The high prevalence of mental health issues among clients attending substance abuse treatment (SAT) has pressured treatment providers to develop integrated substance abuse and mental health care. However, access to integrated care is limited to certain communities. Racial and ethnic minority and low-income communities may not have access to needed integrated care in large urban areas. Because the main principle of health care reform is to expand health insurance to low-income individuals to improve access to care and reduce health disparities among minorities, it is necessary to understand the extent to which integrated care is geographically accessible in minority and low-income communities.N = 402 facilities; 104 offering integrated services) representing the surrounding area within a 10-minute drive. Spatial autocorrelation analyses were used to derive hot spots (or clusters) of census tracts with high concentrations of African American, Asian, Latino, and low-income households. Access to integrated care was reflected by the hot spot coverage of each facility, i.e., the proportion of its service area that overlapped with each type of hot spot.National Survey of Substance Abuse Treatment Services data from 2010 were used to examine geographic availability of facilities offering integration of mental health services in SAT programs in Los Angeles County, California. Using geographic information systems (GIS), service areas were constructed for each facility (GIS analysis suggested that ethnic and low-income communities have limited access to facilities offering integrated care; only one fourth of SAT providers offered integrated care. Regression analysis showed facilities whose service areas overlapped more with Latino hot spots were less likely to offer integrated care, as well as a potential interaction effect between Latino and high-poverty hot spots.Despite significant pressure to enhance access to integrated services, ethnic and racial minority communities are disadvantaged in terms of proximity to this type of care. These findings can inform health care policy to increase geographic access to integrated care for the increasing number of clients with public health insurance. The substance abuse treatment (SAT) field in the United States faces an unprecedented challenge to reduce health disparities among racial and ethnic minority populations suffering from co-occurring substance abuse and mental health disorders -3. AccesHealth care reform in the United States, through the Affordable Care Act, will enable states and counties to provide funding and regulation for behavioral health organizations to further develop integrated care services and expand public insurance coverage for low-income and ethnic minority communities. Los Angeles County plans to expand eligibility for the public insurance program known as Medicaid, referred to as Medi-Cal in California, in 2014 for an estimated 1 million people, mainly Latino (40%) and African American (34%) residents . SAT proThe literature on dual diagnosis has indicated that more than 40% of individuals with substance abuse issues also experience mental illness such as bipolar, depression, or anxiety disorders at some point during their lifetime ,12. In LAccess to integrated mental health and substance abuse treatment is critical to achieve recovery for individuals suffering from co-occurring disorders. Yet, people face significant barriers to accessing this specialty treatment and the literature has suggested that members of racial and ethnic minority groups in particular are less likely to receive treatment due to lack of health insurance, lower socioeconomic status, and consistently high rates of unemployment . In partResearch on access to integrated mental health and substance abuse treatment has focused on the organization, management, and delivery of services. Yet, a growing concern related to access to integrated care for minority and low-income individuals is the burden of traveling to specialized providers. Geographic distance to care represents a significant source of health disparities for low-income individuals and minorities and although several factors contribute to access, high levels of residential segregation and imbalance of geographic proximity to needed services may negatively affect the health and well-being of disadvantaged communities .Studies on health care service utilization have begun to discover place-based disparities involving a significant relationship between the racial and ethnic composition of communities and disparities in health care utilization or availability of physicians, mainly in African American and Latino communities . These aGrowing evidence has suggested that significant disparities exist in access to mental health treatment providers among racial and ethnic minority groups and those living in high-poverty neighborhoods . HoweverFew if any studies regarding low income and racial/ethnic minority communities have focused on distance as a potential barrier to accessing specialty services, yet research has suggested that it is an important factor to promoting health equity by enhancing access to integrated care and improving completion rates -23. FortVarious studies have employed GIS to examine the distribution of treatment