Socio-economic inequities in emergency department visits for wholly alcohol-attributable acute and chronic harms in Canada, 2003-2017

INTRODUCTION

Individuals with low socio-economic position (SEP) experience disproportionate alcohol-attributable harm. Limited research has investigated whether these inequities are driven by alcohol-attributable conditions that are acute or chronic. The study aimed to estimate the sex-specific associations between SEP and incident wholly alcohol-attributable emergency department (ED) visits for acute and chronic harms, respectively.

METHODS

A cohort study was conducted using the Canadian Community Health Survey (2003-2008) linked to the National Ambulatory Care Reporting System (2002-2017) in Alberta and Ontario. SEP was measured using educational attainment. Acute and chronic ED visits were captured in the National Ambulatory Care Reporting System follow-up data. Hazard models were fit to estimate the association between SEP and acute and chronic wholly alcohol-attributable ED visits.

RESULTS

The analytical sample included 88,865 respondents. In men and women, individuals with lower SEP had increased hazard of acute ED visits (women hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.07-2.87; men HR 3.47, 95% CI 2.29-5.25) and chronic ED visits (women HR 2.24, 95% CI 1.04-4.80; men HR 5.02, 95% CI 2.88-8.75). Acute and chronic wholly alcohol-attributable ED visit rates were higher in men than women.

DISCUSSION AND CONCLUSIONS

The findings indicated lower SEP was associated with greater harms for both acute and chronic wholly alcohol-attributable ED visits when compared to their higher SEP counterparts. We conclude that gradients in SEP are associated with acute and chronic harms. These results highlight a need for equitable interventions that reduce the absolute burden of inequities in both acute and chronic wholly alcohol-attributable ED visits.

The equitable impact of sugary drink taxation structures on sugary drink consumption among Canadians: a modelling study using the 2015 Canadian Community Health Survey-Nutrition

OBJECTIVE

Estimate the impact of 20 % flat-rate and tiered sugary drink tax structures on the consumption of sugary drinks, sugar-sweetened beverages and 100 % juice by age, sex and socio-economic position.

DESIGN

We modelled the impact of price changes - for each tax structure - on the demand for sugary drinks by applying own- and cross-price elasticities to self-report sugary drink consumption measured using single-day 24-h dietary recalls from the cross-sectional, nationally representative 2015 Canadian Community Health Survey-Nutrition. For both 20 % flat-rate and tiered sugary drink tax scenarios, we used linear regression to estimate differences in mean energy intake and proportion of energy intake from sugary drinks by age, sex, education, food security and income.

SETTING

Canada.

PARTICIPANTS

19 742 respondents aged 2 and over.

RESULTS

In the 20 % flat-rate scenario, we estimated mean energy intake and proportion of daily energy intake from sugary drinks on a given day would be reduced by 29 kcal/d (95 % UI: 18, 41) and 1·3 % (95 % UI: 0·8, 1·8), respectively. Similarly, in the tiered tax scenario, additional small, but meaningful reductions were estimated in mean energy intake (40 kcal/d, 95 % UI: 24, 55) and proportion of daily energy intake (1·8 %, 95 % UI: 1·1, 2·5). Both tax structures reduced, but did not eliminate, inequities in mean energy intake from sugary drinks despite larger consumption reductions in children/adolescents, males and individuals with lower education, food security and income.

CONCLUSIONS

Sugary drink taxation, including the additional benefit of taxing 100 % juice, could reduce overall and inequities in mean energy intake from sugary drinks in Canada.

Can a health warning label diminish the persuasive effects of health-oriented nutrition advertising on ready-to-drink alcohol product packaging? A randomized experiment

BACKGROUND AND AIMS

A health warning label (HWL) cautioning about the link between alcohol and cancer may be able to communicate alcohol risks to consumers and potentially counter health-oriented nutrition advertising on ready-to-drink alcoholic beverages. This study aimed to examine the independent and combined effects of nutrient content claims (e.g. 0 g sugar) and a HWL on perceived product characteristics and intentions to consume, and whether these effects differed by gender and age.

DESIGN

A between-subjects randomized experiment. Participants were randomized to view one of six experimental label conditions: nutrient content claims plus nutrition declaration (NCC + ND), ND only, NCC + ND + HWL, ND + HWL, HWL only and no NCC, ND or HWL, all on a ready-to-drink (RTD) vodka-based soda container.

SETTING AND PARTICIPANTS

Alcohol consumers (n = 5063; 52% women) in Canada aged 18-64 recruited through a national online panel.

MEASUREMENTS

Participants completed ratings of perceived product characteristics, perceived product health risks, and intentions to try, buy, binge and drink the product.

FINDINGS

Compared with the reference condition NCC + ND (current policy scenario in Canada), the other five experimental label conditions were associated with lower ratings for perceiving the product as healthy. All experimental conditions with a HWL were associated with lower product appeal, higher risk perceptions and reduced intentions to try, buy and binge. The experimental condition with a HWL only was associated with intentions to consume fewer cans in the next 7 days (β = -0.72, 95% confidence interval [CI] = -1.37,-0.08) versus the reference. Few interactions were observed, suggesting that label effects on outcomes were similar by gender and age.

CONCLUSIONS

Health warning labels on alcohol packaging appear to be associated with lower product appeal, higher perceived health risks and reduced consumption intentions, even in the presence of nutrient content claims.

Income inequality and deaths of despair risk in Canada, identifying possible mechanisms

BACKGROUND

Declines in life expectancy in developed countries have been attributed to increases in drug-related overdose, suicide, and liver cirrhosis, collectively referred to as deaths of despair. Income inequality is proposed to be partly responsible for increases in deaths of despair rates. This study investigated the associations between income inequality, deaths of despair risk in Canada, and potential mechanisms (stress, social cohesion, and access to health services).

METHODS

We obtained data from the Canadian Community Health Survey and the Canadian Vital Statistics Database from 2007 to 2017. A total of 504,825 Canadians were included in the analyses. We used multilevel survival analyses, as measured by the Gini coefficient, to examine the relationships between income inequality and mortality attributed to drug overdose, suicide, death of despair, and all-cause. We then used multilevel path analyses to investigate whether each mediator (stress, social cohesion, and access to mental health professionals), which were investigated using separate mediation models, influenced the relationship between income inequality and drug overdose, suicide, deaths of despair, and all-cause death.

RESULTS

Adjusted multilevel survival analyses demonstrated significant relationships between a one-SD increase in Gini coefficient was associated with an increased hazard for drug overdose (HRadj. = 1.28; 95 CI = 1.05, 1.55), suicide (HRadj. = 1.24; 95 CI = 1.06, 1.46), deaths of despair (HRadj. = 1.26; 95 CI = 1.12, 1.40), and all-cause death (HRadj. = 1.04; 95 CI = 1.02, 1.07). Adjusted path analyses indicated that stress, social cohesion, and access to mental health professionals significantly mediated the association between income inequality and mortality outcomes.

CONCLUSION

Income inequality is associated with deaths of despair and this relationship is mediated by stress, social cohesion, and access to mental health professionals. Findings should be applied to develop programs to address income inequality in Canada.

The Impacts of Selling Alcohol in Grocery Stores in Ontario, Canada: A Before-After Study

OBJECTIVE

From 2015 to 2019, the Government of Ontario expanded privatized sales of alcohol, licensing 450 grocery stores to sell beer, cider, and wine. The impacts of a nearby grocery store gaining an alcohol license on adults' alcohol use in Ontario are examined, including whether impacts differed by gender.

METHOD

Data from 2015-2019 Canadian Community Health Survey participants in Ontario (age ≥ 20 years), living within 1,000 m and 1,500 m of grocery stores that gained a license to sell alcohol and propensity-matched controls were included (1,000 m n = 14,052, 1,500 m n = 30,486). Alcohol use outcomes included past-7-day number of standard drinks consumed, near-daily drinking (≥4 days/week), and heavy drinking (5+ drinks in men/4+ in women, at least once/month). Gender-specific difference-in-differences (DiD) analyses compared changes in alcohol use before and after intervention in intervention and control populations.

RESULTS

Decreases in past-7-day drinks, near-daily drinking, and heavy drinking were observed after intervention in both intervention and control populations. At the 1,000 m level, adjusted DiD analyses showed past-7-day drinking in women (risk ratio = 1.21, 95% CI [0.88, 1.60]) and heavy drinking in men (odds ratio = 1.38, 95% CI [0.92, 2.08]) had effect sizes above 1, a relative increase over controls, although confidence intervals crossed 1. Findings did not indicate significant differences in alcohol use in intervention relative to controls for other alcohol use measures and at 1,500 m.

CONCLUSIONS

Findings suggest no association between a partial alcohol deregulation initiative in Ontario and alcohol use from 2015 to 2019. It is important to monitor the impacts on alcohol use over time as further alcohol deregulation plans in Ontario and other jurisdictions are considered.

The Joint Effect of Education and Alcohol Use on 100% Alcohol-attributable Hospitalization or Death in Canada

BACKGROUND

Individuals with low socioeconomic position (SEP) experience disproportionately greater alcohol-attributable harm than individuals with high SEP despite similar or less alcohol use (i.e., the alcohol harm paradox). We examined the sex/gender- specific independent and joint effects of education and heavy drinking or volume of alcohol use on 100% alcohol-attributable hospitalization or death.

METHODS

We conducted a cohort study among 199,125 current and former alcohol users aged 15-64 years from population-representative Canadian Community Health Surveys (2000-2008) linked to hospitalization and mortality records through 2017. We estimated the sex/gender-specific associations between education and heavy drinking or volume of alcohol use and incident 100% alcohol-attributable hospitalization or death using multivariable Fine and Gray subdistribution hazard models with competing risk (non-100% alcohol-attributable deaths), assessing additive interactions using the Synergy Index (S).

