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People with intellectual and developmental disabilities (IDD) vary in terms of the nature and severity of their disabilities, but for all, their disability is lifelong. They experience of health inequities in the form of higher rates of poor health when compared with the general population. Together with biological factors relating to impairment or genetic factors, adverse social determinants of health contribute to their high rates of comorbid and secondary conditions that account for their poor health. There is a human rights imperative to address their health inequities through broader social change to reduce their socio-economic disadvantages, and systemic changes to healthcare systems to ensure they are afforded the same access to quality care as others in the community. This chapter explores the nature of the health inequities of people with IDD and identifies factors contributing to their poor health. The chapter ends with a review of strategies that show promise in addressing existing health problems, preventing the onset of poor health and improving healthcare systems.
In this chapter, I emphasise and try to explain the importance of historical demography for economic history, but also its relative neglect by ancient historians until very recently. Demography involves a range of quantitative measures that are useful both as proxies for economic performance and in comparison. Population sizes and trends also have explanatory power for past economic changes. Some general points about the relationship between population and economy, and what changed and what stayed the same over the last millennium BCE are followed by some more specific observations about the major periods of Greek history. The importance of environmental factors is particularly emphasised, and urbanization is a persistent theme.
Frailty is an important geriatric syndrome that is common and commonly missed, and affects more than a third of people over age 85. Frailty is characterized by diminished physiologic reserves and function, leading to decreased capacity to withstand stressors. Frail adults are at a higher risk of dependency, institutionalization, and death. Multiple interventions have been attempted, including physical activity, improving nutrition, and hormonal therapy, but there are no curative interventions for frailty and it is not clear if frailty can be reversed. Several issues have limited the advancement of frailty research and translation into practice, including the lack of consensus regarding the definition of frailty, the proliferation of assessment tools, and the gaps in validated best practice guidance for frail patients. The recognition of frailty, especially in its early stages, offers the possibility of preventing or mitigating adverse clinical outcomes. Older adults who are frail may benefit most from a comprehensive geriatric evaluation to help elucidate a plan of care that is consistent with patient's goals, values, and preferences.
This study was carried out throughout 10 fishing seasons between 2002 and 2018 to monitor the population and stock variations of Engraulis encrasicolus (L., 1758) on the south-eastern Black Sea coast of Turkey. Asymptotic length (L∞), growth constant (K) and growth performance indexes (φ) were calculated to be between 12.86 and 15.79 cm, 0.69 and 0.99, 2.10 and 2.29, respectively. Theoretical birth ages were determined to range between (to) −0.15 and −0.27, the maximum ages (tmax) ranged between 3.03 and 4.35, total mortality rates (Z) between 2.19 and 2.66, natural mortality rates (M) between 0.93 and 1.26, the fishing mortality rate (F) between 0.93 and 1.47, and the optimum fishing mortality rate (Fopt.) between 0.37 and 0.62. Fishing mortality rates (F) were estimated to be higher than the optimum fishing mortality rates (Fopt). Z/K ratios were determined to range between 1.91 and 3.43. Current exploitation rates (Ecurr.) were calculated to range between 0.42 and 0.62. The first recruit lengths (Lr) and first capture lengths (Lc50) were estimated to range between from 5.25–7.75 and from 7.66–8.74 cm, respectively. The first maturity lengths (Lm50) of E. encrasicolus ranged between 8.57 and 10.53 cm. The maximum sustainable exploitation levels (Emax) were determined to range between 0.72 and 0.83. These data indicate that if current levels of fishing pressure continue, anchovy stocks will collapse in the near future.
Discontinuation of antipsychotic medication may be linked to high risk of relapse, hospitalization and mortality. This study investigated the use and discontinuation of antipsychotics in individuals with first-episode schizophrenia in relation to cohabitation, living with children, employment, hospital admission and death.
Danish registers were used to establish a nationwide cohort of individuals ⩾18 years with schizophrenia included at the time of diagnosis in1995–2013. Exposure was antipsychotic medication calculated using defined daily dose and redeemed prescriptions year 2–5. Outcomes year 5–6 were analysed using binary logistic, negative binomial and Cox proportional hazard regression.