centers and the relationship between distance and access to SAT  or Spanihttp://findtreatment.samhsa.gov). These data include the location and services provided by treatment providers and were created to serve as a treatment referral resource for the general public. We used the search tool to identify and download a data table of treatment facilities located in Los Angeles County, California.We relied on publicly available data collected in 2010 from the National Survey on Substance Abuse Treatment Services (NSSAT-S). The source was the directory of SAT facilities drawn from NSSAT-S and publicly available through SAMHSA’s Behavioral Health Treatment Services Locator . Although the dataset included facilities operated by federal agencies, including the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service, facilities connected to the military and criminal justice systems were excluded. This was mainly because military and criminal justice facilities have different operational and service delivery structures and intake criteria, making them inappropriate to compare with regular programs in terms of access by community residents.N-SSATS data are particularly appropriate for analysis of treatment service trends and comparative analyses for the nation, regions, states, and counties. But N-SSATS does not provide geographic information below the county or Metropolitan Statistical Area level in public use files to protect the identity of providers. Also, certain data limitations must be taken into account when interpreting data from the N-SSATS; for instance, the survey is voluntary and there is no adjustment for nonresponse (approximately 4%). Further, the N-SSATS is a point-prevalence survey that provides a cross-sectional snapshot of yearly statistics.hot spots, in L.A. County, racial/ethnic data were drawn from the 2010 Census and poverty data were based on 2006–2010 American Community Survey data. These two sources of data have been used in other GIS studies to examine hot spots in the Los Angeles County area [To identify racial/ethnic minority and low-income clusters, or nty area ,26.To systematically identify and compare SAT facilities with similar organizational structures, three selection criteria were used when searching the SAMHSA database. A facility was included if it was located in L.A. County and (1) was primarily a substance abuse treatment facility ; (2) provided mainly outpatient services; and (3) was not part of a solo practice or connected to the military or criminal justice systems.Our single outcome focused on SAT facilities that offered integrated care. The survey item asked respondents about the main focus of their services. We selected the variable “FOCUS 3,” which in N-SSATS represents SAT facilities that provide “mix of mental health and substance use” services. We determined the likelihood of a SAT facility offering integrated care, using each facility’s coverage of racial/ethnic minority and low-income hot spots as the main predictors.Our main independent variables were each facility’s coverage of hot spots with high concentrations of (1) African Americans, (2) Asians, (3) Latinos, and (4) low-income households. For each facility, service areas were computed to represent the surrounding area within a 10-minute drive to the facility (using any combination of roads). The 10-minute threshold was drawn from the health services research literature, as well as the literature focused on food deserts ,29. The To obtain this hot spot coverage measure, we needed to identify racial/ethnic minority and low-income hot spots as an intermediary step. We used spatial autocorrelation analysis to identify statistically significant clusters of census tracts with large concentrations of African Americans, Asians, Latinos, and low-income households . Spatial autocorrelation refers to the interdependence or interrelatedness among geographic units , particularly units that are closer to one another ,32. SpatData from the 2010 Census and SAMHSA’s facility locator were managed and analyzed using ArcGIS 10.0, a mapping software system designed to facilitate the collection, management, and analysis of spatially referenced information and associated attribute data . A threet tests to determine differences between hot spot coverage of facilities with and without integrated care. In addition, we employed logistic regression models with robust standard error specification for the dichotomous outcome . Goodness-of-fit tests were used to analyze the appropriateness of the regression model.Data analysis was performed using STATA/SE (version 12) for all procedures. We conducted independent sample The statistical analysis complemented the GIS analysis and consisted of two steps. In the first step, four univariate logistic regression models were used to examine the bivariate relationship between a facility’s hot spot coverage (for each of the four different groups) and its odds of offering integrated care. We started with the most populous group in Los Angeles County , followed by African Americans (Model 2), Asians (Model 3), and low-income households (Model 4). The second step relied on three multivariate logistic regression analyses with robust standard errors using a cumulative approach. Because the conceptual