RESULTS

Overall, heavy drinking prevalence and volume of alcohol use were similar or lower in individuals with lower education compared with higher education. Lower education levels compared with a bachelor's degree or above were associated with increased 100% alcohol-attributable hospitalization or death [e.g., less than high school, men: hazard ratio (HR) = 2.78; 95% CI = 2.17, 3.56; women: HR = 2.98; 95% CI = 2.00, 4.44]. We found superadditive joint effects between low education and heavy drinking (men: S = 1.22; 95% CI = 1.14, 1.30; women: S = 1.34; 95% CI = 0.88, 2.04) and low education and higher volume of alcohol use (e.g., excess volume, men: S = 1.30; 95% CI = 1.05, 1.62; women: S = 1.41; 95% CI = 0.77, 2.58), with larger inequities in women than men with similar alcohol use.

CONCLUSIONS

Our study is consistent with the hypothesis that increased vulnerability to alcohol use among individuals with lower education partially explains the alcohol harm paradox in Canada.

Bridging ethics and epidemiology: Modelling ethical standards of health equity

Health inequities are differences in health that are 'unjust'. Yet, despite competing ethical views about what counts as an 'unjust difference in health', theoretical insights from ethics have not been systematically integrated into epidemiological research. Using diabetes as an example, we explore the impact of adopting different ethical standards of health equity on population health outcomes. Specifically, we explore how the implementation of population-level weight-loss interventions using different ethical standards of equity impacts the intervention's implementation and resultant population health outcomes. We conducted a risk prediction modelling study using the nationally representative 2015-16 Canadian Community Health Survey (n = 75,044, 54% women). We used the Diabetes Population Risk Tool (DPoRT) to calculate individual-level 10-year diabetes risk. Hypothetical weight-loss interventions were modelled in individuals with overweight or obesity based on each ethical standard: 1) health sufficiency (reduce DPoRT risk below a high-risk threshold (16.5%); 2) health equality (equalize DPoRT risk to the low risk group (5%)); 3) social-health sufficiency (reduce DPoRT risk <16.5 in individuals with lower education); 4) social-health equality (equalize DPoRT risk to the level of individuals with high education). For each scenario, we calculated intervention impacts, diabetes cases prevented or delayed, and relative and absolute educational inequities in diabetes. Overall, we estimated that achieving health sufficiency (i.e., all individuals below the diabetes risk threshold) was more feasible than achieving health equality (i.e., diabetes risk equalized for all individuals), requiring smaller initial investments and fewer interventions; however, fewer diabetes cases were prevented or delayed. Further, targeting only diabetes inequalities related to education reduced the target population size and number of interventions required, but consequently resulted in even fewer diabetes cases prevented or delayed. Using diabetes as an example, we found that an explicit, ethically-informed definition of health equity is essential to guide population-level interventions that aim to reduce health inequities.

Income inequality and mental health in adolescents during COVID-19, results from COMPASS 2018-2021

INTRODUCTION

Understanding the inequitable impacts of the ongoing COVID-19 pandemic on youth mental health are leading priorities. Existing research has linked income inequality in schools to adolescent depression, however, it is unclear if the onset of the pandemic exacerbated the effects of income inequality on adolescent mental health. The current study aimed to quantify the association between income inequality and adolescent mental health during COVID-19.

MATERIAL AND METHODS

Longitudinal data were taken from three waves (2018/19 to 2020/21) of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) school-based study. Latent Growth Curve modelling was used to assess the association between Census District (CD)-level income inequality and depressive symptoms before and after the onset of COVID-19.

RESULTS

The study sample included 29,722 students across 43 Census divisions in British Columbia, Alberta, Ontario, and Quebec. The average age of the sample at baseline was 14.9 years [standard deviation (SD) = 1.5] and ranged between 12 and 19 years of age. Most of the sample self-reported as white (76.3%) and female (54.4%). Students who completed the COMPASS survey after the onset of COVID reported 0.20-unit higher depressive scores (95% CI = 0.16, 0.24) compared to pre-COVID. The adjusted analyses indicated that the association between income inequality on anxiety scores was strengthened following the onset of COVID-19 (β = 0.02, 95% CI = 0.0004, 0.03), indicating that income inequality was associated with a greater increase in anxiety scores during COVID-19.

DISCUSSION

The adjusted results indicate that the association between income inequality and adolescent anxiety persisted and was heightened at the onset of COVID-19. Future studies should use quasi-experimental methods to strengthen this finding. The current study can inform policy and program discussions regarding the effects of the COVID-19 pandemic and pandemic recovery for young Canadians and relevant social policies for improving adolescent mental health.

The association between social fragmentation and deaths attributable to alcohol, drug use, and suicide: Longitudinal evidence from a population-based sample of Canadian adults

BACKGROUND

Social fragmentation has been theorized and empirically associated with suicide in prior research. However, less is known about whether social fragmentation is associated with deaths attributed to alcohol use or drug use. This research examined the association between social fragmentation and risk for deaths attributable to alcohol use, drug use, and suicide (collectively known as deaths of despair) among Canadian adults.

METHODS

A weighted sample representing 15,324,645 Canadians within 288 census divisions between 2006 and 2019 was used. Mortality data from the Canadian Vital Statistics Database (alcoholic liver disease, drug use, and suicide) was linked with census division socioeconomic data from the 2006 Canadian census using the Canadian Census Health and Environment Cohorts. Social fragmentation at the census division was created based on the Congdon Index. Cox-proportional hazard regression with survey weights and the sandwich estimator were used to account for clustering of individuals (level-1) nested within census divisions (level-2).

RESULTS

After adjusting for individual and census division confounders, social fragmentation was positively associated with all-cause mortality (HR = 1.04; 95% CI: 1.02, 1.07), suicide (HR = 1.09; 95%CI: 1.01, 1.18), drug overdose related mortality (HR = 1.13; 95%CI: 1.03, 1.24), and deaths of despair (HR = 1.10; 95% CI: 1.04, 1.16), and not significantly associated with alcohol related liver disease (HR = 1.06; 95% CI: 0.91, 1.23).

CONCLUSION

Social fragmentation is associated with an increased hazard of deaths of despair among Canadian adults. Efforts to improve social cohesion in areas that are highly socially fragmented need to be evaluated.

Artificial intelligence and the work-health interface: A research agenda for a technologically transforming world of work

The labor market is undergoing a rapid artificial intelligence (AI) revolution. There is currently limited empirical scholarship that focuses on how AI adoption affects employment opportunities and work environments in ways that shape worker health, safety, well-being and equity. In this article, we present an agenda to guide research examining the implications of AI on the intersection between work and health. To build the agenda, a full day meeting was organized and attended by 50 participants including researchers from diverse disciplines and applied stakeholders. Facilitated meeting discussions aimed to set research priorities related to workplace AI applications and its impact on the health of workers, including critical research questions, methodological approaches, data needs, and resource requirements. Discussions also aimed to identify groups of workers and working contexts that may benefit from AI adoption as well as those that may be disadvantaged by AI. Discussions were synthesized into four research agenda areas: (1) examining the impact of stronger AI on human workers; (2) advancing responsible and healthy AI; (3) informing AI policy for worker health, safety, well-being, and equitable employment; and (4) understanding and addressing worker and employer knowledge needs regarding AI applications. The agenda provides a roadmap for researchers to build a critical evidence base on the impact of AI on workers and workplaces, and will ensure that worker health, safety, well-being, and equity are at the forefront of workplace AI system design and adoption.

The distribution of alcohol-attributable healthcare encounters across the population of alcohol users in Ontario, Canada

Recent evidence suggests there may be no safe level of alcohol use as even low levels are associated with increased risk for harm. However, the magnitude of the population-level health burden from lower levels of alcohol use is poorly understood. The objective was to estimate the distribution of alcohol-attributable healthcare encounters (emergency department (ED) visits and hospitalizations) across the population of alcohol users aged 15+ in Ontario, Canada. Using the International Model of Alcohol Harms and Policies (InterMAHP) tool, wholly and partially alcohol-attributable healthcare encounters were estimated across alcohol users: (1) former (no past-year use); (2) low volume (≤67.3 g ethanol/week); (3) medium volume (>67.3-134.5 g ethanol/week for women and >67.3-201.8 g ethanol/week for men); and (4) high volume (>134.5 g ethanol/week for women and >201.8 g ethanol/week for men). The alcohol-attributable healthcare burden was distributed across the population of alcohol users. A small population of high volume users (23% of men, 13% of women) were estimated to have contributed to the greatest proportion of alcohol-attributable healthcare encounters, particularly among men (men: 65% of ED visits and 71% of hospitalizations, women: 49% of ED visits and 50% of hospitalizations). The 71% of women low and medium volumes users were estimated to have contributed to a substantial proportion of alcohol-attributable healthcare encounters (47% of ED visits and 34% of hospitalizations). Findings provide support for universal alcohol policies (i.e., delivered to the entire population) for reducing population-level alcohol-attributable harm in addition to targeted policies for high-risk users.