Among 21 351, 9.3% took antipsychotics continuously year 2–5, 38.6% took no antipsychotics, 3.4% sustained discontinuation and 48.7% discontinued and resumed treatment. At follow-up year 6, living with children or employment was significantly higher in individuals with sustained discontinuation (OR 1.98, 95% CI 1.53–2.56 and OR 2.60, 95% CI 1.91–3.54), non-sustained discontinuation (OR 1.25, 95% CI 1.05–1.48 and 2.04, 95% CI 1.64–2.53) and no antipsychotics (OR 2.00, 95% CI 1.69–2.38 and 5.64, 95% CI 4.56–6.97) compared to continuous users. Individuals with non-sustained discontinuation had more psychiatric hospital admissions (IRR 1.27, 95% CI 1.10–1.47) and longer admissions (IRR 1.68, 95% CI 1.30–2.16) year 5–6 compared to continuous users. Mortality during year 5–6 did not differ between groups.
Most individuals with first-episode schizophrenia discontinued or took no antipsychotics the first years after diagnosis and had better functional outcomes. Non-sustained discontinuers had more, and longer admissions compared to continuous users. However, associations found could be either cause or effect.
The purpose of this study was to identify factors at various time points in life that are associated with surviving to age 90. Data from men enrolled in a cohort study since 1948 were considered in 12-year intervals. Logistic regression models were constructed with the outcome of surviving to age 90. Factors were: childhood illness, blood pressure (BP), body mass index (BMI), chronic diseases, and electrocardiogram (ECG) findings. After 1996, the Short Form-36 was added. A total of 3,976 men were born in 1928 or earlier, and hence by the end of our study window in 2018, each had the opportunity of surviving to age 90. Of these, 721 did live to beyond his 90th birthday.The factors in 1948 which predicted surviving were: lower diastolic BP, lower BMI, and not smoking. In 1960, these factors were: lower BP, lower BMI, not smoking, and no major ECG changes. In 1972, these factors were lower BP, not smoking, and fewer disease states. In 1984, these factors were lower systolic BP, not smoking, ECG changes, and fewer disease states. In 1996, the factors were fewer disease states and higher physical and mental health functioning. In 2008, only higher physical functioning predicted survival to the age of 90. In young adulthood, risk factors are important predictors of surviving to age 90; in mid-life, chronic illnesses emerge, and in later life, functional status becomes predominant.
Hyperhomocysteinaemia (HHcy) is associated with all-cause mortality in some disease states. However, the correlation between HHcy and the risk of mortality in the general population has rarely been researched. We aimed to evaluate the association between HHcy and all-cause and cause-specific mortality among adults in the USA. This study analysed data from the National Health and Nutrition Examination Survey database (1999–2002 survey cycle). A multivariable Cox regression model was built to evaluate the correlation between HHcy and all-cause and cause-specific mortality. Smooth curve fitting was used to analyse their dose-dependent relationship. A total of 8442 adults aged 18–70 years were included in this study. After a median follow-up period of 14·7 years, 1007 (11·9 %) deaths occurred including 197 CVD-related deaths, 255 cancer-related deaths and fifty-eight respiratory disease deaths. The participants with HHcy had a 93 % increased risk of all-cause mortality (hazard ratio (HR) 1·93; 95 % CI (1·48, 2·51)), 160 % increased risk of CVD mortality (HR 2·60; 95 % CI (1·52, 4·45)) and 82 % increased risk of cancer mortality (HR 1·82; 95 % CI (1·03, 3·21)) compared with those without HHcy. For unmeasured confounding, E-value analysis proved to be robust. In conclusion, HHcy was associated with high risk of all-cause and cause-specific (CVD, cancer) mortality among adults aged below 70 years.
Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a severe and life-threatening complication, characterised by multi-organ failure and high short-term mortality. However, there is limited information on the impact of various comorbidities on HBV-ACLF in a large population. This study aimed to investigate the relationship between comorbidities, complications and mortality. In this retrospective observational study, we identified 2166 cases of HBV-ACLF hospitalised from January 2010 to March 2018. Demographic data from the patients, medical history, treatment, laboratory indices, comorbidities and complications were collected. The mortality rate in our study group was 47.37%. Type 2 diabetes mellitus was the most common comorbidity, followed by alcoholic liver disease. Spontaneous bacterial peritonitis, pneumonia and hepatic encephalopathy (HE) were common in these patients. Diabetes mellitus and hyperthyroidism are risk factors for death within 90 days, together with gastrointestinal bleeding and HE at admission, HE and hepatorenal syndrome during hospitalisation. Knowledge of risk factors can help identify HBV-ACLF patients with a poor prognosis for HBV-ACLF with comorbidities and complications.
