverage, quality, affordability) between PwD and without disabilities in LAC. The search retrieved 16,538 records and 30 studies were included, most of which had a medium or high risk of bias (n = 23; 76%). Overall, the studies indicated that PwD use healthcare services more than those without disabilities. Some evidence indicated that women with disabilities were less likely to have received cancer screening. Limited evidence showed that health services affordability and quality were lower among PwD. In LAC, PwD appear to experience health inequities, although large gaps exist in the current evidence. Harmonization of disability and health access data collection is urgently needed to address this issue.

HIV knowledge and access to testing for people with and without disabilities in low- and middle-income countries: evidence from 37 Multiple Indicator Cluster Surveys

INTRODUCTION

Disability and HIV are intricately linked, as people with disabilities are at higher risk of contracting HIV, and living with HIV can lead to impairments and disability. Despite this well-established relationship, there remains limited internationally comparable evidence on HIV knowledge and access to testing for people with disabilities.

METHODS

We used cross-sectional data from 37 Multiple Indicator Cluster Surveys. Surveys were from six UNICEF regions, including East Asia and Pacific (n = 6), East and Central Asia (n = 7), Latin America and the Caribbean (n = 6), Middle East and North Africa (n = 4), South Asia (n = 2) and sub-Saharan Africa (n = 12). A total of 513,252 people were eligible for inclusion, including 24,695 (4.8%) people with disabilities. We examined risk ratios and 95% confidence intervals for key indicators on HIV knowledge and access to testing for people with disabilities by sex and country. We also conducted a meta-analysis to get a pooled estimate for each sex and indicator.

RESULTS

Men and women with disabilities were less likely to have comprehensive knowledge about HIV prevention (aRR: 0.74 [0.67, 0.81] and 0.75 [0.69, 0.83], respectively) and to know of a place to be tested for HIV (aRR: 0.95 [0.92, 0.99] and 0.94 [0.92, 0.97], respectively) compared to men and women without disabilities. Women with disabilities were also less likely to know how to prevent mother-to-child transmission (aRR: 0.87 [0.81, 0.93]) and ever have been tested for HIV (aRR: 0.90 [0.85, 0.94]).

CONCLUSIONS

Men and women with disabilities have lower overall HIV knowledge and in particular women with disabilities also indicate lower testing rates. Governments must include people with disabilities in HIV programmes by improving disability-inclusion and accessibility to HIV-related information, education and healthcare services.

Evaluation of a disability-inclusive ultra-poor graduation programme in Uganda: study protocol for a cluster-randomised controlled trial with process evaluation

BACKGROUND

There is little evidence on how to support ultra-poor people with disabilities to adopt sustainable livelihoods. The Disability-Inclusive Graduation (DIG) programme targets ultra-poor people with disabilities and/or women living in rural Uganda. The programme is an adaptation of an ultra-poor graduation model that has been shown to be effective in many contexts but not evaluated for people with disabilities.

METHODS

The DIG programme works with project participants over a period of 18 months. Participants receive unconditional cash transfers for 6 months, training, access to savings-and-loans groups, and a capital asset that forms the basis of their new livelihood. The programme is also adapted to address specific barriers that people with disabilities face. Eligible households are clustered by geographical proximity in order to deliver the intervention. Eligibility is based on household screening to identify the 'ultra-poor' based on proxy means testing-both households with and without people with disabilities are included in the programme. Clusters are randomly selected prior to implementation, resulting in 96 intervention and 89 control clusters. The primary outcome of the trial is per-capita household consumption. Before the start of the intervention, a baseline household survey is conducted (November 2020) among project participants and those not offered the programme, a similar endline survey is conducted with participants with disabilities at the end of programme implementation in July 2022, and a second endline survey for all participants in October 2023. These activities are complemented by a process evaluation to understand DIG programme implementation, mechanisms, and context using complementary qualitative and quantitative methods. Ethical approval for the research has been received from Mildmay Uganda Research Ethics Committee and London School of Hygiene and Tropical Medicine.

DISCUSSION

DIG is a promising intervention to evaluate for people with disabilities, adapted to be disability inclusive across programme components through extensive consultations and collaboration, and has proven efficacy at reducing poverty in other marginalised groups. However, evaluating a well-evidenced intervention among a new target group poses ethical considerations.

TRIAL REGISTRATION

Registry for International Development Impact Evaluations, RIDIE-STUDY-ID-626008898983a (20/04/22). ISRCTN registry, ISRCTN78592382 . Retrospectively registered on 17/08/2023.

Improving access to family planning for women with disabilities in Kaduna city, Nigeria: study protocol for a pragmatic cluster-randomized controlled trial with integrated process evaluation

BACKGROUND

Globally, women with disabilities are less likely to have access to family planning services compared to their peers without disabilities. However, evidence of effective interventions for promoting their sexual and reproductive health and rights remains limited, particularly in low- and middle-income settings. To help address disparities, an inclusive sexual and reproductive health project was developed to increase access to modern contraceptive methods and reduce unmet need for family planning for women of reproductive age with disabilities in Kaduna city, Nigeria. The project uses demand-side, supply-side and contextual interventions, with an adaptive management approach. This protocol presents a study to evaluate the project's impact.

METHODS

A pragmatic cluster-randomized controlled trial design with surveys at baseline and endline will be used to evaluate interventions delivered for at least 1 year at health facility and community levels in comparison to 'standard' state provision of family planning services, in the context of state-wide and national broadcast media and advocacy. Randomization will be conducted based on the health facility catchment area, with 19 clusters in the intervention arm and 18 in the control arm. The primary outcome measure will be access to family planning. It was calculated that at least 950 women aged 18 to 49 years with disabilities (475 in each arm) will be recruited to detect a 50% increase in access compared to the control arm. For each woman with disabilities enrolled, a neighbouring woman without disabilities in the same cluster and age group will be recruited to assess whether the intervention has a specific effect amongst women with disabilities. The trial will be complemented by an integrated process evaluation. Ethical approval for the study has been given by the National Health Research Ethics Committee of Nigeria and London School of Hygiene & Tropical Medicine.

DISCUSSION

Defining access to services is complex, as it is not a single variable that can be measured directly and need for family planning is subjectively defined. Consequently, we have conceptualized 'access to family planning' based on a composite of beliefs about using services if needed.

TRIAL REGISTRATION

ISRCTN registry ISRCTN12671153. Retrospectively registered on 17/04/2023.

Impact of a disability-targeted microentrepreneurship programme in Kenya: study protocol for a randomised controlled trial of the InBusiness programme

BACKGROUND

There is a lack of evidence on the effectiveness of livelihood interventions amongst people with disabilities. In many countries, self-employment or microentrepreneurship is a dominant source of livelihoods for people with disabilities and their caregivers. However, this group may face heightened barriers to successful microentrepreneurship, including discrimination, exclusion from training or inaccessible transport, infrastructure and communication systems. The InBusiness programme is a livelihoods programme targeted to microentrepeneurs with disabilities or their caregivers delivered by a consortium of non-governmental organisations. The programme focuses on improving the skills, practices and opportunities of microentrepreneurs while linking them with procurement opportunities with private and public institutions. This protocol describes a randomised controlled trial of the InBusiness programme in eight counties of Kenya.

METHODS

The randomised controlled trial will involve 495 microentrepreneurs who have been verified as eligible for InBusiness by programme implementers. Individuals will be randomised within counties, either being invited to enrol in InBusiness in March 2023 or allocated to a control group. Participants in the control arm will receive information about compliance with business-related laws and available social protection programmes. The trial will assess the impact of InBusiness on household consumption and individual economic empowerment (primary outcomes) as well as food security, well-being, social attitudes, unmet need for disability-related services and microenterprise profits (secondary outcomes). Baseline was conducted in March 2023, and follow-up will be 24 months from baseline (12 months from completion of the programme). Analysis will be through intention to treat. A process evaluation will explore fidelity, mechanisms of impact and the role of context, and complementary qualitative research with participants will be used to triangulate findings across the trial.

DISCUSSION

This study will provide evidence on the impact of a large-scale disability-targeted livelihood programme on household and individual financial security and well-being. Currently, there is a lack of evidence on the effectiveness of livelihood programmes amongst people with disabilities, and so this trial can help inform the design and delivery of InBusiness as well as other livelihood programmes targeted to people with disabilities.