Validation of a parent proxy-reported beverage screener compared to a 24-hour dietary recall for the measurement of sugar-containing beverage intake among young children

Measures that can provide reasonably accurate estimates of sugar-containing beverage (SCB) intake among children are needed. The primary objective of this study was to evaluate the relative validity of a short beverage screener (Nutrition and Health Questionnaire, NHQ) compared to a 24-hour recall (Automated Self-Administered 24-h (ASA24) Dietary Assessment Tool-Canada) for assessing parent proxy-reported daily SCB intake among children aged 4-14 years from the TARGet Kids! research network in Toronto, Canada. Children for whom a NHQ completed between March 2018 and June 2019 and an ASA24 completed within one year were included. A total of 471 parents who completed the NHQ beverage screener were also asked to complete the ASA24. One-hundred sixty-three completed the ASA24 and of this group, 109 were analyzed. Estimates of daily intake of 100% juices, sweetened drinks and soda, and total SCBs from the two measures were compared. The mean difference in beverage intake, Spearman correlations, and Bland-Altman plots were estimated for continuous measures. The kappa coefficient, sensitivity, and specificity were calculated for dichotomous measures of any daily intake versus none. The mean difference in total SCB intake between the NHQ and ASA24 was 0.14 cups/day (95% CI 0.01, 0.29) and the correlation was 0.43 (95% CI 0.26, 0.57). Sensitivity and specificity for any daily SCB intake were 0.63 and 0.76, respectively. Overall, parent proxy-reporting of children's total SCB intake from a beverage screener can provide reasonable estimates of SCB intake when detailed dietary assessment is not feasible.

Evaluation of the gap in delivery of opioid agonist therapy among individuals with opioid-related health problems: a population-based retrospective cohort study

AIMS

Although opioid-related harms have reached new heights across North America, the size of the gap in opioid agonist therapy (OAT) delivery for opioid-related health problems is unknown in most jurisdictions. This study sought to characterize the gap in OAT treatment using a cascade of care framework, and determine factors associated with engagement and retention in treatment.

DESIGN

A population-based retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Individuals who sought medical care for opioid-related health problems or died from an opioid-related cause between 2005 and 2019.

MEASUREMENTS

Monthly treatment status for buprenorphine/naloxone or methadone OAT between 2013 and 2019 (i.e. 'off OAT', 'retained on OAT < 6 months', 'retained on OAT ≥ 6 months').

FINDINGS

Of 122 811 individuals in the cohort, 97 516 (79.4%) received OAT at least once during the study period. There was decreasing 6-month treatment retention over time. Model results indicated that males had higher odds of being on OAT each month [odds ratio (OR) = 1.26, 95% confidence interval (CI) = 1.23-1.28] but lower odds of OAT retention (OR = 0.90, 95% CI = 0.88-0.92), while the reverse was observed for older individuals (monthly: OR = 0.76 per 10-year increase, 95% CI = 0.76-0.77; retention: OR = 1.36 per 10-year increase, 95% CI = 1.34-1.38) and individuals with higher neighbourhood income (e.g. highest income quintile, monthly: OR = 0.79, 95% CI = 0.77-0.82; highest income quintile, retention: OR = 1.15, 95% CI = 1.11-1.20). Individuals residing in rural areas and with a history of mental health diagnoses had poorer outcomes overall, including lower odds of being on OAT each month (rural: OR = 0.75, 95% CI = 0.73-0.78; mental health: OR = 0.89, 95% CI = 0.87-0.92) and OAT retention (rural: OR = 0.79, 95% CI = 0.77-0.82; mental health: OR = 0.81, 95% CI = 0.78-0.83), as well as higher risk of starting/stopping OAT [rural, starting OAT: hazard ratio (HR) = 1.07, 95% CI = 1.05-1.10; mental health, starting OAT: HR = 1.20, 95% CI: 1.18-1.23; rural, stopping OAT: HR = 1.24, 95% CI: = 1.22-1.26; mental health, stopping OAT: HR = 1.11, 95% CI = 1.09-1.13]. Individuals with a history of mental health diagnoses also had a higher risk of death, regardless of OAT status (off OAT death: HR = 1.49, 95% CI = 1.33-1.66; on OAT death: HR = 1.20, 95% CI = 1.09-1.31).

CONCLUSIONS

Factors influencing engagement and declining retention in treatment with opioid agonist therapy in Ontario's health system include age, sex and neighbourhood income, as well as mental health diagnoses or residing in rural regions.

Trends in alcohol-attributable hospitalisations and emergency department visits by age, sex, drinking group and health condition in Ontario, Canada

INTRODUCTION

Alcohol-attributable harms are increasing in Canada. We described trends in alcohol-attributable hospitalisations and emergency department (ED) visits by age, sex, drinking group, attribution and health condition.

METHODS

Hospitalisation and ED visits for partially or wholly alcohol-attributable health conditions by age and sex were obtained from population-based health administrative data for individuals aged 15+ in Ontario, Canada. Population-level alcohol exposure was estimated using per capita alcohol sales and alcohol use data. We estimated the number and rate of alcohol-attributable hospitalisations (2008-2018) and ED visits (2008-2019) using the International Model of Alcohol Harms and Policies (InterMAHP).

RESULTS

Over the study period, the modelled rates of alcohol-attributable health-care encounters were higher in males, but increased faster in females. Specifically, rates of alcohol-attributable hospitalisations and ED visits increased by 300% (19-76 per 100,000) and 37% (774-1,064 per 100,000) in females, compared to 20% (322-386 per 100,000) and 2% (2563-2626 per 100,000) in males, respectively. Alcohol-attributable ED visit rates were highest among individuals aged 15-34, however, increased faster among individuals aged 65+ (females: 266%; males: 44%) than 15-34 years (females:+17%; males: -16%). High-volume drinkers had the highest rates of alcohol-attributable health-care encounters; yet, low-/medium-volume drinkers contributed substantial hospitalisations (11%) and ED visits (36%), with increasing rates of ED visits in females drinking low/medium volumes.

DISCUSSION AND CONCLUSIONS

Alcohol-attributable health-care encounters increased overall, and faster among females, adults aged 65+ and low-/medium-volume drinkers. Monitoring trends across subpopulations is imperative to inform equitable interventions to mitigate alcohol-attributable harms.

Income precarity and child and parent weight change during the COVID-19 pandemic: a cross-sectional analysis of the Ontario Parent Survey

OBJECTIVES

To describe child and parent weight change during the pandemic, overall and by income precarity.

DESIGN

A cross-sectional online survey was conducted.

SETTING

Caregivers of children 0-17 years of age living in Ontario, Canada, during the COVID-19 pandemic from May 2021 to July 2021.

PARTICIPANTS

A convenience sample of parents (n=9099) with children (n=9667) living in Ontario were identified through crowdsourcing.

PRIMARY OUTCOME MEASURE

Parents recalled, for themselves and their child, whether they lost weight, gained weight or remained the same over the past year. OR and 95% CI were estimated using multinomial logistic regression for the association between income precarity variables and weight loss or gain, adjusted for age, gender and ethnicity.

RESULTS

Overall, 5.5% of children lost weight and 20.2% gained weight. Among adolescents, 11.1% lost weight and 27.1% gained weight. For parents, 17.1% reported weight loss and 57.7% reported weight gain. Parent weight change was strongly associated with child weight change. Income precarity measures, including job loss by both parents (OR=7.81, 95% CI 5.16 to 11.83) and disruption to household food supply (OR=6.05, 95% CI 4.77 to 7.68), were strongly associated with child weight loss. Similarly, job loss by both parents (OR=2.03, 95% CI 1.37 to 3.03) and disruption to household food supply (OR=2.99, 95% CI 2.52 to 3.54) were associated with child weight gain.

CONCLUSIONS

Weight changes during the COVID-19 pandemic were widespread and income precarity was strongly associated with weight loss and weight gain in children and parents. Further research is needed to investigate the health outcomes related to weight change during the pandemic, especially for youth, and the impacts of income precarity.

Investigating the association between income inequality in youth and deaths of despair in Canada: a population-based cohort study from 2006 to 2019

BACKGROUND

Deaths due to suicide, drug overdose and alcohol-related liver disease, collectively known as 'deaths of despair', have been markedly increasing since the early 2000s and are especially prominent in young Canadians. Income inequality has been linked to this rise in deaths of despair; however, this association has not yet been examined in a Canadian context, nor at the individual level or in youth. The study objective was to examine the association between income inequality in youth and deaths of despair among youth over time.

METHODS

We conducted a population-based longitudinal study of Canadians aged 20 years or younger using data from the Canadian Census Health and Environment Cohorts. Baseline data from the 2006 Canadian Census were linked to the Canadian Vital Statistics Database up to 2019. We employed multilevel survival analysis models to quantify the association between income inequality in youth and time-to deaths of despair.

RESULTS

The study sample included 1.5 million Canadians, representing 7.7 million Canadians between the ages of 0 and 19 at baseline. Results from the weighted, adjusted multilevel survival models demonstrated that income inequality was associated with an increased hazard of deaths of despair (adjusted HR (AHR) 1.35; 95% CI 1.04 to 1.75), drug overdose (AHR 2.38; 95% CI 1.63 to 3.48) and all-cause deaths (AHR 1.10; 95% CI 1.04 to 1.18). Income inequality was not significantly associated with suicide deaths (AHR 1.23, 95% CI 0.93 to 1.63).

CONCLUSION

The results show that higher levels of income inequality in youth are associated with an increased hazard of all-cause death, deaths of despair and drug overdose in young Canadians. This study is the first to reveal the association between income inequality and deaths of despair in youth and does so using a population-based longitudinal cohort involving multilevel data. The results of this study can inform policies related to income inequality and deaths of despair in Canada.

Neighbourhood-level socio-demographic characteristics and risk of COVID-19 incidence and mortality in Ontario, Canada: A population-based study

OBJECTIVES

We aimed to estimate associations between COVID-19 incidence and mortality with neighbourhood-level immigration, race, housing, and socio-economic characteristics.