The success of legal time is to be found in its exterior and standardized character. In this chapter, it argued on the basis of Heidegger and Bergson that such a perspective misses the peculiar characteristics of human time and does not relate well to processes. The first characteristic of human time is that it cannot be stopped. This does not only imply that time is finite, it also means that human time inevitably moves forward from birth to one’s inescapable death. Furthermore, human time cannot be traversed: in a human life, one cannot actually go back to the past or move forward to the future. A third characteristic of human time lies in its irreducible relationship with eternity. If one wants to eternally exclude someone, it is unclear how long this will actually last. Bergson furthermore reminds us that the reference to processes is always inadequate, it is qualitatively different from what it refers. We see this in the discussion of formal and material criteria used to refer to the process of migrants living within a certain territory. Two dominant approaches – jus domicilii and jus nexi – both ultimately fail to grasp such process.
We analysed 23 years of data on strandings of the Antillean manatee Trichechus manatus manatus in Belize, documented by the Belize Marine Mammal Stranding Network, to examine the threats to this population. A total of 451 stranding incidents were reported, of which 376 (83.4%) cases were verified. A total of 286 (63.4%) of the incidents occurred within Belize District, where the number of strandings has almost tripled since 2009. Watercraft collisions accounted for the highest number of strandings, with 131 confirmed cases, and is the leading cause of anthropogenic mortality for this population. Collision with watercraft is an emerging and major threat to manatees in Belize, and is correlated with increases in human activity, in particular associated with tourism. This finding of high levels of manatee deaths in Belize is consistent with trends previously reported for manatees in Florida and Puerto Rico. This work can provide guidance to detect and address similar patterns of mortality in other Antillean manatee populations across the species' range. There is a need for greater awareness of the threats facing the species and its habitat, for stakeholder partnerships to address these threats, implementation of legislation for the protection of manatees, and consistent enforcement of regulations to protect this population. Boating regulations, such as no-wake zones within areas of high manatee presence, as well as regulation of tourism boating activities, need to be implemented to reduce the threats to the species.
Although many studies have reported no rise in suicides in the general population following the COVID-19 pandemic, little is known regarding mental health and substance misuse service patients, groups who have reportedly faced substantial reductions in their access to care during phases of lockdown. However, in this observational study using national registry data, during the first 10 months of the pandemic we found no evidence of an increased risk among people in recent (within 12 months) contact with secondary care. Both long-term and differential effects on subgroups remain to be studied.
Euthanasia and assisted suicide (EAS) are practices that aim to alleviate the suffering of people with life-limiting illnesses, but are controversial. One area of debate is the relationship between EAS and suicide rates in the population, where there have been claims that availability of EAS will reduce the number of self-initiated deaths (EAS and suicide combined). Others claim that legislation for EAS makes it acceptable to end one's own life, a message at variance with that of suicide prevention campaigns.
To examine the relationship between the introduction of EAS and rates of non-assisted suicide and self-initiated death.
We conducted a systematic review to examine the association between EAS and rates of non-assisted suicide and of self-initiated death. We searched PubMed, Scopus, PsycINFO and Science Direct, until 20 December 2021. Studies that examined EAS and reported data on population-based suicide rates were included.
Six studies met the inclusion criteria; four reported increases in overall rates of self-initiated death and, in some cases, increased non-assisted suicide. This increase in non-assisted suicide was mostly non-significant when sociodemographic factors were controlled for. Studies from Switzerland and Oregon reported elevated rates of self-initiated death among older women, consistent with higher rates of depressive illnesses in this population.
The findings of this review do not support the hypothesis that introducing EAS reduces rates of non-assisted suicide. The disproportionate impact on older women indicates unmet suicide prevention needs in this population.
Machine learning has recently entered the mortality literature in order to improve the forecasts of stochastic mortality models. This paper proposes to use two pure, tree-based machine learning models: random forests and gradient boosting, based on the differenced log-mortality rates to produce more accurate mortality forecasts. These forecasts are compared with forecasts from traditional, stochastic mortality models and with forecasts from random forests and gradient boosting variants of the stochastic models. The comparisons are based on the Model Confidence Set procedure. The results show that the pure, tree-based models significantly outperform all other models in the majority of cases considered. To address the lack of interpretability issue associated with machine learning models, we demonstrate how to extract information about the relationships uncovered by the tree-based models. For this purpose, we consider variable importance, partial dependence plots, and variable split conditions. Results from the in-sample fit suggest that tree-based models can be very useful tools for detecting patterns within and between variables that are not commonly identifiable with traditional methods.
Description: Beside pandemics and famines, humans have also suffered from the impact of other kinds of disasters, which at times were very destructive of lives and property. Among these natural disasters there were earthquakes, volcanic eruptions, major floods, hurricanes and tornadoes, and tsunamis. While some of these were clearly Acts of God, increasingly some had some human contribution, because of the growing impact that humans had started to have on nature. This human impact was growing with the passing of time. The increase in the standard of living of humans was increasingly coming at a high natural cost. The chapter provides information on some of the major disasters.