TRIAL REGISTRATION

ClinicalTrials.gov ISRCTN13693137. Registered on April 24, 2023.

Impacts of the COVID-19 pandemic on access to healthcare among people with disabilities: evidence from six low- and middle-income countries

BACKGROUND

The pandemic has placed considerable strain on health systems, especially in low- and middle-income countries (LMICs), leading to reductions in the availability of routine health services. Emerging evidence suggests that people with disabilities have encountered marked challenges in accessing healthcare services and supports in the context of the pandemic. Further research is needed to explore specific barriers to accessing healthcare during the pandemic, and any strategies that promoted continued access to health services in LMICs where the vast majority of people with disabilities live.

METHODS

Qualitative in-depth interviews were conducted with persons with disabilities in Ghana, Zimbabwe, Viet Nam, Türkiye (Syrian refugees), Bangladesh, and India as part of a larger project exploring the experiences of people with disabilities during the COVID-19 pandemic and their inclusion in government response activities. Data were analysed using thematic analysis.

RESULTS

This research found that people with disabilities in six countries - representing a diverse geographic spread, with different health systems and COVID-19 responses - all experienced additional difficulties accessing healthcare during the pandemic. Key barriers to accessing healthcare during the pandemic included changes in availability of services due to systems restructuring, difficulty affording care due to the economic impacts of the pandemic, fear of contracting coronavirus, and a lack of human support to enable care-seeking.

CONCLUSION

These barriers ultimately led to decreased utilisation of services which, in turn, negatively impacted their health and wellbeing. However, we also found that certain factors, including active and engaged Organisations of Persons with Disabilities (OPDs) and Non-Governmental Organizations (NGOs) played a role in reducing some of the impact of pandemic-related healthcare access barriers.

"If he has education, there will not be any problem": Factors affecting access to education for children with disabilities in Tamil Nadu, India

This study explores factors affecting children with disabilities' enrolment and experience in school in Tamil Nadu, India. In-depth interviews were conducted with 40 caregivers and 20 children with disabilities. Children were purposively selected to maximise heterogeneity by gender, impairment type and enrolment status, using data from a previous survey. Overall, caregivers recognised the importance of school for their children's future livelihoods or at least as a means of socialisation. However, some questioned the value of school, particularly for children with intellectual or sensory impairments. Other barriers to school enrolment and regular attendance included poor availability and affordability of transport, safety concerns or school staffs' concerns about children's behaviour being disruptive. While in school, many children's learning was limited by the lack of teacher training and resources for inclusive education. Poor physical accessibility of schools, as well as negative or overly protective attitudes from teachers and peers, often limited children's social inclusion while in school. These findings carry implications for the implementation of inclusive education in India and elsewhere, as they indicate that despite legislative progress, significant gaps in attendance, learning and social inclusion remain for children with disabilities, which may not be captured in traditional metrics on education access.

Disability and the achievement of Universal Health Coverage in the Maldives

OBJECTIVE

To assess access to general and disability-related health care among people with disabilities in the Maldives.

METHODS

This study uses data from a case-control study (n = 711) nested within a population-based, nationally representative survey to compare health status and access to general healthcare amongst people with and without disabilities. Cases and controls were matched by gender, location and age. Unmet need for disability-related healthcare is also assessed. Multivariate regression was used for comparisons between people with and without disabilities.

RESULTS

People with disabilities had poorer levels of health compared to people without disabilities, including poorer self-rated health, increased likelihood of having a chronic condition and of having had a serious health event in the previous 12 months. Although most people with and without disabilities sought care when needed, people with disabilities were much more likely to report difficulties when routinely accessing healthcare services compared to people without disabilities. Additionally, 24% of people with disabilities reported an unmet need for disability-related healthcare, which was highest amongst people with hearing, communication and cognitive difficulties, as well as amongst older adults and people living in the lowest income per capita quartile. Median healthcare spending in the past month was modest for people with and without disabilities. However, people with disabilities appear to have high episodic healthcare costs, such as for disability-related healthcare and when experiencing a serious health event.

CONCLUSIONS

This study found evidence that people with disabilities experience unmet needs for both disability-related and general healthcare. There is therefore evidence that people with disabilities in the Maldives are falling behind in core components relevant to UHC: availability of all services needed, and quality and affordability of healthcare.

Impact of a disability-targeted livelihoods programme in Bangladesh: study protocol for a cluster randomised controlled trial of STAR

INTRODUCTION

There is little evidence on the impact of livelihood interventions amongst people with disabilities. Effective programmes are critical for reducing the heightened risk of poverty and unemployment facing persons with disabilities. STAR+ is a skills development and job placement programme targeted to out-of-school youth with disabilities (ages 14-35) living in poverty. It is a disability-targeted adaptation to an existing, effective intervention (STAR), which has been designed to address barriers to decent work for people with disabilities. This protocol describes the design of a cluster randomised controlled trial of STAR+ in 39 of the 64 districts of Bangladesh.

METHODS

BRAC has identified 1500 youth with disabilities eligible for STAR+ across its 91 branch offices (typically a geographical areas covering about 8 km radius from local BRAC office) catchment areas (clusters). BRAC has limited funding to deliver STAR+ and so 45 of the 91 branches have been randomly allocated to implement STAR+ (intervention arm). The remaining 46 branches will not deliver STAR+ at this time (control arm). Participants in the control-arm will receive usual care, meaning they are free to enrol in any other livelihood programmes run by BRAC or other organisations including standard STAR (being run in 15 control branches). The cRCT will assess the impact of STAR+ after 12 months on employment status and earnings (primary outcomes), as well as poverty, participation and quality of life (secondary outcomes). Analysis will be through intention-to-treat, with a random mixed effect at cluster level to account for the clustered design. Complementary qualitative research with participants will be conducted to triangulate findings of the cRCT, and a process evaluation will assess implementation fidelity, mechanisms of impact and the role of contextual factors in shaping variations in outcomes.

DISCUSSION

This trial will provide evidence on the impact of a large-scale, disability-targeted intervention. Knowledge on the effectiveness of programmes is critical for informing policy and programming to address poverty and marginalisation amongst this group. Currently, there is little robust data on the effectiveness of livelihood programmes amongst people with disabilities, and so this trial will fill an important evidence gap.

TRIAL REGISTRATION

This study has been registered with the Registry for International Development Impact Evaluations, (RIDIE Study ID: 6238114b481ad ) on February 25, 2022, and the ISRCTN Registry (ID: ISRCTN15742977 ).

Effectiveness of interventions for improving livelihood outcomes for people with disabilities in low- and middle-income countries: A systematic review

BACKGROUND

People with disabilities-more than a billion people worldwide-are frequently excluded from livelihood opportunities, including employment, social protection, and access to finance. Interventions are therefore needed to improve livelihood outcomes for people with disabilities, such as improving access to financial capital (e.g., social protection), human capital (e.g., health and education/training), social capital (e.g., support) or physical capital (e.g., accessible buildings). However, evidence is lacking as to which approaches should be promoted.

OBJECTIVES

This review examines whether interventions for people with disabilities result in improved livelihood outcomes in low- and middle-income countries (LMIC): acquisition of skills for the workplace, access to the job market, employment in formal and informal sectors, income and earnings from work, access to financial services such as grants and loans, and/or access to social protection programmes.

SEARCH METHODS

The search, up to date as of February 2020, comprised of: (1)an electronic search of databases (MEDLINE, Embase, PsychINFO, CAB Global Health, ERIC, PubMED and CINAHL),(2)screening of all included studies in the instances where reviews were identified,(3)screening reference lists and citations of identified recent papers and reviews, and(4)An electronic search of a range of organisational websites and databases (including ILO, R4D, UNESCO and WHO) using the keyword search for unpublished grey to ensure maximum coverage of unpublished literature, and reduce the potential for publication bias.

SELECTION CRITERIA

We included all studies which reported on impact evaluations of interventions to improve livelihood outcomes for people with disabilities in LMIC.