METHODS

We conducted a population-based study of 28,808 COVID-19 cases in the provincial reportable infectious disease surveillance systems (Public Health Case and Contact Management System) which includes all known COVID-19 infections and deaths from Ontario, Canada reported between January 23, 2020 and July 28, 2020. Residents of congregate settings, Indigenous communities living on reserves or small neighbourhoods with populations <1,000 were excluded. Comparing neighbourhoods in the 90th to the 10th percentiles of socio-demographic characteristics, we estimated the associations between 18 neighbourhood-level measures of immigration, race, housing and socio-economic characteristics and COVID-19 incidence and mortality using Poisson generalized linear mixed models.

RESULTS

Neighbourhoods with the highest proportion of immigrants (relative risk (RR): 4.0, 95%CI:3.5-4.5) and visible minority residents (RR: 3.3, 95%CI:2.9-3.7) showed the strongest association with COVID-19 incidence in adjusted models. Among individual race groups, COVID-19 incidence was highest among neighbourhoods with the high proportions of Black (RR: 2.4, 95%CI:2.2-2.6), South Asian (RR: 1.9, 95%CI:1.8-2.1), Latin American (RR: 1.8, 95%CI:1.6-2.0) and Middle Eastern (RR: 1.2, 95%CI:1.1-1.3) residents. Neighbourhoods with the highest average household size (RR: 1.9, 95%CI:1.7-2.1), proportion of multigenerational families (RR: 1.8, 95%CI:1.7-2.0) and unsuitably crowded housing (RR: 2.1, 95%CI:2.0-2.3) were associated with COVID-19 incidence. Neighbourhoods with the highest proportion of residents with less than high school education (RR: 1.6, 95%CI:1.4-1.8), low income (RR: 1.4, 95%CI:1.2-1.5) and unaffordable housing (RR: 1.6, 95%CI:1.4-1.8) were associated with COVID-19 incidence. Similar inequities were observed across neighbourhood-level sociodemographic characteristics and COVID-19 mortality.

CONCLUSIONS

Neighbourhood-level inequities in COVID-19 incidence and mortality were observed in Ontario, with excess burden experienced in neighbourhoods with a higher proportion of immigrants, racialized populations, large households and low socio-economic status.

Socioeconomic position and consumption of sugary drinks, sugar-sweetened beverages and 100% juice among Canadians: a cross-sectional analysis of the 2015 Canadian Community Health Survey–Nutrition

Objective

The aim of this study was to describe sugary drink (beverages with free sugars), sugar-sweetened beverage (beverages with added sugars, SSB) and 100% juice (beverages with natural sugars) consumption across socioeconomic position (SEP) among Canadians.

Methods

We conducted a cross-sectional analysis of 19,742 respondents of single-day 24-h dietary recalls in the nationally representative 2015 Canadian Community Health Survey–Nutrition. Poisson regressions were used to estimate the prevalence of consuming each beverage type on a given day. Among consumers on a given day, linear regressions were used to estimate mean energy intake. Models included household education, food security and income quintiles as separate unadjusted exposures. Sex-specific models were estimated separately for children/adolescents (2–18 years) and adults (19 +).

Results

Among female children/adolescents, the prevalence of consuming sugary drinks and, separately, SSB ranged from 11 to 21 and 8 to 27 percentage-points higher among lower education compared to ‘Bachelor degree or above’ households. In female adults, the prevalence of consuming sugary drinks and, separately, SSB was 10 (95% CI: 1, 19) and 14 (95% CI: 2, 27) percentage-points higher in food insecure compared to secure households. In males, the prevalence of consuming 100% juice was 9 (95% CI: − 18, 0) percentage-points lower among food insecure compared to secure households. Social inequities in energy intake were observed in female adult consumers, among whom mean energy from sugary drinks was 27 kcal (95% CI: 3, 51) higher among food insecure compared to secure and 35 kcal (95% CI: 2, 67) higher from 100% juice among ‘less than high school’ education compared to ‘Bachelor degree or above’ households.

Conclusion

Social inequities in sugary drink consumption exist in Canada. The associations differed by SEP indicator. Equitable interventions to reduce consumption are warranted.

Incidence of outbreak-associated COVID-19 cases by industry in Ontario, Canada, 1 April 2020-31 March 2021

OBJECTIVES

The objective of our study was to estimate the rate of workplace outbreak-associated cases of COVID-19 by industry in labour market participants aged 15-69 years who reported working the majority of hours outside the home in Ontario, Canada.

METHODS

We conducted a population-based cross-sectional study of COVID-19 workplace outbreaks and associated cases reported in Ontario between 1 April 2020 and 31 March 2021. All outbreaks were manually classified into two-digit North American Industry Classification System codes. We obtained monthly denominator estimates from the Statistics Canada Labour Force Survey to estimate the incidence of outbreak-associated cases per 100 000 000 hours among individuals who reported the majority of hours were worked outside the home. We performed this analysis across industries and in three distinct time periods.

RESULTS

Overall, 12% of cases were attributed to workplace outbreaks among working-age adults across our study period. While incidence varied across the time periods, the five industries with the highest incidence rates across our study period were agriculture, healthcare and social assistance, food manufacturing, educational services, and transportation and warehousing.

CONCLUSIONS

Certain industries have consistently increased the incidence of COVID-19 over the course of the pandemic. These results may assist in ongoing efforts to reduce transmission of COVID-19 by prioritising resources, as well as industry-specific guidance, vaccination and public health messaging.

Changes in chronic disease risk factors and current exercise habits among Canadian adults living with and without a child during the COVID-19 pandemic

BACKGROUND

Canadians have been gravely impacted by the COVID-19 pandemic, and adults living with children may have been disproportionately impacted. The objective of this study was to describe changes in chronic disease risk factors and current exercise habits among adults living with and without a child younger than 18 years old.

DATA AND METHODS

A repeated cross-sectional study was conducted using data collected from Canadians aged 15 and older via the Canadian Perspective Survey Series (CPSS) in late March (CPSS1, N=4,383), early May (CPSS2, N=4,367) and mid-July 2020 (CPSS4, N=4,050). This analysis included participants aged 25 and older. At three points during 2020, participants reported whether they increased, decreased, or had not changed their consumption of alcohol, tobacco and junk food or sweets, their screen use, and whether they currently exercised indoors or outdoors. Behaviours were compared for adults living with and without a child, and unadjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression.

RESULTS

The presence of a child in the household was associated with higher odds of increased (compared with decreased or no change) alcohol consumption at all three time points, consumption of junk food and sweets at CPSS1 (OR: 1.69, 95% CI: 1.09-2.60), and time on the Internet at CPSS1 (OR: 1.59, 95% CI: 1.05-2.41) and CPSS4 (OR: 1.56, 95% CI: 1.05-2.29). Compared with older adults (aged 55 and older), younger adults (aged 25 to 54) were more likely to exhibit increases in chronic disease risk factors regardless of the presence of a child in the household.

INTERPRETATION

A substantial proportion of Canadian adults reported increased chronic disease risk factors during the pandemic, with greater increases noted among adults living with a child, compared with those living without a child. Public health interventions are urgently needed to mitigate the long-term impact of the pandemic on population health.

Multi-use physical activity trails in an urban setting and cardiovascular disease: a difference-in-differences analysis of a natural experiment in Winnipeg, Manitoba, Canada

Objective

To determine if expansion of multi-use physical activity trails in an urban centre is associated with reduced rates of cardiovascular disease (CVD).

Methods

This was a natural experiment with a difference in differences analysis using administrative health records and trail-based cycling data in Winnipeg, Canada. Prior to the intervention, each year, 314,595 (IQR: 309,044 to 319,860) persons over 30 years without CVD were in the comparison group and 37,901 residents (IQR: 37,213 to 38,488) were in the intervention group. Following the intervention, each year, 303,853 (IQR: 302,843 to 304,465) persons were in the comparison group and 35,778 (IQR: 35,551 to 36,053) in the intervention group. The natural experiment was the construction of four multi-use trails, 4-7 km in length, between 2010 and 2012. Intervention and comparison areas were based on buffers of 400 m, 800 m and 1200 m from a new multi-use trail. Bicycle counts were obtained from electromagnetic counters embedded in the trail. The primary outcome was a composite of incident CVD events: CVD-related mortality, ischemic heart disease, cerebrovascular events and congestive heart failure. The secondary outcome was a composite of incident CVD risk factors: hypertension, diabetes and dyslipidemia.

Results

Between 2014 and 2018, 1,681,125 cyclists were recorded on the trails, which varied ~ 2.0-fold across the four trails (2358 vs 4264 counts/week in summer months). Between 2000 and 2018, there were 82,632 CVD events and 201,058 CVD risk events. In propensity score matched Poisson regression models, the incident rate ratio (IRR) was 1.06 (95% CI: 0.90 to 1.24) for CVD events and 0.95 (95%CI: 0.88 to 1.02) for CVD risk factors for areas within 400 m of a trail, relative to comparison areas. Sensitivity analyses indicated this effect was greatest among households adjacent to the trail with highest cycling counts (IRR = 0.85; 95% CI: 0.75 to 0.96).

Conclusions

The addition of multi-use trails was not associated with differences in CVD events or CVD risk factors, however the differences in CVD risk may depend on the level of trail use.

Trial registration

Trial registration number: NCT04057417.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01279-z.

Interrupted time series analysis of Canadian legal cannabis sales during the COVID-19 pandemic

Introduction

There were repeated reports of increased cannabis sales, use and health impacts in Canada during the COVID‐19 pandemic. However, it was unclear whether the increases were due to pandemic effects or industry expansion.