The UK Biobank is a large middle-aged cohort recruited in 2006–2010. We used data from its participants to analyze mortality, survival, and causes of death associated with mental disorders.
Our exposures were mental disorders identified using (1) symptom-based outcomes derived from an online Mental Health Questionnaire (n = 157 329), including lifetime/current depression, lifetime/current generalized anxiety disorder, lifetime/recent psychotic experience, lifetime bipolar disorder, current alcohol use disorder, and current posttraumatic stress disorder and (2) hospital data linkage of diagnoses within the International Classification of Diseases, 10th revision (ICD-10) (n = 502 422), including (A) selected diagnoses or groups of diagnoses corresponding to symptom-based outcomes and (B) all psychiatric diagnoses, grouped by ICD-10 section. For all exposures, we estimated age-adjusted mortality rates and hazard ratios, as well as proportions of deaths by cause.
We found significantly increased mortality risk associated with all mental disorders identified by symptom-based outcomes, except for lifetime generalized anxiety disorder (with hazard ratios in the range of 1.08–3.0). We also found significantly increased mortality risk associated with all conditions identified by hospital data linkage, including selected ICD-10 diagnoses or groups of diagnoses (2.15–7.87) and ICD-10 diagnoses grouped by section (2.02–5.44). Causes of death associated with mental disorders were heterogeneous and mostly natural.
In a middle-aged cohort, we found a higher mortality risk associated with most mental disorders identified by symptom-based outcomes and with all disorders or groups of disorders identified by hospital data linkage of ICD-10 diagnoses. The majority of deaths associated with mental disorders were natural.
This study aimed to address the role of various inflammation-related blood indices for the assessment of in-hospital outcomes in subjects undergoing Glenn procedure. Subjects who underwent the Glenn procedure for hypoplastic left heart syndrome were analysed retrospectively. Subjects were divided into two groups: Group 1 consisted of 78 patients who were discharged, and Group 2 included 12 patients who died after surgery. Post-operative third-day neutrophil count and neutrophil-to-lymphocyte ratio value were significantly higher in the exitus group compared to the discharged group (p = 0.006 and p = 0.003, respectively). Third-day neutrophil-to-lymphocyte ratio was positively correlated with duration of intubation (r = 0.253, p = 0.018), length of stay in ICU (r = 0.296, p = 0.006) and length of hospital stay (r = 0.297, p = 0.005). Multiple logistic regression analysis revealed that patients with high third-day neutrophil-to-lymphocyte ratio (≥6) had 14.227-fold higher risk of death compared to those with lower values. In addition, higher pulmonary arterial pressure was associated with increased risk of death. Receiver operating characteristics analysis revealed that neutrophil-to-lymphocyte ratio had 66.67% sensitivity, 84% specificity, 81.61% accuracy, 40.00% positive predictive value and 94.03% negative predictive value with a cut-off point of ≥6 to predict mortality. Third-day neutrophil-to-lymphocyte ratio and increased post-operative pulmonary arterial pressure are significant predictors for in-hospital mortality in Glenn procedure recipients. A cut-off value of ≥6 for third-day neutrophil-to-lymphocyte ratio predicts mortality with 66.67% sensitivity and 84% specificity. Given its simplicity and availability, post-operative neutrophil-to-lymphocyte ratio should be monitored on a daily basis to identify patients with high risk for mortality after Glenn procedure.
The coronavirus disease 2019 (COVID-19) pandemic had a global impact. The study explores the various COVID-19 experiences in Malta over the past year and provides a snapshot of acute and post-acute COVID-19 symptoms, as well as national vaccination roll-out and hesitancy.
Data on medical access, lifestyle habits, acute and post-acute COVID-19 symptoms, and vaccination hesitancy was gathered through a social media survey targeting adults of Malta. COVID-19 data were gathered from the Malta Ministry of Health COVID-19 dashboard.
Malta controlled COVID-19 spread exceptionally well initially. Since August 2020, the positivity rate, mortality, and hospital admission rates saw a fluctuating incline. From COVID-19 onset, a decrease in physical activity and an increase in body weight was reported. Most participants acquiring COVID-19 were asymptomatic but nontrivial proportion experienced post-acute symptoms. The majority opted to take the COVID-19 vaccine with only a minority expressing safety concerns.