DATA COLLECTION AND ANALYSIS

We used review management software EPPI Reviewer to screen the search results. A total of 10 studies were identified as meeting the inclusion criteria. We searched for errata for our included publications and found none. Two review authors independently extracted the data from each study report, including for the confidence in study findings appraisal. Data and information were extracted regarding available characteristics of participants, intervention characteristics and control conditions, research design, sample size, risk of bias and outcomes, and results. We found that it was not possible to conduct a meta-analysis, and generate pooled results or compare effect sizes, given the diversity of designs, methodologies, measures, and rigour across studies in this area. As such, we presented out findings narratively.

MAIN RESULTS

Only one of the nine interventions targeted children with disabilities alone, and only two included a mix of age groups (children and adults with disabilities. Most of the interventions targeted adults with disabilities only. Most single impairment group interventions targeted people with physical impairments alone. The research designs of the studies included one randomised controlled trial, one quasi-randomised controlled trial (a randomised, posttest only study using propensity score matching (PSM), one case-control study with PSM, four uncontrolled before and after studies, and three posttest only studies. Our confidence in the overall findings is low to medium on the basis of our appraisal of the studies. Two studies scored medium using our assessment tool, with the remaining eight scoring low on one or more item. All the included studies reported positive impacts on livelihoods outcomes. However, outcomes varied substantially by study, as did the methods used to establish intervention impact, and the quality and reporting of findings.

AUTHORS' CONCLUSIONS

The findings of this review suggest that it may be possible for a variety of programming approaches to improve livelihood outcomes of people with disabilities in LMIC. However, given low confidence in study findings related to methodological limitations in all the included studies, positive findings must be interpreted with caution. Additional rigorous evaluations of livelihoods interventions for people with disabilities in LMIC are needed.

Childhood disability in rural Niger: a population-based assessment using the Key Informant Method

Background

Data on childhood disability is essential for planning health, education and other services. However, information is lacking in many low- and middle-income countries, including Niger. This study uses the Key Informant Method, an innovative and cost-effective strategy for generating population-based estimates of childhood disability, to estimate the prevalence and causes of moderate/severe impairments and disabling health conditions in children of school-going age (7–16 years) in the Kollo department of western Niger.

Methods

Community-based key informants were trained to identify children who were suspected of having the impairment types/health conditions included in this study. Children identified by key informants were visited by paediatricians and underwent an assessment for moderate/severe vision, hearing, physical and intellectual impairments, as well as epilepsy, albinism and emotional distress.

Results

Two thousand, five hundred sixty-one children were identified by key informants, of whom 2191 were visited by paediatricians (response rate = 85.6%). Overall, 597 children were determined to have an impairment/health condition, giving a prevalence of disability of 11.4 per 1000 children (10.6- 12.2). Intellectual impairment was most common (6.5 per 1000), followed by physical (4.9 per 1000) and hearing impairments (4.7 per 1000). Many children had never sought medical attention for their impairment/health condition, with health seeking ranging from 40.0% of children with visual impairment to 67.2% for children with physical impairments.

Conclusion

The Key Informant Method enabled the identification of a large number of children with disabling impairments and health conditions in rural Niger, many of whom have unmet needs for health and other services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03226-0.

"The weather is not good": exploring the menstrual health experiences of menstruators with and without disabilities in Vanuatu

Background

Menstrual health is essential for gender equality and achieving the sustainable development goals. Though currently lacking, understanding and addressing menstrual health and social related inequalities requires comparison of experiences between menstruators with and without disabilities.

Methods

We completed a mixed-methods population-based study of water, sanitation and hygiene, disability and menstrual health in TORBA and SANMA Provinces, Vanuatu. Methods included a census, nested case-control study, in-depth interviews (IDIs), focus group discussions (FGDs), PhotoVoice and structured observations. We undertook a population census of 11,000+ households and recruited 164 menstruators with and 169 without disabilities (aged 10-45) into a nested case-control study. 20 menstruators across both groups were selected for the qualitative component.

Findings

Menstruators with disabilities were five times (adjusted Odds Ratio [aOR] 5.5, 95% Confidence Interval 1.8 - 16.5) more likely to use different bathing facilities to others in the household, nearly twice as likely (1.8, 1.1 - 3.1) to miss social activities, and three times (3.0, 1.6 - 5.7) more likely to eat alone during menstruation. Menstrual restrictions were widespread for all, but collecting water and managing menstrual materials was harder for menstruators with disabilities, particularly those requiring caregivers' support. These factors negatively impacted menstruators with disabilities' comfort, safety and hygiene, yet they reported less interference of menstruation on participation.

Interpretation

Negative factors affecting all menstruators disproportionately impact those with disabilities, compounding existing inequalities. Menstruators with disabilities may have reported less interference because they are accustomed to greater participation restrictions than others.

Funding

Australian Government's Water for Women fund and public donations.

Experiences and Perceptions of Ophthalmic Simulation-Based Surgical Education in Sub-Saharan Africa

BACKGROUND

Simulation-based surgical education (SBSE) can positively impact trainee surgical competence. However, a detailed qualitative study of the role of simulation in ophthalmic surgical education has not previously been conducted.

OBJECTIVE

To explore the experiences of trainee ophthalmologists and ophthalmic surgeon educators' use of simulation, and the perceived challenges in surgical training.

METHODS

A multi-center, multi-country qualitative study was conducted between October 2017 and August 2020. Trainee ophthalmologists from six training centers in sub-Saharan Africa (SSA) (in Kenya, Uganda, Tanzania, Zimbabwe and South Africa) participated in semi-structured interviews, before and after an intense simulation training course in intraocular surgery. Semi-structured interviews were also conducted with experienced ophthalmic surgeon educators. Interviews were anonymized, recorded, transcribed and coded. An inductive, bottom-up, constant comparative method was used for thematic analysis.

RESULTS

Twenty-seven trainee ophthalmologists and 12 ophthalmic surgeon educators were included in the study and interviewed. The benefits and challenges of conventional surgical teaching, attributes of surgical educators, value of simulation in training and barriers to implementing ophthalmic surgical simulation were identified as major themes. Almost all trainees and trainers reported patient safety, a calm environment, the possibility of repetitive practice, and facilitation of reflective learning as beneficial aspects of ophthalmic SBSE. Perceived barriers in surgical training included a lack of surgical cases, poor supervision and limited simulation facilities.

CONCLUSIONS

Simulation is perceived as an important and valuable model for education amongst trainees and ophthalmic surgeon educators in SSA. Advocating for the expansion and integration of educationally robust simulation surgical skills centers may improve the delivery of ophthalmic surgical education throughout SSA.

PROTOCOL: Effectiveness of interventions for improving livelihood outcomes for people with disabilities in low- and middle-income countries: A systematic review

The objectives of this review are to answer the following research questions: (1) What is the effect size of the effectiveness of interventions to improve livelihood outcomes for people with disabilities in low- and middle-income countries (LMICs), and what is the quality of the evidence base? (2) What works to improve livelihood outcomes for people with disabilities in LMICs? (3) Which interventions appear most effective for different categories of disability? (4) What are the barriers and facilitators to the improvement of livelihood outcomes to people with disabilities?

Interrogating and Reflecting on Disability Prevalence Data Collected Using the Washington Group Tools: Results from Population-Based Surveys in Cameroon, Guatemala, India, Maldives, Nepal, Turkey and Vanuatu

The Washington Group (WG) tools capture self-reported functional limitations, ranging from 6 domains in the Short Set (SS) to 11 in the Extended Set (ESF). Prevalence estimates can vary considerably on account of differences between modules and the different applications of them. We compare prevalence estimates by WG module, threshold, application and domain to explore these nuances and consider whether alternative combinations of questions may be valuable in reduced sets. We conducted secondary analyses of seven population-based surveys (analyses restricted to adults 18+) in Low- and Middle-Income Countries that used the WG tools. The prevalence estimates using the SS standard threshold (a lot of difficulty or higher in one or more domain) varied between 3.2% (95% Confidence Interval 2.9-3.6) in Vanuatu to 14.1% (12.2-16.2) in Turkey. The prevalence was higher using the ESF than the SS, and much higher (5 to 10-fold) using a wider threshold of "some" or greater difficulty. Two of the SS domains (communication, self-care) identified few additional individuals with functional limitations. An alternative SS replacing these domains with the psychosocial domains of anxiety and depression would identify more participants with functional limitations for the same number of items. The WG tools are valuable for collecting harmonised population data on disability. It is important that the impact on prevalence of use of different modules, thresholds and applications is recognised. An alternative SS may capture a greater proportion of people with functional domains without increasing the number of items.