framework indicated that communities in Los Angeles County are diverse and feature high rates of low-income individuals, particularly in African American and Latino neighborhoods, a hierarchical nested regressions analysis was conducted to capture the unique explained variance in the outcome for each hot spot across three cumulative statistical models (Models 5–7). Examination of Wald Chi-square tests and quadrature statistics were examined as a goodness-of-fit test to determine the appropriateness of our logistic regression models.Figure t tests, we found that the difference between hot spot coverage of facilities with and without integrated care was only significant for Latino hot spots. Specifically, facilities with integrated care covered significantly less of the Latino hot spots compared to facilities without integrated care . For the other two ethnic minority groups, the difference in hot spot coverage between facilities with and without integrated care was negligible: 17.8% versus 17.0% for African American hot spots  and 10.2% versus 9.7% for Asian hot spots .Among facilities providing integrated care, the hot spot coverage was 17.8% for African Americans, 17.6% for Latinos, and 10.2% for Asians (results only shown in text). Based on these results, Asian communities seemed to have the least access to facilities providing integrated care. However, based on independent sample Logistic regression results for facility coverage of ethnic and low-income hot spots and the likelihood of offering integrated care showed that facilities with greater Latino hot spot coverage were less likely to offer integrated care Table , Model 1In the cumulative regression models, the negative effects of Latino hot spot coverage were consistently statistically significant after adding hot spot coverage for African Americans and Asians .To identify this potential interaction, we tested the interaction of Latino and poverty hot spot coverage and added it to Model 7 (results only shown in text). This interaction was statistically significant and associated with a large odds ratio . Although those providers are also scarce in minority and low income communities , togetheFinally, although we used the same N-SSATS survey data collected in 2010 for the GIS and statistical regression analyses, different versions of N-SSATS data were used. The statistical analysis of N-SSATS used data on organizational and service characteristics, which did not have identifiers, whereas the GIS analysis relied on SAMHSA facility locator N-SSATS data with location and identifiers but limited information on organizational characteristics. However, because the N-SSATS data on treatment facilities represent all treatment providers in the country, both samples were highly correlated. Despite these challenges, the data and methods used here allowed us to develop preliminary evidence of travel burden in distinct areas of L.A. County.Findings from this study provide valuable insight about the access of racial/ethnic communities to integrated care. Although Asian communities had the least coverage in terms of number of facilities providing integrated care, Latino communities were significantly less likely to be located near facilities that provided integrated care than those without integrated care. Latino communities also represented some of the most impoverished areas in the county. Hence, both Latino and low-income communities had limited access to integrated care. Finally, although we did not include Whites in our analysis, the lack of integrated care in low-income communities suggests that this issue may also affect low-income Whites who may also face geographic barriers to services.In sum, access to care in terms of geographic proximity of providers to ethnic and low-income communities varies based on ethnic group, but was most limited among Latino and low-income communities. Although driving time may vary in different cities, the findings still suggest that that certain communities have less access to integrated care than other communities—particularly those that are more reliant on public transportation. These place-based disparities involving a significant relationship between the racial and ethnic composition of communities and disparities in health care utilization or availability of providers  may be rThe authors declare that they have no competing interests.EG participated in the design of the study, developed the first draft of the literature review, and performed the statistical analysis. DK participated in the design and coordination of the study, conducted the GIS analysis, and helped to draft the final manuscript. Both authors read and approved the final manuscript.EG is an assistant professor at the University of Southern California, School of Social Work. His funded research focuses on the geographical and organizational context of Latino health disparities, the implementation of culturally responsive and evidence-based practices, and the integration of behavioral health and primary care. DK is an assistant professor at the University of Houston, Graduate College of Social Work. His funded research focuses on access to behavioral health services and the use of geographic information system data to inform policies on service delivery.