Methods

We performed interrupted time series regressions of monthly per capita legal cannabis sales from March 2019 to February 2021, first with national averages, then with provincial/territorial data after adjusting for store density. We considered two interruption alternatives: January 2020, when product variety increased; and March 2020, when pandemic restrictions began.

Results

The provincial/territorial regression with the January interruption explained R² = 69.6% of within‐jurisdiction variation: baseline monthly per capita sales growth averaged $0.21 (95% confidence interval [CI] 0.15, 0.26), sales immediately dropped in January by $1.02 (95% CI −1.67, −0.37), and monthly growth thereafter increased by $0.16 (95% CI 0.06, 0.25). With the March interruption, the regression instead explained 68.7% of variation: baseline sales growth averaged $0.14 (95% CI 0.06, 0.22), there was no immediate drop and growth thereafter increased by $0.22 per month (95% CI 0.08, 0.35).

Discussion and Conclusions

Increasing cannabis sales during the pandemic was consistent with pre‐existing trends and increasing store numbers. The extra increased growth was more aligned with January's new product arrivals than with March's pandemic measures, though the latter cannot be ruled out. We found little evidence of pandemic impacts on Canada's aggregate legal cannabis sales. We therefore caution against attributing increased population‐level cannabis use or health impacts primarily to the pandemic.

Neighbourhood-level socio-demographic characteristics and risk of COVID-19 incidence and mortality in Ontario, Canada: A population-based study

OBJECTIVES

We aimed to estimate associations between COVID-19 incidence and mortality with neighbourhood-level immigration, race, housing, and socio-economic characteristics.

METHODS

We conducted a population-based study of 28,808 COVID-19 cases in the provincial reportable infectious disease surveillance systems (Public Health Case and Contact Management System) which includes all known COVID-19 infections and deaths from Ontario, Canada reported between January 23, 2020 and July 28, 2020. Residents of congregate settings, Indigenous communities living on reserves or small neighbourhoods with populations <1,000 were excluded. Comparing neighbourhoods in the 90th to the 10th percentiles of socio-demographic characteristics, we estimated the associations between 18 neighbourhood-level measures of immigration, race, housing and socio-economic characteristics and COVID-19 incidence and mortality using Poisson generalized linear mixed models.

RESULTS

Neighbourhoods with the highest proportion of immigrants (relative risk (RR): 4.0, 95%CI:3.5-4.5) and visible minority residents (RR: 3.3, 95%CI:2.9-3.7) showed the strongest association with COVID-19 incidence in adjusted models. Among individual race groups, COVID-19 incidence was highest among neighbourhoods with the high proportions of Black (RR: 2.4, 95%CI:2.2-2.6), South Asian (RR: 1.9, 95%CI:1.8-2.1), Latin American (RR: 1.8, 95%CI:1.6-2.0) and Middle Eastern (RR: 1.2, 95%CI:1.1-1.3) residents. Neighbourhoods with the highest average household size (RR: 1.9, 95%CI:1.7-2.1), proportion of multigenerational families (RR: 1.8, 95%CI:1.7-2.0) and unsuitably crowded housing (RR: 2.1, 95%CI:2.0-2.3) were associated with COVID-19 incidence. Neighbourhoods with the highest proportion of residents with less than high school education (RR: 1.6, 95%CI:1.4-1.8), low income (RR: 1.4, 95%CI:1.2-1.5) and unaffordable housing (RR: 1.6, 95%CI:1.4-1.8) were associated with COVID-19 incidence. Similar inequities were observed across neighbourhood-level sociodemographic characteristics and COVID-19 mortality.

CONCLUSIONS

Neighbourhood-level inequities in COVID-19 incidence and mortality were observed in Ontario, with excess burden experienced in neighbourhoods with a higher proportion of immigrants, racialized populations, large households and low socio-economic status.

Changes in the dollar value of per capita alcohol, essential, and non-essential retail sales in Canada during COVID-19

Background

Multiple survey reports suggest that alcohol use has increased in Canada during the COVID-19 pandemic. However, less is known about how per capita alcohol sales, which predict population-level alcohol use, have changed and whether changes in alcohol sales differ from changes in sales of other products due to pandemic factors.

Methods

We obtained monthly retail sales data by industry from Statistics Canada, for the six largest provinces in Canada (containing 93% of the national population), between January 2010 and November 2020, representing time before and 9 months after the start of the pandemic in Canada. We used an interrupted time series analysis to estimate pandemic impacts on the dollar value of monthly per capita (per individuals 15+ years) alcohol, essential and non-essential retail sales. We adjusted our analyses for pre-pandemic sales trends, inflation, seasonality and changing population demographics over time.

Results

During the first 9 months of the pandemic, the values of per capita alcohol, essential and non-essential sales were, respectively, 13.2% higher, 3.6% higher and 13.1% lower than the average values during the same period in the prior 3 years. Interrupted time series models showed significant level change for the value of monthly per capita alcohol sales (+$4.86, 95% CIs: 2.88, 6.83), essential sales (−$59.80, 95% CIs: − 78.47, − 41.03) and non-essential sales (−$308.70, 95% CIs: − $326.60, − 290.79) during the pandemic. Alcohol sales were consistently elevated during the pandemic, and the pre- and post-pandemic slopes were comparable. In contrast, essential and non-essential retail sales declined in the early months of the pandemic before returning to regular spending levels.

Conclusion

During the first 9 months of the pandemic, per capita alcohol sales were moderately elevated in Canada. In contrast, non-essential sales were lower than prior years, driven by large decreases during the initial months of the pandemic. These findings suggest that the pandemic was associated with increased population-level alcohol consumption, which may lead to increased alcohol-related harms. Ongoing research is needed to examine how factors, including pandemic-related stressors and specific alcohol sales-related policies, may have influenced changes in alcohol use and harms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12226-1.

Income and neighbourhood deprivation in relation to obesity in urban dwelling children 0-12 years of age: a cross-sectional study from 2013 to 2019

BACKGROUND

Childhood obesity is a major public health concern. This study evaluated the independent and joint associations of family-level income, neighbourhood-level income and neighbourhood deprivation, in relation to child obesity.

METHODS

A cross-sectional study was conducted in children ≤12 years of age from TARGet Kids! primary care network (Greater Toronto Area, 2013-2019). Parent-reported family income was compared with median neighbourhood income and neighbourhood deprivation measured using the Ontario Marginalization Index. Children's height and weight were measured and body mass index (BMI) z-scores (zBMI) were calculated. ORs and 95% CIs were estimated for the three exposure variables separately using multilevel multinomial logistic regression models with zBMI categories as the outcome, adjusting in model 1 for age, sex, ethnicity and number of family members and in model 2 adding family income. A joint measure was derived combining income and deprivation measures.

RESULTS

A total of 5962 children were included. Low family income (Q1 vs Q5: OR=4.69, 95% CI 2.65 to 8.29), low neighbourhood income (Q1 vs Q5: OR=2.18, 95% CI 1.33 to 3.58) and high neighbourhood deprivation (Q1 vs Q5: OR=2.45, 95% CI 1.52 to 3.95) were each associated with increased OR of child obesity. However, after adjustment for family income, the association for both neighbourhood income (OR=1.39, 95% CI 0.82 to 2.34) and deprivation (OR=1.56, 95% CI 0.94 to 2.58) and obesity was attenuated. Children from low-income families living in low-income or high deprivation neighbourhoods had higher OR of obesity.

CONCLUSION

Child obesity was independently associated with low family-level income and a joint measure suggests that neighbourhood also matters. Socioeconomic inequalities at both individual and neighbourhood levels should be addressed in childhood obesity interventions.

COVID-19 Workplace Outbreaks by Industry Sector and Their Associated Household Transmission, Ontario, Canada, January to June, 2020

OBJECTIVE

To analyze workplace outbreaks by industry sector in the first wave of the pandemic, and associated household cases.

METHODS

Number, size, and duration of outbreaks were described by sector, and outbreak cases were compared to sporadic cases in the same time frame. Address matching identified household cases with onset ≥2 days before, ≥2 days after, or within 1 day of the workplace outbreak case.

RESULTS

There were 199 outbreaks with 1245 cases, and 68% of outbreaks and 80% of cases belonged to (1) Manufacturing, (2) Agriculture, Forestry, Fishing, Hunting, (3) Transportation and Warehousing. There were 608 household cases associated with 339 (31%) outbreak cases, increasing the burden of illness by 56%.

CONCLUSIONS

Workplace outbreaks primarily occurred in three sectors. Prevention measures should target industry sectors at risk to prevent spread in and out of the workplace.

Automated Self-Administered 24-H Dietary Assessment Tool (ASA24) recalls for parent proxy-reporting of children's intake (> 4 years of age): a feasibility study

BACKGROUND

Robust measurement of dietary intake in population studies of children is critical to better understand the diet-health nexus. It is unknown whether parent proxy-report of children's dietary intake through online 24-h recalls is feasible in large cohort studies.

OBJECTIVES

The primary objective of this study was to describe the feasibility of the Automated Self-Administered 24-h Dietary Assessment Tool (ASA24) to measure parent proxy-reported child dietary intake. A secondary objective was to compare intake estimates with those from national surveillance.

METHODS

Parents of children aged 4-15 years participating in the TARGet Kids! research network in Toronto, Canada were invited by email to complete an online ASA24-Canada-2016 recall for their child, with a subsample prompted to complete a second recall about 2 weeks later. Descriptive statistics were reported for ASA24 completion characteristics and intake of several nutrients. Comparisons were made to the 2015 Canadian Community Health Survey (CCHS) 24-h recall data.