Disability among Older People: Analysis of Data from Disability Surveys in Six Low- and Middle-Income Countries

This analysis of surveys from six low- and middle-income countries (LMICs) aimed to (i) estimate the prevalence of disability among older adults and (ii) compare experiences and participation in key life areas among older people with and without disabilities which may show vulnerability during the COVID-19 pandemic. Data were analysed from district-level or national surveys in Cameroon, Guatemala, Haiti, India, Nepal and the Maldives, which across the six databases totalled 3499 participants aged 60 years and above including 691 people with disabilities. Disability was common among adults 60+, ranging from 9.7% (8.0–11.8) in Nepal to 39.2% in India (95% CI 34.1–44.5%). Mobility was the most commonly reported functional difficulty. In each setting, older people with disabilities were significantly less likely to be working and reported greater participation restrictions and environmental barriers in key life areas compared to people in the same age categories without disabilities (p < 0.05). Disability is common in this population, and older people with disabilities may have greater difficulties participating in COVID-19 responses and have high economic vulnerabilities. It is imperative to prioritise the needs of older people with disabilities in the COVID-19 pandemic, including ensuring accessibility of both health services and the community in general.

Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries

The one billion people living with disabilities globally already face a heightened risk of poverty, which will likely be exacerbated by the COVID-19 pandemic unless interventions to address its economic impacts are disability-inclusive. This paper draws on the literature on disability, poverty and social protection in low- and middle-income countries to explore the pathways through which the current pandemic may increase the risk of poverty amongst people with disabilities, such as loss of income from disruptions to work, particularly in the informal sector, and higher future spending and productivity losses from disruptions to healthcare and other key services (e.g. rehabilitation, assistive devices). It also explores how social protection and other initiatives to mitigate the economic impacts of the pandemic should consider the needs of people with disabilities, with recommendations for disability-inclusive actions in the design and implementation of eligibility criteria and application procedures, as well as the delivery and content of benefits. Across recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability are key for improving access to and impact of economic responses amongst people with disabilities.

Association of anxiety and depression with physical and sensory functional difficulties in adults in five population-based surveys in low and middle-income countries

Background

The aim of this study was to assess the association between anxiety and depression with physical and sensory functional difficulties, among adults living in five low and middle-income countries (LMICs).

Methods and findings

A secondary data analysis was undertaken using population-based disability survey data from five LMICs, including two national surveys (Guatemala, Maldives) and 3 regional/district surveys (Nepal, India, Cameroon). 19,337 participants were sampled in total (range 1,617–7,604 in individual studies). Anxiety, depression, and physical and sensory functional difficulties were assessed using the Washington Group Extended Question Set on Functioning. Age-sex adjusted logistic regression analyses were undertaken to assess the association of anxiety and depression with hearing, visual or mobility functional difficulties.

The findings demonstrated an increased adjusted odds of severe depression and severe anxiety among adults with mobility, hearing and visual functional difficulties in all settings (with ORs ranging from 2.0 to 14.2) except for in relation to hearing loss in India, the Maldives and Cameroon, where no clear association was found. For all settings and types of functional difficulties, there was a stronger association with severe anxiety and depression than with moderate. Both India and Cameroon had higher reported prevalences of physical and sensory functional difficulties compared with Nepal and Guatemala, and weaker associations with anxiety and depression.

Conclusion

People with physical and sensory functional difficulties are more likely to report experiencing depression and anxiety. This evidence supports the need for ensuring a good awareness of mental health among those working with individuals with physical and sensory functional difficulties in LMICs. This implies that these practitioners must have the skills to identify anxiety and depression. Furthermore, mental health services must be available and accessible to patients with these conditions, which will likely require further programmatic scale-up in these LMIC settings.

Disability-inclusive COVID-19 response: What it is, why it is important and what we can learn from the United Kingdom's response

All too often, disabled people are left behind in emergencies, and this is a risk in the ongoing COVID-19 pandemic. This is an important issue, as globally there are approximately one billion people with disabilities. This number includes one in three people aged over 60, who are the group at greatest risk from COVID-19. The COVID-19 pandemic in the UK has highlighted additional difficulties that disabled people may face. Complying with preventative measures, like social distancing, can be challenging, particular for people who rely on carers. Disabled people may also be at greater risk of morbidity and mortality if they contract the virus, yet in danger of being de-prioritised for care. Many people with disabilities have ongoing healthcare needs, and these need to still be supported during the pandemic. Furthermore, people may become newly disabled as a result of the pandemic, and therefore require appropriate care. Good practice examples have emerged for meeting these challenges, such as guidance for healthcare professionals on treating people with dementia, but these need to be scaled up further and adapted for other settings. In conclusion, it is clear that a disability-inclusive COVID-19 response is needed, both in the UK and as the pandemic unfolds globally. This response will require inclusion of disability measures within data collection, consulting with disabled people, and tailoring responses to be appropriate for this group.

Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review

BACKGROUND

One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC.

METHODS

We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care.

RESULTS

The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments.

CONCLUSION

Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.

How to conduct good quality research on violence against children with disabilities: key ethical, measurement, and research principles

Background

Approximately one billion children experience violence every year. Violence against children is an urgent global public health concern and violation of children’s rights. It is also a risk factor for serious negative health and social outcomes and is therefore addressed within the Sustainable Development Goals (SDGs). Children with disabilities, who make up one in 20 children worldwide, are particularly vulnerable to violence although good quality data are lacking on causes and means of prevention of violence against children with disabilities. Key challenges exist in the measurement of disability and violence, which in part explains the dearth in evidence.

Improving research on violence against children with disabilities

This paper provides guidance on how to conduct good quality, ethical, and inclusive research on violence against children with disabilities, particularly in low-income settings. The lack of an international agreed ‘gold standard’ frustrates efforts to measure violence across settings and time. Careful consideration must be given to the design of survey tools. Qualitative and participatory research methods also offer important opportunities to explore children’s subjective understanding and experiences of violence. Challenges also exist around the measurement of disability. Disability may be measured by asking directly about disability, through self-reported functioning, or through the presence of impairments or health conditions. These approaches have strengths and limitations and should build on what children are able to do and include appropriate adaptations for specific impairments where necessary. Ethical research also requires adherence to ethical guidelines and approvals, obtaining informed consent, appropriate child protection responses, and careful consideration of interviewer-related issues including their selection, training, and welfare. Key methodological gaps remain - how to include children with severe communication challenges in research; how to respond in instances of weak child protection systems; designing sampling procedures that adequately represent children with disabilities in large-scale violence surveys; and determining how best to ask about violence safely in large-scale surveys and monitoring data. This paper further advocates for the dissemination of research results in inclusive and accessible formats.

Conclusion

With careful planning, challenges in collecting data on disability and violence can be overcome to generate evidence in this neglected area.

Reducing Physical Violence Toward Primary School Students With Disabilities

PURPOSE

We tested whether the Good School Toolkit reduces physical violence from peers and school staff toward students with and without disabilities in Ugandan primary schools.

METHODS

We conducted a cluster randomized controlled trial, with data collected via cross-sectional surveys in 2012 and 2014. Forty-two primary schools in Luwero District, Uganda, were randomly assigned to receive the Good School Toolkit for 18 months, or to a waitlisted control group. The primary outcome was past week physical violence from school staff, measured by primary 5, 6, and 7 students' (aged 11-14 years) self-reports using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional. Disability was assessed through the six Short Set Washington Group questions on functioning. Analyses were by intention to treat.

RESULTS

At endline, 53% of control group students with no functional difficulties reported violence from peers or school staff, versus 84% of students with a disability. Prevalence of past week physical violence from school staff was lower in intervention schools than in the control schools after the intervention, in students with no functional difficulties (adjusted odds ratio [aOR] = .41, 95% confidence interval [CI .26-.65]), students with some functional difficulties (aOR = .36, 95% CI .21-.63), and students with disabilities (aOR = .29, 95% CI .14-.59). The intervention also reduced violence from peers in young adolescents, with no evidence of a difference in effect by disability status.