Dear Editor,High quality health services need not only be universally accessible but also utilized by those for whom they are meant. Client satisfaction is an important determinant of health service utilization. According to Keegan, satisfaction comprises both cognitive and emotional facets and is related to previous experiences, expectations and social networks. FulfilliDuring a six months period, 415 patients were recruited from all of the public and private rehabilitation clinics existing in the Kurdistan Province of Iran using stratified sampling method. M/F ratio was 202/197. More than 50% of the participants were in the 25-44 year-old age group. A telephone interview was carried using a questionnaire which was a newly developed Iranian rehabilitation client satisfaction questionnaire and consisted of two main parts. The first part intended to measure and score clients’ satisfaction. The secoAfter completing the interviews, the responses were reviewed and coded by multiple researchers. Codes were grouped together under larger themes. Factors mentioned by clients as the major satisfying and major dissatisfying factors, were categorized into 7 main dimensions; physical environment, physical accessibility, time accessibility, financial accessibility, quality of care and equipments, personnel’s social interaction, and equity.The five most frequently stated ‘negative dissatisfying situation’s were: lifelessness of the environment mentioned by both public and private center clients, no insurance coverage mentioned only by private center clients, closed afternoon hours mentioned only by public center clients, having stairs mentioned only by private center clients and narrow corridors for wheelchair passage mentioned by both public and private center clients.The five most commonly stated ‘positive satisfying situations’ were therapist's precise answers to the clients' questions mentioned by both public and private center clients, reasonable fees and low costs mentioned only by public center clients, the admittance personnel's good, kind and calm behavior mentioned only by private center clients, the therapist's kind and empathic behavior mentioned by both public and private center clients, open afternoon hours mentioned only by private center clients and being under the coverage of all insurance companies mentioned only by the clients of public centers.Surprisingly, to our knowledge, current literature on client satisfaction rarely focuses on factors comprising the different dimensions of satisfaction in details. This is true despite the fact that knowledge about the details of client satisfaction is the key to reform in every kind of service. We have intentionally avoided this pitfall in the present study. According to our findings, we suggest that making the following changes is required for assuring more satisfying conditions in rehabilitation centers:(i) In terms of physical characteristics: Utilization of lively colors and provision of sufficient light for the environment, (ii) In terms of time accessibility: Introducing different kinds of rehabilitation services in each center, especially those frequently required simultaneously by rehabilitation clients and also providing afternoon open hours, (iii) In terms of financial accessibility: provision of insurance coverage, and (iv) In terms of personnel’s social interaction: Training the logistic staff, especially the admittance personnel, on personal interactions, along with ongoing monitoring and feedbacks.


Electrodiagnostic Functional Assessment (EFA) objectively evaluates injuries to muscles by incorporating surface electromyography (EMG) to measure myoelectrical signals of muscle groups recorded from up to 18 sensors placed on the skin surface while simultaneously assessing functional capacity at rest and during full range of motion. The evaluation is non-invasive and non-loading and provides measurements in real time. Soft-tissue damage of ligaments, tendons, and muscles, commonly referred to as sprains and strains, has proven to be very difficult to accurately diagnose and assess and represents the highest incidence rate, lost days and medical costs in the workers' compensation system. 100 patients presenting with work-related musculoskeletal injuries exhibiting physical complaints that persisted for at least two consecutive weeks for which no general medical explanation could be established after medical history and exam, were evaluated using EFA in our Occupational Clinic in New Jersey over a 36 month period. The results of this study demonstrated the clinical effectiveness of the EFA as an objective diagnostic aid for identifying and quantifying soft tissue injuries and devising site specific physical therapy treatment regimen to return the injured worker to full duty work release. The U.S. Department of Labor and Occupational Safety and Health Administration (OSHA) define a musculoskeletal disorder (MSD) as an injury of the muscles, nerves, tendons, ligaments, joints, cartilage and spinal discs. OSHA identifies examples of MSDs to include: Carpal tunnel syndrome, Rotator Cuff syndrome, De Quervain's disease, Trigger finger, Tarsal tunnel syndrome, Sciatica, Epicondylitis, Tendinitis, Raynaud's phenomenon, Carpet layers knee, Herniated spinal disc, and Low back pain. The World Health Organization characterizes work-related MSDs as multifactorial to indicate the inclusion of physical, organizational, psychosocial, and sociological risk factors.These types of disorders commonly referred to as soft tissue injuries (STI) as well as sprains and strains most often present as injury or pain of the back, neck, shoulder or knee, are a major source of disability. Taken together, they represent the majority of compensable injuries accounting for 29% of total cases . The eveAccording to OSHA, the average cost per incidence of an MSD is estimated to be $12,000. If surgery is required, the average cost rises to $43,000 per incidence according to the American