RESULTS

A total of 163 parents completed the first recall, and 46 completed the second, reflecting response rates of 35% and 59%, respectively. Seven (4%) first recalls and one (2%) second recall were excluded for ineligibility, missing data, or inadvertent parental self-report. The median number of foods reported on the first recall was 18.0 (interquartile range (IQR) 6.0) and median time to complete was 29.5 min (IQR 17.0). Nutrient intakes for energy, total fat, protein, carbohydrates, fiber, sodium, total sugars, and added sugars were similar across the two recalls and the CCHS.

CONCLUSIONS

The ASA24 was found to be feasible for parent proxy-reporting of children's intake and to yield intake estimates comparable to those from national surveillance, but strategies are needed to increase response rate and support completion to enhance generalizability.

The Equity and Effectiveness of Achieving Canada's Voluntary Sodium Reduction Guidance Targets: A Modelling Study Using the 2015 Canadian Community Health Survey-Nutrition

Background: High sodium intake is a leading modifiable risk factor for cardiovascular diseases. This study estimated full compliance to Canada’s voluntary sodium reduction guidance (SRG) targets on social inequities and population sodium intake. Methods: We conducted a modeling study using n = 19,645, 24 h dietary recalls (Canadians ≥ 2 years) from the 2015 Canadian Community Health Survey—Nutrition (2015 CCHS-N). Multivariable linear regressions were used to estimate mean sodium intake in measured (in the 2015 CCHS-N) and modelled (achieving SRG targets) scenarios across education, income and food security. The percentage of Canadians with sodium intakes above chronic disease risk reduction (CDRR) thresholds was estimated using the US National Cancer Institute (NCI) method. Results: In children aged 2–8, achieving SRG targets reduced mean sodium intake differences between food secure and insecure households from 271 mg/day (95%CI: 75,468) to 83 mg/day (95%CI: −45,212); a finding consistent across education and income. Mean sodium intake inequities between low and high education households were eliminated for females aged 9–18 (96 mg/day, 95%CI: −149,341) and adults aged 19 and older (males: 148 mg/day, 95%CI: −30,327; female: −45 mg/day, 95%CI: −141,51). Despite these declines (after achieving the SRG targets) the majority of Canadians’ are above the CDRR thresholds. Conclusion: Achieving SRG targets would eliminate social inequities in sodium intake and reduce population sodium intake overall; however, additional interventions are required to reach recommended sodium levels.

Trajectories of physical activity, from young adulthood to older adulthood, and pancreatic cancer risk; a population-based case-control study in Ontario, Canada

Background

There is inconsistent evidence on the association between physical activity and pancreatic cancer risk and few studies have investigated early life or life-course physical activity. The objective of this study was to evaluate the association between trajectories of physical activity across the life-course and pancreatic cancer risk.

Methods

A population-based case-control study was conducted (2011–2013) using cases (n = 315) from the Ontario Pancreas Cancer Study and controls (n = 1254) from the Ontario Cancer Risk Factor Study. Self-reported recall of moderate and vigorous physical activity was measured at three time points: young adulthood (20s–30s), mid-adulthood (40s–50s) and older-adulthood (1 year prior to questionnaire completion). Physical activity trajectories were identified using latent class analysis. Odds ratios (OR) and 95% confidence intervals (CI) were estimated from multivariable logistic regression adjusted for covariates: age, sex, race, alcohol, smoking, vegetable, fruit and meat consumption, and family history of pancreatic cancer.

Results

Six life-course physical activity trajectories were identified: inactive at all ages (41.2%), low activity at all ages (31.9%), increasingly active (3.6%), high activity in young adulthood with substantial decrease (13.0%), high activity in young adulthood with slight decrease (5.0%), and persistent high activity (5.3%). Compared to the inactive at all ages trajectory, the associations between each trajectory and pancreatic cancer after confounder adjustment were: low activity at all ages (OR: 1.11; 95% CI: 0.75, 1.66), increasingly active (OR: 1.11; 95% CI: 0.56, 2.21), high activity in young adulthood with substantial decrease in older adulthood (OR: 0.76; 95% CI: 0.47, 1.23), high activity in young adulthood with slight decrease in older adulthood (OR: 0.98; 95% CI: 0.62, 1.53), and persistently high activity (OR: 1.50; 95% CI: 0.86, 2.62). When time periods were evaluated separately, the OR for the association between high moderate activity in the 20s–30s and pancreatic cancer was 0.89 (95% CI: 0.64, 1.25) and some sex differences were observed.

Conclusion

Distinct life-course physical activity trajectories were identified, but there was no evidence that any of the trajectories were associated with pancreatic cancer. Future studies with larger sample sizes are needed to understand the associations between physical activity trajectories over the life-course and pancreatic cancer risk.

Physical activity trails in an urban setting and cardiovascular disease morbidity and mortality in Winnipeg, Manitoba, Canada: a study protocol for a natural experiment

INTRODUCTION

Aspects of the built environment that support physical activity are associated with better population health outcomes. Few experimental data exist to support these observations. This protocol describes the study of the creation of urban trials on cardiovascular disease (CVD)-related morbidity and mortality in a large urban centre.

METHODS AND ANALYSIS

Between 2008 and 2010, the city of Winnipeg, Canada, built four, paved, multiuse (eg, cycling, walking and running), two-lane trails that are 5-8 km long and span ~60 neighbourhoods. Linking a population-based health data with census and environmental data, we will perform an interrupted time series analysis to assess the impact of this natural experiment on CVD-related morbidity and mortality among individuals 30-65 years of age residing within 400-1200 m of the trail. The primary outcome of interest is a composite measure of incident major adverse CVD events (ie, CVD-related mortality, ischaemic heart disease, stroke and congestive heart failure). The secondary outcome of interest is a composite measure of incident CVD-related risk factors (ie, diabetes, hypertension and dyslipidaemia). Outcomes will be assessed quarterly in the 10 years before the intervention and 5 years following the intervention, with a 4-year interruption. We will adjust analyses for differences in age, sex, ethnicity, immigration status, income, gentrification and other aspects of the built environment (ie, greenspace, fitness/recreation centres and walkability). We will also assess trail use and trail user profiles using field data collection methods.

ETHICS AND DISSEMINATION

Ethical approvals for the study have been granted by the Health Research Ethics Board at the University of Manitoba and the Health Information Privacy Committee within the Winnipeg Regional Health Authority. We have adopted an integrated knowledge translation approach. Information will be disseminated with public and government partners.

TRIAL REGISTRATION NUMBER

NCT04057417.

The Association between Early Childhood and Later Childhood Sugar-Containing Beverage Intake: A Prospective Cohort Study

Sugar-containing beverages (SCBs) are a major source of sugar intake in children. Early life intake of SCBs may be a strong predictor of SCB intake later in life. The primary objective of this study was to evaluate if SCB intake (defined as 100% fruit juice, soda, and sweetened drinks) in early childhood (≤2.5 years of age) was associated with SCB intake in later childhood (5-9 years of age). A prospective cohort study was conducted using data from the TARGet Kids! primary care practice network (n = 999). Typical daily SCB intake was measured by parent-completed questionnaires. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression. A total of 43% of children consumed ≥0.5 cups/day of SCBs at ≤2.5 years and this increased to 64% by 5-9 years. Daily SCB intake, compared to no daily intake, at ≤2.5 years was significantly associated with SCB intake at 5-9 years (adjusted OR: 4.03; 95% CI: 2.92-5.55) and this association was much stronger for soda/sweetened drinks (adjusted OR: 12.83; 95% CI: 4.98, 33.0) than 100% fruit juice (OR: 3.61; 95% CI: 2.63-4.95). Other early life risk factors for SCB intake at 5-9 years were presence of older siblings, low household income, and shorter breastfeeding duration. Daily intake of SCBs in early childhood was strongly associated with greater SCB intake in later childhood. Early life may be an important period to target for population prevention strategies.

Validity of self-reported recall of anthropometric measures in early life: A systematic review and meta-analysis

Overweight and obesity in early life are risk factors for many adult-onset chronic diseases. The objective of this study was to assess the validity of self-reported recall of early life anthropometric measures. A systematic review was conducted by searching four electronic databases (PubMed, ProQuest, EMBASE, and MEDLINE). Studies were eligible if they evaluated the validity or reliability of self-reported recall by adults of their own body mass index, height, and/or weight during earlier life periods. Meta-analyses were conducted to pool correlation coefficients and mean differences. There were 15 studies included with a total of 17 477 participants. The mean pooled difference between self-reported recall of BMI compared with prospective measures was 0.06 kg/m² (95% CI, -0.62 to 0.73), and the pooled correlation coefficient was 0.72 (95% CI, 0.65-0.79). Self-reported weight was also strongly correlated with reference standard measures (pooled r = 0.83; 95% CI, 0.72-0.90) with a small mean difference (0.87 kg; 95% CI, 0.19-1.56; I² = 91%). Despite significant heterogeneity, the findings from this review suggest self-reported recall of early life body mass index, height, and weight may be valid measures. This evidence may inform life-course epidemiology studies considering the use of retrospective assessment of self-reported anthropometry.

Continuous cardiometabolic risk score definitions in early childhood: a scoping review

BACKGROUND

Cardiometabolic risk (CMR) in young children has been measured using various approaches, including a continuous summary score that incorporates components such as adiposity, lipids, metabolic factors and blood pressure.

OBJECTIVES

The objective of this study was to comprehensively review definitions of continuous CMR scores in children <10 years of age.

METHODS

A scoping review was conducted using a systematic search of four scientific databases up to June 2016. Inclusion criteria were children <10 years of age and report of a continuous CMR score.