CONCLUSIONS

The Good School Toolkit is an effective intervention to reduce violence perpetrated by peers and school staff against young adolescents with disabilities in Ugandan primary schools.

Poverty and disability in low- and middle-income countries: A systematic review

INTRODUCTION

Disability and poverty are believed to operate in a cycle, with each reinforcing the other. While agreement on the existence of a link is strong, robust empirical evidence substantiating and describing this potential association is lacking. Consequently, a systematic review was undertaken to explore the relationship between disability and economic poverty, with a focus on the situation in low and middle income countries (LMICs).

METHODS

Ten electronic databases were searched to retrieve studies of any epidemiological design, published between 1990-March 2016 with data comparing the level of poverty between people with and without disabilities in LMICs (World Bank classifications). Poverty was defined using economic measures (e.g. assets, income), while disability included both broad assessments (e.g. self-reported functional or activity limitations) and specific impairments/disorders. Data extracted included: measures of association between disability and poverty, population characteristics and study characteristics. Proportions of studies finding positive, negative, null or mixed associations between poverty and disability were then disaggregated by population and study characteristics.

RESULTS

From the 15,500 records retrieved and screened, 150 studies were included in the final sample. Almost half of included studies were conducted in China, India or Brazil (n = 70, 47%). Most studies were cross-sectional in design (n = 124, 83%), focussed on specific impairment types (n = 115, 77%) and used income as the measure for economic poverty (n = 82, 55%). 122 studies (81%) found evidence of a positive association between disability and a poverty marker. This relationship persisted when results were disaggregated by gender, measure of poverty used and impairment types. By country income group at the time of data collection, the proportion of country-level analyses with a positive association increased with the rising income level, with 59% of low-income, 67% of lower-middle and 72% of upper-middle income countries finding a positive relationship. By age group, the proportion of studies reporting a positive association between disability and poverty was lowest for older adults and highest for working-age adults (69% vs. 86%).

CONCLUSIONS

There is strong evidence for a link between disability and poverty in LMICs and an urgent need for further research and programmatic/policy action to break the cycle.

Childhood disability in Malawi: a population based assessment using the key informant method

Background

Epidemiological data on childhood disability are lacking in Low and Middle Income countries (LMICs) such as Malawi, hampering effective service planning and advocacy. The Key Informant Method (KIM) is an innovative, cost-effective method for generating population data on the prevalence and causes of impairment in children. The aim of this study was to use the Key Informant Method to estimate the prevalence of moderate/severe, hearing, vision and physical impairments, intellectual impairments and epilepsy in children in two districts in Malawi and to estimate the associated need for rehabilitation and other services.

Methods

Five hundred key informants (KIs) were trained to identify children in their communities who may have the impairment types included in this study. Identified children were invited to attend a screening camp where they underwent assessment by medical professionals for moderate/severe hearing, vision and physical impairments, intellectual impairments and epilepsy.

Results

Approximately 15,000 children were identified by KIs as potentially having an impairment of whom 7220 (48%) attended a screening camp. The estimated prevalence of impairments/epilepsy was 17.3/1000 children (95% CI: 16.9–17.7). Physical impairment (39%) was the commonest impairment type followed by hearing impairment (27%), intellectual impairment (26%), epilepsy (22%) and vision impairment (4%). Approximately 2100 children per million population could benefit from physiotherapy and occupational therapy and 300 per million are in need of a wheelchair. An estimated 1800 children per million population have hearing impairment caused by conditions that could be prevented or treated through basic primary ear care. Corneal opacity was the leading cause of vision impairment. Only 50% of children with suspected epilepsy were receiving medication. The majority (73%) of children were attending school, but attendance varied by impairment type and was lowest among children with multiple impairments (38%).

Conclusion

Using the KIM this study identified more than 2500 children with impairments in two districts of Malawi. As well as providing data on child disability, rehabilitation and referral service needs which can be used to plan and advocate for appropriate services and interventions, this method study also has an important capacity building and disability awareness raising component.

"If he could speak, he would be able to point out who does those things to him": Experiences of violence and access to child protection among children with disabilities in Uganda and Malawi

Introduction

There is growing evidence that children with disabilities face an increased risk of violence globally. While child protection mechanisms to prevent and respond to violence–including formal government systems and more informal programmes and activities run by local communities or NGOs–are slowly becoming operationalised in low- and- middle-income countries, little is known about whether existing mechanisms are disability-inclusive. The aim of this study is to provide a better understanding of children with disabilities’ experiences of violence and their access to available child protection mechanisms in low resource settings.

Methods

This study was conducted in Kasungu and Mulanje districts in Malawi and Kamuli district in Uganda between October-December 2015. In-depth, semi-structured interviews were conducted with approximately 20 purposively selected child/caregiver pairs in each country (43 pairs total). Interviews with key informants involved in the provision of child protection and disability support were also conducted. All interviews were recorded, transcribed and coded in NVivo. Thematic Analysis, complemented by constant comparison as described in Grounded Theory, was used to analyse the data.

Results

Almost all children with disabilities reported experiencing violence, with verbal abuse and bullying the most common forms. Very few of these children sought recourse through available child protection mechanisms. Some of the key factors impeding access to child protection for children with disabilities included: lack of local government disability-inclusive planning and budgeting; centralization of limited disability and social protection services; financial barriers to seeking and receiving care; and stigma and negative attitudes toward disabilities.

Conclusion

Children with disabilities face both high levels of violence and high barriers to accessing available child protection mechanisms. There is an urgent need to ensure that all efforts to prevent and respond to violence against children are more disability-inclusive. In addition, it may be appropriate to target child protection mechanisms specifically toward children with disabilities because of the different and intersecting vulnerabilities that they face.

The relationship between HIV and prevalence of disabilities in sub-Saharan Africa: systematic review (FA)

OBJECTIVE

To systematically review evidence on the prevalence and risk of disabilities among children and adults living with HIV in sub-Saharan Africa.

METHODS

Articles were identified from 1980 to June 2013 through searching seven electronic databases. Epidemiological studies conducted in sub-Saharan Africa that explored the association between HIV status and general disability or specific impairments, with or without an HIV-uninfected comparison group, were eligible for inclusion.

RESULTS

Of 12 867 records initially identified, 61 papers were deemed eligible for inclusion. The prevalence of disability was high across age groups, impairment types and study locations. Furthermore, 73% of studies using an HIV- comparator found significantly lower levels of functioning in people living with HIV (PLHIV). By disability type, the results were as follows: (i) for studies measuring physical impairments (n = 14), median prevalence of limitations in mobility and motor function among PLHIV was 25.0% (95% CI: 21.8-28.2%). Five of eight comparator studies found significantly reduced functioning among PLHIV; for arthritis, two of three studies which used an HIV- comparison group found significantly increased prevalence among PLHIV; (ii) for sensory impairment studies (n = 17), median prevalence of visual impairment was 11.2% (95%CI: 9.5-13.1%) and hearing impairment was 24.1% (95%CI: 19.2-29.0%) in PLHIV. Significantly increased prevalence among PLHIV was found in one of four (vision) and three of three studies (hearing) with comparators; (iii) for cognitive impairment in adults (n = 30), median prevalence for dementia was 25.3% (95% CI: 22.0-28.6%) and 40.9% (95% CI: 37.7-44.1%) for general cognitive impairment. Across all types of cognitive impairment, twelve of fourteen studies found a significant detrimental effect of HIV infection; (iv) for developmental delay in children with HIV (n = 20), median prevalence of motor delay was 67.7% (95% CI: 62.2-73.2%). All nine studies that included a comparator found a significant difference between PLHIV and controls; for cognitive development and global delay, a significant detrimental effect of HIV was found in five of six and one of two studies, respectively. In the nine cohort studies comparing vertically infected and uninfected children, eight showed a significant gap in development over time in children with HIV. Finally, fifteen of thirty-one (48%) studies found a statistically significant dose-response relationship between indicators of disease progression (CD4 or WHO stage) and disability.