Malta has experienced roller coaster events over a year. The population faced elevated levels of morbidity, mortality, and economic hardship along with negative and positive risk-associated behaviors. Vaccination in combination with population adherence to social distancing, mask wearing, and personal hygiene are expected to be the beacons of hope in the coming months.
The aim of this study was to compare the ability of the Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) to predict 30-d mortality in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection aged 65 y and over.
This prospective, single-center, observational study was carried out with 122 volunteers aged 65 y and over with patients confirmed to have SARS-CoV-2 infection according to the reverse transcriptase-polymerase chain reaction (RT-PCR) test, who presented to the emergency department between March 1, 2020, and May 1, 2020. Demographic data, comorbidities, vital parameters, hematological parameters, and MEWS, REMS, and RAPS values of the patients were recorded prospectively.
Among the 122 patients included in the study, the median age was 71 (25th-75th quartile: 67-79) y. The rate of 30-d mortality was 10.7% for the study cohort. The area under the receiver operating characteristic curve values for MEWS, RAPS, and REMS were 0.512 (95% confidence interval [CI]: 0.420-0.604; P = 0.910), 0.500 (95% CI: 0.408-0.592; P = 0.996), and 0.675 (95% CI: 0.585-0.757; P = 0.014), respectively. The odds ratios of MEWS (≥2), RAPS (>2), and REMS (>5) for 30-d mortality were 0.374 (95% CI: 0.089-1.568; P = 0.179), 1.696 (95% CI: 0.090-31.815; P = 0.724), and 1.008 (95% CI: 0.257-3.948; P = 0.991), respectively.
REMS, RAPS, and MEWS do not seem to be useful in predicting 30-d mortality in geriatric patients with SARS-CoV-2 infection presenting to the emergency department.
Coronavirus disease 2019 (COVID-19) spread globally, including across Europe, resulting in different morbidity and mortality outcomes. The aim of this study was to explore the progression of the COVID-19 pandemic over 18 mo in relation to the effect of COVID-19 vaccination at a population level across 35 nations in Europe, while evaluating the data for cross-border epidemiological trends to identify any pertinent lessons that can be implemented in the future.
Epidemiological data were obtained from European Centre for Disease Prevention and Control and Our World in Data databases while Ministry of Health websites of each respective country and local newspapers were used for COVID-19-related vaccination strategies. Case, mortality, and vaccination incidence comparative analyses were made across neighboring countries.
Similar morbidity and mortality outcomes were evident across neighboring countries over 18 mo, with a bidirectional relationship evident between cumulative fully vaccinated population and case fatality rates.
Countries’ COVID-19 outcome is related on national mitigative measures, vaccination rollouts, and neighboring countries’ actions and COVID-19 situations. Mass population vaccination appeared to be effective in reducing COVID-19 case severity and mortality rates. Vaccination equity and pan-European commitment for cross-border governance appear to be the way forward to ensure populations’ return to “normality.”
People with serious mental illness (SMI) experience higher mortality partially attributable to higher long-term condition (LTC) prevalence. However, little is known about multiple LTCs (MLTCs) clustering in this population.
People from South London with SMI and two or more existing LTCs aged 18+ at diagnosis were included using linked primary and mental healthcare records, 2012–2020. Latent class analysis (LCA) determined MLTC classes and multinominal logistic regression examined associations between demographic/clinical characteristics and latent class membership.
The sample included 1924 patients (mean (s.d.) age 48.2 (17.3) years). Five latent classes were identified: ‘substance related’ (24.9%), ‘atopic’ (24.2%), ‘pure affective’ (30.4%), ‘cardiovascular’ (14.1%), and ‘complex multimorbidity’ (6.4%). Patients had on average 7–9 LTCs in each cluster. Males were at increased odds of MLTCs in all four clusters, compared to the ‘pure affective’. Compared to the largest cluster (‘pure affective’), the ‘substance related’ and the ‘atopic’ clusters were younger [odds ratios (OR) per year increase 0.99 (95% CI 0.98–1.00) and 0.96 (0.95–0.97) respectively], and the ‘cardiovascular’ and ‘complex multimorbidity’ clusters were older (ORs 1.09 (1.07–1.10) and 1.16 (1.14–1.18) respectively). The ‘substance related’ cluster was more likely to be White, the ‘cardiovascular’ cluster more likely to be Black (compared to White; OR 1.75, 95% CI 1.10–2.79), and both more likely to have schizophrenia, compared to other clusters.
The current study identified five latent class MLTC clusters among patients with SMI. An integrated care model for treating MLTCs in this population is recommended to improve multimorbidity care.