RESULTS

Ninety-one articles were included. Most studies were published from 2007 to 2016 (96%). Nearly all continuous CMR scores (90%) were calculated using the sum or the mean of z-scores, and many articles age-standardized and sex-standardized components within their own population. The mean number of variables included in the risk scores was 5 with a range of 3-11. The most commonly included score components were waist circumference (52%), triglycerides (87%), high-density lipoprotein cholesterol (67%), glucose (43%) and systolic blood pressure (52%).

IMPORTANCE

Continuous CMR scores are emerging frequently in the child health literature and are calculated using numerous methods with diverse components. This heterogeneity limits comparability across studies. A harmonized definition of CMR in childhood is needed.

Relation between opioid-related harms and socioeconomic inequalities in Ontario: a population-based descriptive study

BACKGROUND

Negative health outcomes associated with the use of both prescribed and nonprescribed opioids are increasingly prevalent. We examined long-term trends in opioid-related harms in Ontario across a set of 6 indicators and the relation between harms and neighbourhood income in 2016.

METHODS

We examined rates of neonatal abstinence syndrome, opioid poisoning (fatal and nonfatal) and nonpoisoning opioid-related events from 2003 to 2016 in Ontario using population-based health administrative databases. We conducted descriptive analyses for harm indicators across neighbourhood income quintiles in 2016 (2015 for death). We examined social inequalities in opioid-related harms on both relative (prevalence ratio) and absolute (potential rate reduction) scales.

RESULTS

Rates of opioid-related harms increased dramatically between 2003 and 2016. In 2016, neonatal abstinence syndrome and opioid poisoning and nonpoisoning events showed a strong social gradient, with harm rates being lowest in higher-income neighbourhoods and highest in lower-income neighbourhoods. Prevalence ratios for the lowest-income neighbourhoods compared to the highest-income neighbourhoods ranged from 2.36 (95% confidence interval [CI] 2.15-2.58) for emergency department visits for opioid poisoning to 3.70 (95% CI 2.62-5.23) for neonatal abstinence syndrome. Potential rate reductions for opioid-related harms ranged from 34.8% (95% CI 29.1-40.1) to 49.9% (95% CI 36.7-60.5), which suggests that at least one-third of all harmful events could be prevented if all neighbourhoods had the same socioeconomic profile as the highest-income neighbourhoods.

INTERPRETATION

Rates of opioid-related harms increased in Ontario between 2003 and 2016, and people in lower-income neighbourhoods experienced substantially higher rates of opioid-related harms than those in higher-income neighbourhoods. This finding can inform planning for opioid-related public health interventions with consideration of health equity.

Reducing social inequalities in health: the role of simulation modelling in chronic disease epidemiology to evaluate the impact of population health interventions

Reducing health inequalities has become a major public health priority internationally. However, how best to achieve this goal is not well understood. Population health intervention research has the potential to address some of this knowledge gap. This review argues that simulation studies can produce unique evidence to build the population health intervention research evidence base on reducing social inequalities in health. To this effect, the advantages of using simulation models over other population health intervention research methods are discussed. Key questions regarding the potential challenges of developing simulation models to investigate population health intervention research on reducing social inequalities in health and the types of population health intervention research questions that can be answered using this methodology are reviewed. We use the example of social inequalities in coronary heart disease to illustrate how simulation models can elucidate the effectiveness of a number of ‘what-if’ counterfactual population health interventions on reducing social inequalities in coronary heart disease. Simulation models are a flexible, cost-effective, evidence-based research method with the capacity to inform public health policy-makers regarding the implementation of population health interventions to reduce social inequalities in health.

Effects of cycling and/or electrical stimulation on bone mineral density in children with spinal cord injury

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To determine the effect of cycling and/or electrical stimulation on hip and knee bone mineral density (BMD) in children with spinal cord injury (SCI).

SETTING

Children's hospital specializing in pediatric SCI.

METHODS

A total of 30 children, aged 5-13 years, with chronic SCI were randomized to one of three interventions: functional electrical stimulation cycling (FESC), passive cycling (PC), and non-cycling, electrically stimulated exercise (ES). Each group exercised for 1 h, three times per week for 6 months at home. The hip, distal femur and proximal tibia BMD were examined via dual-energy X-ray absorptiometry (DXA) pre- and post-intervention.

RESULTS

In all, 28 children completed data collection. The FESC group exhibited increases in hip, distal femur and proximal tibia BMD of 32.4, 6.62 and 10.3%, respectively. The PC group exhibited increases at the hip (29.2%), but no change at the distal femur (1.5%) or proximal tibia (-1.0%). The ES group had no change at the hip (-0.24%) and distal femur (3.3%), but a loss at the proximal tibia (-7.06%). There were no differences between groups or within groups over time. Significant negative correlations were found between baseline BMD and the amount of BMD change.

CONCLUSION

Although not achieving statistical significance, hip BMD changes observed were greater than the reported 0.9-10% gains after exercise for children with and without disability. Thus, cycling with and without electrical stimulation may be beneficial for skeletal health in pediatric SCI, but further research is needed with a larger sample size.

Life-course socioeconomic position and type 2 diabetes mellitus: The Framingham Offspring Study

Evidence is lacking on whether the duration and timing of low socioeconomic position (SEP) across a person's life course may be associated with incidence of type 2 diabetes mellitus (T2D). The authors' objectives were to investigate associations between cumulative SEP and the incidence of T2D in the Framingham Offspring Study (n = 1,893; 52% women; mean baseline age = 34 years). Pooled logistic regression analyses demonstrated that age-adjusted cumulative SEP was associated with T2D in women (for low vs. high cumulative SEP, odds ratio (OR) = 1.92, 95% confidence interval (CI): 1.08, 3.42). Age-adjusted analyses for young-adulthood SEP (7.85 for ≤12 vs. >16 years of education, OR = 2.84, 95% CI: 1.03), active professional life SEP (for laborer vs. professional/executive/supervisory/technical occupations, OR = 2.40, 95% CI: 1.05, 5.47), and social-mobility frameworks (for declining life-course SEP, OR = 2.99, 95% CI: 1.39, 6.44; for stable low vs. stable high life-course SEP, OR = 1.85, 95% CI: 1.02, 3.35) all demonstrated associations between low SEP and T2D incidence in women. No association was observed between childhood SEP and T2D in women for father's education (some high school or less vs. any postsecondary education, OR = 1.26, 95% CI: 0.72, 2.22). In men, there was little evidence of associations between life-course SEP and T2D incidence. These findings suggest that cumulative SEP is inversely associated with incidence of T2D in women, and that this association may be primarily due to the women's educational levels and occupations.

Associations between childhood socioeconomic position and adulthood obesity

Childhood socioeconomic position (SEP) is inversely associated with cardiovascular disease and all-cause mortality. Obesity in adulthood may be a biologic mechanism. Objectives were to systematically review literature published between 1998 and 2008 that examined associations of childhood SEP with adulthood obesity. Five databases (Cochrane Library, MEDLINE, EMBASE, PsycINFO, Web of Science) were searched for studies from any country, in any language. Forty-eight publications based on 30 studies were identified. In age-adjusted analyses, inverse associations were found between childhood SEP and adulthood obesity in 70% (14 of 20) of studies in females and 27% (4 of 15) in males. In studies of females showing inverse associations between childhood SEP and adulthood obesity, typical effect sizes in age-adjusted analyses for the difference in body mass index between the highest and lowest SEP were 1.0-2.0 kg/m(2); for males, effect sizes were typically 0.2-0.5 kg/m(2). Analyses adjusted for age and adult SEP showed inverse associations in 47% (8 of 17) of studies in females and 14% (2 of 14) of studies in males. When other covariates were additionally adjusted for, inverse associations were found in 4 of 12 studies in females and 2 of 8 studies in males; effect sizes were typically reduced compared with analyses adjusted for age only. In summary, the findings suggest that childhood SEP is inversely related to adulthood obesity in females and not associated in males after adjustment for age. Adulthood SEP and other obesity risk factors may be the mechanisms responsible for the observed associations between childhood SEP and adulthood obesity.

Improved efficiency Si-photonic attenuator

A forward-biased p-i-n diode integrated with a ridge waveguide forms a basic Si attenuator building block. Disruptive power improvement was achieved through a recessed contact configuration by limiting the amount of Si volume for carrier recombination. A device model was established by using realistic surface recombination velocities instead of effective carrier lifetime concept to understand the device physics of the afore-mentioned Si attenuator.

Implantable FES system for upright mobility and bladder and bowel function for individuals with spinal cord injury

STUDY DESIGN

Postintervention.

OBJECTIVES

To determine the effectiveness of the Praxis multifunctional implantable functional electrical stimulation (FES) system (Neopraxis Pty. Ltd, Lane Cove, NSW, Australia) to provide standing and stepping ability and bladder and bowel management for individuals with motor complete thoracic level spinal cord injuries (SCI).

SETTING

Pediatric orthopedic hospital specializing in SCI.

SUBJECTS

Three males, ages 17 and 21 years, with motor-complete thoracic level SCI and intact lower motor neurons to the muscles targeted for stimulation.

METHODS

Each subject was successfully implanted with the Praxis FES system. All three subjects received electrodes for upright mobility and the first two subjects received additional electrodes for stimulated bladder and bowel management. Following training, subjects were evaluated in their ability to use FES for nine mobility activities. Acute and chronic experiments of the effect of stimulation on bowel and bladder function were also performed.