CONCLUSIONS

HIV is widespread in sub-Saharan Africa and the evidence suggests that it is linked to disabilities, affecting a range of body structures and functions. More research is needed to better understand the implications of HIV-related disability for individuals, their families as well as those working in the fields of disability and HIV so that appropriate interventions can be developed.

Transdermal estradiol improves bone density when used as single agent therapy for prostate cancer

PURPOSE

Current androgen deprivation therapies for men with prostate cancer cause accelerated osteoporosis and a significant risk of osteoporotic fracture. We have recently shown that transdermal estradiol is an effective alternative for such patients. Here we report the impact of transdermal estradiol therapy on the bone mineral density of men with prostate cancer.

MATERIALS AND METHODS

A total of 20 patients with newly diagnosed locally advanced or metastatic prostate cancer were treated with transdermal estradiol patches. Bone mineral density of the lumbar spine and the proximal femur was measured with dual-energy x-ray absorptiometry, and correlated with computerized tomography and isotope bone scan findings at 6-month intervals.

RESULTS

In all measured regions bone mineral density increased with time. By 1 year mean bone mineral density +/- SEM had increased by 3.60% +/- 1.6% in the lumbar spine (p = 0.055), 2.19% +/- 1.03% in the femoral neck (p = 0.055), 3.76% +/- 1.35% in the Ward's region (p = 0.008) and 1.90% +/- 0.85% in the total hip (p = 0.031), respectively. Of 12 osteoporotic sites 4 had improvement based on World Health Organization grading. All other sites improved toward a better classification.

CONCLUSIONS

Transdermal estradiol protects against bone loss in men with prostate cancer and may improve bone density in those at risk for osteoporotic fracture.

Bone mineral density in a paediatric spinal muscular atrophy population

BACKGROUND/OBJECTIVE

Reduced bone mineral density is a feature of patients with reduced mobility. The aim of this study was to assess bone mineral density in children with spinal muscular atrophy (SMA) and to evaluate bone mineral density in relation to age and motor disability.

PATIENTS AND METHODS

We analysed bone mineral density measurements on twelve patients (4 with SMA type II, mean age 8.2 years [range 6.2 - 11.8]; 8 with SMA type III, mean age 11.8 years [range 5.5 - 20]). Dual-energy X-ray absorptiometry (DXA) was used to determine total body bone mineral density. The results were matched with published normative data for age and sex for a white Caucasian population.

RESULTS

The total body bone mineral density values were in the normal range in 10 out of the 12 SMA patients studied, all below the age of 17 (mean age 8.8 years [range 5.5 - 16.33]). Four of them had SMA II and six had had SMA III and were still ambulant. Total body bone mineral density was, however, below 2 SD in the remaining 2 patients aged 19.7 and 20 years, respectively. Both had SMA III but had lost independent ambulation for a period of 3.5 years.

CONCLUSION

Our results suggest that bone mineral density was surprisingly normal in most of the young SMA children studied. This is in contrast to what is reported in other conditions characterised by reduced mobility such as Duchenne muscular dystrophy. However, there was a tendency to decreasing bone mineral density with increasing age, not always related to the ability to walk, with the two eldest patients having the lowest values in spite of a relatively good mobility. These findings suggest that factors other than mobility are likely to have an effect on SMA bone mineral density.

The relationship between lean body mass and bone mineral content in paediatric health and disease

INTRODUCTION

The correct interpretation of DXA data is critical to the diagnosis and management of children with suspected bone disease. This study examines the various influences on bone mineral content (BMC), as measured by dual-energy X-ray absorptiometry (DXA).

MATERIALS AND METHODS

Six hundred and forty-six healthy school children and forty-three children with chronic diseases, aged 5-18 years, had their lumbar spine and whole body measured using a Lunar DPX-L DXA scanner.

RESULTS

Stepwise linear regression identified lean body mass (LBM) as the strongest single predictor of BMC in the lumbar spine and the total body. A significant gender difference was observed in the relationship between BMC and LBM with girls having significantly more bone per unit LBM from 9 years of age in the spine and 13 years of age in the total body. To investigate the relationship between LBM and BMC in children with chronic disease, a two-stage algorithm based upon calculation of Z scores from the normative data was applied. Stage 1 assessed LBM for height and stage 2 assessed BMC for LBM. Ten children with spinal muscular atrophy had a mean LBM for height Z score of -1.8(1.4) but a mean BMC for LBM Z score of 1.2(1.3) indicating their primary abnormality was reduced muscle mass (sarcopenia) with no evidence of osteopenia. In contrast, 21 children with osteogenesis imperfecta had a mean LBM for height Z score of 0.4(1.7) but a mean BMC for LBM Z score of -2.5(1.8) indicating normal LBM for size but significantly reduced BMC for LBM (i.e. osteopenia) confirming a primary bone abnormality. A third group consisting of 12 children with low trauma fractures demonstrated little evidence of sarcopenia [mean LBM for height Z score -1.1(2.1)] but significant osteopenia [mean BMC for LBM Z score -1.9(1.5)].

CONCLUSION

The results from this study demonstrate how the relationship between height and lean body mass, and lean body mass and bone mineral content can be a useful method of diagnosing osteoporosis in children and how the relationships can be used to identify if the primary abnormality is in muscle or bone.

Pilot trial of albuterol in spinal muscular atrophy

The aim of this pilot study was to evaluate the effect of albuterol in children with spinal muscular atrophy (SMA). Thirteen patients (five with SMA II and eight with SMA III) were given oral albuterol for 6 months. There was a significant increase in myometry, forced vital capacity, and lean body mass between the baseline and the 6-month assessments (p < 0.05). Albuterol may have a beneficial effect in patients with SMA without causing any significant adverse effects. Larger randomized, placebo-controlled trials are needed to confirm this observation.

Dual X-ray absorptiometry detects disease- and treatment-related alterations of bone density in prostate cancer patients

Metastatic bone disease is an important clinical problem which has proven difficult to study because of a lack of noninvasive investigative modalities. Here we show that dual-energy X-ray absorptiometry (DXA) scanning provides clinically useful information about the status of metastatic bone lesions in cancer patients undergoing palliative treatment. In the study group of 21 patients, a significant increase in metastatic bone mineral density (BMD) was confirmed in prostate (n = 14) relative to breast (n = 7) cancer patients. With respect to the prostate cancer cohort, further increases in lesional BMD were evident in all evaluable patients in whom biochemical progression occurred; conversely, lesional BMD declined in patients who had a partial response to therapy. BMD of uninvolved bone decreased with all types of androgen-deprivation therapy regardless of whether patients responded or relapsed. We conclude that BMD changes in both lesional and uninvolved bone are readily detectable in metastatic prostate cancer, and propose that DXA scanning represents a promising new approach to monitoring the natural history and therapeutic course of this disease.

Sibutramine is effective for weight loss and diabetic control in obesity with type 2 diabetes: a randomised, double-blind, placebo-controlled study

AIM

To assess the efficacy and tolerability of sibutramine 15 mg once daily as a weight reduction agent in overweight and obese patients (body mass index (b.m.i.) > 26 kg/m2) with type 2 diabetes when given with a customised, reduced-calorie diet, and to evaluate the influence of weight loss on diabetic control.

METHODS

Randomised, placebo-controlled, double-blind, parallel-group, 12-week study conducted at two hospital-based obesity/diabetes clinics. Patients were men and women aged 30-65 years, with b.m.i. > 26 kg/m2 and < or = 35 kg/m2 and treated or untreated type 2 diabetes diagnosed > or = 6 months previously. Each patient was given sibutramine 15 mg or placebo once daily and advised to follow a customised diet of 500 kcal/day less than the individual's energy needs. The principal measure of efficacy was change in body weight (b.w.). Additional efficacy measurements were changes in b.m.i., body composition as measured by dual-energy X-ray absorptiometry, and change in waist and hip measurements. Changes in diabetic control were assessed by blood glucose levels fasting and after a standard test meal, fasting insulin level, and glycosylated haemoglobin level. Adverse events (AEs) were monitored at each visit, and routine laboratory safety tests were done at 4-week intervals.

RESULTS

Ninety-one patients were randomised into the study, 44 to placebo and 47 to sibutramine 15 mg once daily. Eighty-three patients (91%) completed the study, 40 (91%) on placebo and 43 (91%) on sibutramine. Mean weight reduction from baseline was statistically significantly greater with sibutramine than with placebo at every measurement and at the end of the study (2.4 vs. 0.1 kg at week 12; p < 0.001; intent-to-treat). The proportion of patients who lost > 5% of their baseline b.w. was 19% in the sibutramine group and 0% in the placebo group (p < 0.001; 95% confidence interval: 9, 30). Patients receiving sibutramine lost significantly more fat mass compared with those receiving placebo, as a percentage (1.0% vs. 0.1%; p < 0.05) and in absolute terms (1.8 vs. 0.2 kg, p < 0.001). Loss of lean mass was not significantly different between the groups. Mean peak blood glucose concentration after a standard test meal decreased by 1.1 mmol/l in the sibutramine treatment group but increased by 0.5 mmol/l in the placebo group (p = 0.04; difference in means, 1.6, 95% confidence interval: -3.3, -0.1). Mean fasting blood glucose decreased by 0.3 mmol/l with sibutramine and increased by 1.4 mmol/l with placebo. Mean glycosylated haemoglobin levels decreased by 0.3% units with sibutramine treatment, and were unchanged with placebo. However, more sibutramine-treated patients (33%) than placebo-treated patients (5%) achieved decreases in glycosylated haemoglobin of 1% unit or more (p < 0.05). Sibutramine 15 mg was safe and well tolerated, and AEs were mostly mild or moderate in severity. No significant differences were found between treatment groups in blood pressure. No clinically significant conduction or rhythm abnormalities were observed on ECG.

CONCLUSIONS

Sibutramine 15 mg once daily with a customised, reduced-calorie diet significantly reduced weight compared with placebo in overweight and obese patients (b.m.i. > 26 kg/m2) with type 2 diabetes. Sibutramine was well tolerated, and significant improvement in diabetic control was seen in conjunction with weight reduction on sibutramine treatment.

Abdominal obesity, impaired nonesterified fatty acid suppression, and insulin-mediated glucose disposal are early metabolic abnormalities in families with premature myocardial infarction

British Indian Asian men aged <40 years have a twofold to threefold increased risk of death from coronary heart disease (CHD) compared with British whites. Epidemiological studies have suggested an association between glucose intolerance and hyperinsulinemia with premature CHD in Indian Asians. We tested the association of insulin action with myocardial infarction (MI) by using the hyperinsulinemic-euglycemic clamp in 17 MI patients: 8 Punjabi Sikhs (PSMIs), 9 British whites (BWMIs), and 17 control subjects (9 PSCs and 8 BWCs). Metabolic factors associated with insulin resistance were investigated in 51 MI patients (24 PSMIs and 27 BWMIs) and 53 control subjects (28 PSCs and 25 BWCs). Familial aggregation of defective insulin action was examined by studying five pedigrees of Sikh survivors of MI. Sikh survivors of premature MI demonstrated impaired insulin-mediated glucose uptake (P<.001) by use of the clamp technique and nonesterified fatty acid (NEFA) suppression (P<.05) by using both clamp techniques and the oral glucose tolerance test, as compared with Sikh control subjects. White patients had impaired insulin-mediated glucose uptake but normal NEFA suppression. Metabolic factors usually associated with insulin resistance, including increased 2-hour post-oral glucose tolerance test triglycerides, smaller low density lipoprotein particle size, and increased plasminogen activator inhibitor-1, were present in white (all P<.05) but surprisingly absent in Sikh (all P>.05) MI patients compared with respective ethnic control subjects. Fasting glucose and total cholesterol levels did not differ between patients and control subjects. Abdominal obesity, impaired NEFA suppression after oral glucose, and fasting hyperinsulinemia were present in Sikh MI patients and their nondiabetic first-degree relatives compared with Sikh control subjects. PS survivors of premature MI demonstrated impaired insulin-mediated glucose disposal and NEFA suppression compared with ethnic control subjects. BWMI patients showed abnormalities of carbohydrate, but not of NEFA, metabolism compared with white control subjects. Defects of insulin action manifested as abdominal obesity, impaired NEFA suppression, and fasting hyperinsulinemia are present in Sikh MI patients and their asymptomatic, nondiabetic, first-degree relatives. We suggest that these defects may be early metabolic markers that predict risk of premature MI among PSs.

Intranasal salmon calcitonin for the prevention and treatment of postmenopausal osteoporosis

In a randomized, double-blind, placebo-controlled trial, we have studied the effects of intranasal salmon calcitonin (SCT) on bone mineral density (BMD) and biochemical markers of bone turnover over a period of 2 years. Our study comprised 117 Caucasian postmenopausal women, otherwise healthy apart from reduced bone density. They received either intranasal synthetic SCT (200 IU either three times weekly or daily) or placebo. Compared with placebo, daily intranasal calcitonin resulted in no significant bone loss in the lumbar spine, as assessed by dual photon absorptiometry, over the 2-year study period (P < 0.02). In this group, women more than 5 years postmenopause, with the lowest baseline bone mass, showed the greatest response to this treatment, with a total increase placebo in lumbar spine BMD of 3.1%. Significant spinal bone loss (P < 0.005) occurred in women receiving either placebo or thrice-weekly calcitonin. Although the rates of bone loss in the proximal femur were not significantly different in the three groups, there were differences over time. Whereas bone loss in the daily calcitonin group was insignificant, women who received placebo or thrice-weekly calcitonin experienced significant bone loss (P < 0. 001). No significant changes in biochemical markers were observed in any group. Therapy was well tolerated and there were no significant treatment-related adverse events. We conclude that intranasal SCT 200 IU daily is effective and safe for the prevention of bone loss in postmenopausal women with reduced bone mass.

The use of xenon-133 for measurement of blood flow through systemic arteriovenous malformations before and after therapeutic embolization

Embolization is increasingly used to treat systemic arteriovenous (AV) shunts although its success, as judged by either angiographic or clinical means, is difficult to quantify. The aim of the study was to quantify blood flow through AV shunts with 133Xe, which, because of its relatively long transit time through peripheral tissues, behaves like microspheres. Following arterial injection, 133Xe entering an AV shunt rapidly arrives in the lung and can be quantified with a scintillation probe. In 17 patients with systemic AV shunts, the reduction in shunt flow following therapeutic embolization was quantified in the angiography theatre by comparing the initial count rates in the lung, recorded by probe, following injection of identical quantities of 133Xe into a supplying artery before and after embolization. By comparing the lung counts with those given by an intravenous injection of 133Xe, the fraction of flow at the catheter tip entering the shunt was also quantified. Tissue perfusion in the vascular territory distal to the shunt was measured at the same time by recording the clearance of non-shunted 133Xe with a second probe over the extremity. Control injections of 133Xe were given in the contralateral limb in order to assess 133Xe transit in the absence of shunting and to compare tissue perfusion between the two sides. Shunt flow ranged from 40% to 100% (of that at the tip of the catheter) (n = 14), while the reduction in shunt flow following embolization ranged from 15% to 96% (n = 19). Tissue perfusion distal to the shunt and in the contralateral limb was about 5 ml 100 ml-1 min-1. Contrast medium had no consistent effect on tissue perfusion in either limb, or on shunt flow. There was no difference in peripheral perfusion between the abnormal and control sides, nor any significant difference in perfusion in the distal tissue on the abnormal side before and after embolization. There was, however, a consistent increase in the fraction of the injected 133Xe delivered to the distal tissue after embolization (median increase 93%, p < 0.001). The technique is relatively simple and merits further development as a means of continuous quantification of systemic AV shunt flow in the angiography theatre at the time of embolization.