RESULTS

All three subjects could independently stand up from the wheelchair and could walk at least 6 m using a swing through gait pattern. Two subjects were able to independently perform swing through gait for 6 min and one subject was able to independently ascend and descend stairs. Suppression of reflex bladder contractions by neuromodulation (subject 1) and stimulated contractions of the rectum (subject 2) were observed in acute experiments. When stimulation was applied over the course of several weeks, a positive effect on bowel function was measured. Stimulated bladder contractions were not achieved.

CONCLUSION

The feasibility of using the Praxis FES system for upright mobility and aiding aspects of bladder and bowel function was demonstrated with three subjects with thoracic level SCI.

Patterns of lower extremity innervation in pediatric spinal cord injury

STUDY DESIGN

Retrospective review.

OBJECTIVES

To identify relationships between lower extremity innervation and level of injury, mechanism of injury, and age at injury in a pediatric population with spinal cord injury (SCI). Secondarily, relationships between innervation and completeness of injury, time since injury, race, and sex were evaluated.

SETTING

Pediatric orthopedic referral hospital, Philadelphia, Pennsylvania.

METHODS

Records of 190 subjects, ages 1-21 years, were reviewed. Data collected from the medical record included lower extremity muscle innervation, American Spinal Injury Association (ASIA) level and class, mechanism of injury, age at injury, time since injury, race, and sex. To determine innervation, lower extremity muscles had been tested using surface electrical stimulation and identified as being innervated or denervated. If a muscle responded weakly, strength duration testing was performed. For analysis via logistic regression, subjects were grouped based upon level and mechanism of injury.

RESULTS

A relationship (P<0.0001) was found between ASIA level and lower extremity innervation of all muscles and between length of time since injury and lower extremity innervation for some muscles. Following multiple logistic regression, only ASIA level remained as an independent predictor of lower extremity innervation status.

CONCLUSION

Our results show that lower extremity innervation does differ based on the level of the injury. Denervation began to be seen with injuries in the lower thoracic region and more predominantly with injuries in the lumbar region. This supports our hypothesis that the incidence of lower motor neuron injuries would increase as injuries became more caudal. Our hypotheses of a relationship between innervation status and mechanism of injury and age at injury were not supported. This information is important in determining treatment strategies, eligibility for electrical stimulation techniques, and potential regenerative strategies.

SPONSORSHIP

This study was funded by Shriners Hospitals for Children, Grant #8530.

Implantation of the Freehand System during initial rehabilitation using minimally invasive techniques

STUDY DESIGN

Series of four single subjects with and without intervention design.

OBJECTIVES

To describe a minimally invasive surgical technique used to implant the Freehand System during initial spinal cord injury (SCI) rehabilitation and to report rehabilitation outcomes of four recently injured adolescents using the Freehand System.

SETTING

Nonprofit children's hospital specializing in orthopedic and SCI care.

METHODS

Four subjects with C5 tetraplegia between 13 and 16 years of age and between 9 and 16 weeks following traumatic SCI underwent implantation of the Freehand System using minimally invasive surgical techniques. Outcomes on muscle strength, pinch force, hand function, performance of activities of daily living and satisfaction with and without the Freehand System were collected.

RESULTS

Each subject was successfully implanted with the Freehand System without perioperative complications and employed the Freehand System during therapy services and ad lib on the rehabilitation floor. At the last follow-up, every subject remained a motor candidate for the Freehand System. With the Freehand System, average lateral and palmar pinch force was 1.8 and 1.6 kg respectively; average pinch force without functional electrical stimulation (FES) was 0.29 kg. With the Freehand System, three subjects improved their rate of performance on The Upper Extremity Capabilities Questionnaire. All subjects increased their level of independence on The Quadriplegia Index of Function. On the Canadian Occupational Performance Measure (COPM) with the Freehand System, average performance and satisfaction scores improved for every patient. Three of the four subjects continued to use the system at home.

CONCLUSION

This case series demonstrates that the Freehand System can vastly improve hand function and performance of rehabilitation activities within days after a minimally invasive implant procedure during initial SCI rehabilitation. Satisfaction with the Freehand System beyond initial rehabilitation is evidenced by continued use at home.

Implanted functional electrical stimulation: an alternative for standing and walking in pediatric spinal cord injury

STUDY DESIGN

Post intervention, repeated measures design, comparing two interventions.

SETTING

Orthopedic pediatric hospital specializing in spinal cord injury.

METHODS

Nine subjects, ages 7-20 years, received an eight-channel implanted lower extremity functional electrical stimulation (FES) system for standing and walking. Electrodes were placed to stimulate hip and knee extension, and hip abduction and adduction. Standing and walking were achieved through constant stimulation to the implanted muscles, allowing a swing through gait pattern with an assistive device. After training with FES and long leg braces (LLB), subjects were tested in eight upright mobility activities, which were scored based upon completion time and level of independence.

RESULTS

Seven subjects completed data collection. These subjects completed four activities faster (P<0.02) and five activities more independently (P<0.025) with FES as compared to LLB. Transitions between sitting and standing, which were scored in isolation for two mobility activities, were achieved faster and with more independence with FES. In addition, subjects reported preferring FES for the majority of activities. No activity required more time or more assistance to complete with FES as compared to LLB.

CONCLUSION

The implanted FES system provided these subjects with enhanced functional abilities over traditional LLB and decreased the need for physical assistance by a caregiver, suggesting that it is a realistic alternative for upright mobility in a pediatric population with spinal cord injury.

Visualization of mismatch repair in bacterial cells

We determined the localizations of mismatch repair proteins in living Bacillus subtilis cells. MutS-GFP colocalized with the chromosome in all cells and formed foci in a subset of cells. MutL-GFP formed foci in a subset of cells, and its localization was MutS dependent. The introduction of mismatches by growth in 2-aminopurine caused a replication-dependent increase in the number of cells with MutS and MutL foci. Approximately half of the MutS foci colocalized with DNA polymerase foci. We conclude that MutS is associated with the entire chromosome, poised to detect mismatches. After detection, it appears that mismatch repair foci assemble at mismatches as they emerge from the DNA polymerase and are then carried away from the replisome by continuing replication.

The SOS response: recent insights into umuDC-dependent mutagenesis and DNA damage tolerance

Be they prokaryotic or eukaryotic, organisms are exposed to a multitude of deoxyribonucleic acid (DNA) damaging agents ranging from ultraviolet (UV) light to fungal metabolites, like Aflatoxin B1. Furthermore, DNA damaging agents, such as reactive oxygen species, can be produced by cells themselves as metabolic byproducts and intermediates. Together, these agents pose a constant threat to an organism's genome. As a result, organisms have evolved a number of vitally important mechanisms to repair DNA damage in a high fidelity manner. They have also evolved systems (cell cycle checkpoints) that delay the resumption of the cell cycle after DNA damage to allow more time for these accurate processes to occur. If a cell cannot repair DNA damage accurately, a mutagenic event may occur. Most bacteria, including Escherichia coli, have evolved a coordinated response to these challenges to the integrity of their genomes. In E. coli, this inducible system is termed the SOS response, and it controls both accurate and potentially mutagenic DNA repair functions [reviewed comprehensively in () and also in ()]. Recent advances have focused attention on the umuD(+)C(+)-dependent, translesion DNA synthesis (TLS) process that is responsible for SOS mutagenesis (). Here we discuss the SOS response of E. coli and concentrate in particular on the roles of the umuD(+)C(+) gene products in promoting cell survival after DNA damage via TLS and a primitive DNA damage checkpoint.

An implantable upper extremity neuroprosthesis in a growing child with a C5 spinal cord injury

OBJECTIVES

To implement a functional electrical stimulation (FES) hand neuroprosthesis called the Freehand System in a growing child with spinal cord injury (SCI) using extra lead wire to accommodate limb growth, and to evaluate the performance of the Freehand System during the subject's maturation.

SETTING

Pediatric orthopedic hospital specializing in SCI rehabilitation.

SUBJECT

Ten-year-old female patient with a C5 level SCI.

METHOD

The Freehand System was implanted. Eight electrodes were implanted to targeted forearm and hand muscles to provide grasp and release function. The lead wire associated with each electrode was pathed subcutaneously up the arm with 4 cm of extra lead distributed throughout the path to accommodate expected limb growth. All leads were attached to a stimulator placed in the upper chest. Measures of lead unwinding, limb growth, stimulated muscle strength, and hand function were made at 6 and 16 months after implant.

RESULTS

By 16 months post implant, the upper limb growth plates were closed and humeral and radial bone growth combined was 2.7 cm from the time of surgery. For all eight leads, lead unwinding in the upper arm was approximately 1.2 cm and was comparable to humeral bone growth (1.4 cm). Lead unwinding in the lower arm was also measurable for the two electrodes in hand muscles. Six of eight electrodes maintained grade 3 or better stimulated muscle strength throughout the growth period according to a manual muscle test. Of the two other electrodes, one appeared to have lost function due to depletion of excess lead. However, hand function with FES was comparable at 6 and 16 months post implant suggesting that growth did not negatively impact performance with the FES system. Hand function with FES was improved over voluntary hand function as well. Using the Freehand System, a pinch force of approximately 15 N was achieved compared to 1.3 N of voluntary tenodesis pinch force. Scores on the Functional Independence Measure (FIM) increased by 9 points when FES was used as compared to voluntary function. Improvements occurred primarily in eating and grooming. Independence in writing was achieved only with FES.

CONCLUSIONS

For this child, hand function with the Freehand System was sustained over the growth period and was a significant functional improvement over voluntary hand function. By using excess lead wire, the Freehand System was successfully implemented before skeletal maturity, affording the child improved hand function earlier than would be otherwise indicated.