Non-invasive measurement of microvascular permeability to a small solute in man: validation of the technique

1. The purpose of the study was to evaluate a non-invasive technique for measurement of microvascular permeability to a small hydrophilic solute. 2. The technique measures the clearance of 99mTc-labelled diethylenetriaminepenta-acetic acid (99mTc-DTPA) from plasma into interstitial fluid in a limb after intravenous injection and uses a scintillation probe and a technique of graphical analysis called the Patlak plot, the uptake constant of which reflects 99mTc-DTPA transfer from plasma to interstitial fluid. Using deconvolution analysis, the retention function in the limb of intravenous 99mTc-DTPA was also measured. 3. The clearance values given by these two analytical techniques were compared with clearance from the same vascular bed after bolus femoral intra-arterial injection of 99mTc-DTPA. 4. Sixteen patients undergoing routine diagnostic arteriography were studied: six received sequential femoral intra-arterial injections of 99mTc-labelled human serum albumin (HSA) and 99mTc-DTPA, two received sequential intra-arterial and intravenous injections of 99mTc-HSA and eight received sequential intra-arterial and intravenous injections of 99mTc-DTPA. Tissue uptake and clearance were recorded from the limb with a scintillation probe and plasma clearance by arterial blood sampling. Tracer recirculation was addressed using a second scintillation probe over the contralateral limb. 5. After intra-arterial injection, 99mTc-HSA clearance was monoexponential, reflecting intravascular transit, and was completed by 2-5 min in seven subjects and in about 10 min in one. The corresponding 99mTc-DTPA clearance curves in the six subjects who also received intra-arterial DTPA were biexponential, analysis of which yielded a 99mTc-DTPA extraction fraction of about 0.6. By comparison with 99mTc-HSA clearance, the first exponential clearly corresponded to intravascular transit of unextracted 99mTc-DTPA. 6. In the eight patients given sequential intra-arterial and intravenous injections of 99mTc-DTPA, the second exponential recorded after intra-arterial injection, representing 99mTc-DTPA clearance from the interstitial fluid, agreed well with (a) the Patlak uptake constant recorded over the limb after intravenous injection, representing clearance from plasma into the interstitial fluid and (b) the retention function of 99mTc-DTPA in a limb calculated by deconvolution analysis. The mean clearance following intra-arterial injection (expressed in relation to extracellular fluid volume) was 9.6 (SD 2.4) ml min-1 100 ml-1, while the corresponding mean clearance after intravenous injection was 8.8 (2.1) ml min-1 100 ml-1 calculated by Patlak analysis and 10.5 (2.7) ml min-1 100 ml-1 by deconvolution analysis.(ABSTRACT TRUNCATED AT 400 WORDS)

Detection of low bone mineral density by dual energy x ray absorptiometry in unsuspected suboptimally treated coeliac disease

Patients with coeliac disease may present with calcium malabsorption but it is unclear whether this results in longterm impairment of bone mineralisation. Dual energy x ray absorptiometry (DXA) was used to study bone mineral density in 34 asymptomatic coeliac disease patients, treated with a gluten free diet for at least two years, and also in 10 newly diagnosed or untreated patients. As expected, untreated patients had low bone mineral density in all regions. In the 29 treated female coeliac disease patients, overall mean values for age adjusted bone mineral density expressed as Z scores were normal although there were many patients with low values, particularly of the lumbar spine and total body. Scores in the postmenopausal patients were significantly worse than in the premenopausal patients and low mean Z scores were found in the five treated male patients. The subjects who had reduced bone mineral density could not be predicted clinically but, despite being asymptomatic, were more likely to have subtotal or partial villous atrophy on small intestinal biopsy (p < 0.0275). In conclusion, although many treated coeliac disease patients have normal bone mineral density, suboptimally treated and newly diagnosed or untreated patients have osteopenia. To reduce the risk of osteoporotic fractures, it is recommended that bone mineral density be measured in all treated coeliac disease patients and those with osteopenia have a repeat intestinal biopsy to assess disease activity.

Holmium-YAG laser for gall stone fragmentation: an endoscopic tool

A systematic review of the 2.1 mu holmium-YAG laser for gall stone lithotripsy was undertaken. This infrared laser, which can be used endoscopically and percutaneously, has safety advantages over other lasers and has potential as a general purpose vascular and surgical tool. Twenty nine gall stones (mean mass 1.3 g) were fragmented in vitro using pulse energies of 114 to 159 mJ/pulse at 5 Hz with a 0.6 mm fibre, while being held in an endoscopy basket. All stones were successfully fragmented, requiring an average of 566 pulses with a 5 Hz pulse repetition frequency. The number of pulses required increased with gall stone size and mass (p < 0.01), and decreased with both pulse energy (p < 0.01) and operator experience (p < 0.05). The biochemical content of the stone did not significantly affect the number of pulses needed. The potential hazard of the laser to the biliary endothelium was investigated. At the pulse energies used, five pulses at close contact penetrated into the serosa of fresh gall bladder wall. No damage was seen when two pulses were fired. This laser shows considerable promise in gall stone lithotripsy. Until further safety data are available, however, its use with endoscopic vision is advised.

Effect of degenerative spinal and aortic calcification on bone density measurements in post-menopausal women: links between osteoporosis and cardiovascular disease?

The effect of spinal degenerative changes and aortic calcification on bone mineral density measurements was studied in 115 healthy early post-menopausal women. Lateral lumbar spine radiographs and quantitative computer tomography images were used to determine the presence and severity of aortic calcification and degenerative changes in the lumbar spine. Women with spinal degenerative calcification had higher spine bone density when measured by dual photon absorptiometry compared to those without calcification (P < 0.01), but this was not reflected by the quantitative computer tomography or the proximal femur bone densities, suggesting that spinal calcification artefactually increases spinal bone density when measured by dual photon techniques. Women with aortic calcification had significantly lower quantitative computer tomography and proximal femur bone density compared to those without calcification (both P < 0.05). These women may be at increased risk for both osteoporosis and cardiovascular disease, suggesting a common aetiological factor such as oestrogen deficiency.

Therapeutic success in severe iatrogenic osteoporosis in a young woman

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Baculovirus expression of the human papillomavirus type 16 capsid proteins: detection of L1-L2 protein complexes

The human papillomavirus (HPV) type 16 major capsid proteins L1 and L2 have been produced in a baculovirus expression system. Both proteins are expressed at a high level and can be readily solubilized. The L1 capsid protein migrates close to its expected Mr of 60K. On the other hand L2 exhibits a much higher Mr migrating at 73K, which is considerably greater than its predicted Mr of 50K. The identity of both proteins has been confirmed also by Western blot analysis. Both proteins are produced in drastically reduced amounts in the presence of tunicamycin. In addition both L1 and L2 show interesting patterns of phosphorylation. L1 is phosphorylated only weakly and this appears to be quite labile, whereas L2 is very heavily phosphorylated and this, in contrast, appears to be very stable. We have also made use of a dual expression vector for co-expressing the L1 and L2 proteins within the same baculovirus-infected cell. The results obtained from this system demonstrate the presence of protein complexes forming between the two capsid proteins. These studies indicate that at least the initial events in capsid assembly of HPVs can occur in the absence of viral DNA.

Dietary intake of calcium and postmenopausal bone loss

The use of calcium supplements to prevent postmenopausal bone loss and hence osteoporosis is widespread, but the evidence for their efficacy, either alone or in combination with other treatments, is contradictory. Skeletal measurements and dietary intake of calcium were determined in 59 healthy postmenopausal women, most of whom were within five years of the menopause. No correlation was found between current intake of calcium and either total calcium in the body or the density of trabecular or cortical bone in the forearm or vertebral trabecular bone. Dietary intake of calcium did not influence the rate of postmenopausal bone loss in the 54 women who completed 12 months of active or placebo treatment. Even when extremes of calcium intake were examined no difference was found in bone measurements between the women with the highest and lowest intakes. The results of this study suggest that the bone density of women in the early menopause is not influenced by current dietary intake of calcium.

Production of antibodies of predetermined specificity against herpes simplex virus DNA polymerase and their use in characterization of the enzyme

Peptides from preselected regions of the herpes simplex virus DNA polymerase were used to generate monospecific antisera to defined regions of the enzyme. The antisera were used to localize the polymerase within the infected cell and to determine the time of synthesis during productive infection. Comparison with a neutralizing polyclonal antiserum was used to show the specificity of the peptide antisera. By using the antisera the stabilities of the DNA polymerase, the alkaline nuclease, and the major DNA-binding protein were determined, and the state of phosphorylation of the DNA polymerase was compared with each of these proteins.