Society of Orthopedic Surgeons. MSDs cost U.S. industry $15-20 billion in worker's compensation costs with total costs as high as $45-60 billion per year [Although workers compensation claims have steadily decreased at approximately 3% annually for the past two decades, the number and frequency of Permanent Total Disability (PTD) claims has significantly increased since 2005 in part, attributable to the aging of the U.S. workforce. Of equal concern, indemnity & medical costs in workers compensation have continued to increase 9-12% per year, while lost days from work have incurred annual increases of 5-7% . UtilizaThe standard approach to managing soft tissue injuries is to obtain a medical history and perform a physical examination. Imaging or testing usually is not needed in the early phases of treatment. In most cases, the natural history of an STI condition resolves without intervention. However, in those cases where complaints of pain and disability persist, the Occupational Medicine (OM) provider should adhere to treating the problem within evidence-based medicine (EBM) guidelines.While frequently utilized, subsequent diagnostic modalities are, in many cases, not appropriate for assessing soft tissue injuries.X-ray investigation can be used to assess the possibility of fracture or dislocation; however, in low back pain (LBP) x-ray is rarely indicated. Nerve conduction studies may be used to localize nerve dysfunction, and Electrodiagnosis may help differentiate between myopathy and neuropathy. Magnetic resonance imaging (MRI) and CT scans, while excellent tests to evaluate structure are static and not designed to assess muscle function dynamically (while patient is in motion). In addition, these standard tests all carry a high false positive rate . The resNot surprisingly, soft tissue injuries are difficult to diagnose because the above diagnostics are frequently unable to document the presence of pain and loss of function. In many instances, this leads to prolonged duration of disability and lost time, and increased medical costs, based on poorly defined diagnosis and no classification of work category. This can lead to costly misdiagnosis, unnecessary surgery, prolonged treatment periods, and fraudulent claims. In the absence of objective medical evidence, "proof" of a soft tissue injury is typically established through medical records documenting results of medical examinations and the insured's complaints of pain and in cases of litigation, testimony from duelling experts whereby each party presents a medical opinion. The need for accurate, timely and evidence-based diagnosis and treatment for soft tissue injuries is needed to curtail these escalating costs and improve clinical outcomes.In Occupational injuries, the physician's role is to assess the injury, determine causality/work relatedness as well as determine if the injury is acute or chronic pre-existing pathology. This task has become increasingly complex as the workforce gets older, workers develop degenerative pathology that may or may not be the responsibility of the employer. It is estimated that over 57% of the working population would have "abnormal findings" if they were to undergo a lumbar MRI .The concept of probing for and identifying psycho-social issues by OM providers can no longer be ignored. In work-related back and neck pain there is strong evidence that psychosocial variables generally have more impact than biomedical or biomechanical factors . Job disIt is important for the OM provider to perform structured and detailed histories. It is not uncommon for patients to forget or deny prior injuries, claims, or operations. One study reported 42% of patients claimed pre-injury status as superior in 15/16 areas tested . Under-rIn this retrospective analysis of 100 individuals with reported work-related soft tissue injuries, we sought to determine the effectiveness of Electrodiagnostic Functional Assessment (EFA) in diagnosing soft tissue related injuries and to access the impact on outcomes to include claim closure, return to work, and litigation. Patients were initially managed by standard methods including work restrictions, physical therapy, and medications. Patients were referred for EFA testing when physical exam findings had normalized; however, they still reported significant subjective complaints.The Electrodiagnostic Functional Assessment (EFA) was utilized to evaluate people who presented with soft tissue injuries. The EFA instrumentation is an FDA 510 K registered Class II Diagnostic Device.The EFA can objectively determine the nature, acuity, and extent of the injury, the precise location of injury and source of referred pain, the significance of disc pathology and site specific treatment. The EFA is the integration and enhancement of accepted diagnostic tests into one dynamic evaluation. Specifically, EFA incorporates surface electromyography (EMG) to measure myoelectrical signals of muscle groups recorded from up to 18 sensors affixed to the skin surface of underlying muscle groups while simultaneously assessing functional capacity at rest and during full range of motion (ROM). The resulting output is an accurate representation of muscle function and effort. According to the FDA registration, it has false positive rating of +- ten (10) percent. Raw EMG data is analyzed to give a more accurate representation. The limiting factor would be if a packet sample is missed but this is adjusted by reviewing the raw data. Peer reviewed evaluation of clinical and diagnostic utility of surface EMG concluded that it may be useful to detect the presence of neuromuscular disease, allows prolonged recordings of muscle activity from multiple sites simultaneously, and is deemed an acceptable method for recording and quantifying clinically important muscle related activity with the least interference on the clinical picture  FunctionA state-of-the-art ROM apparatus captures full freedom of movement: flexion, extension, rotation, as well as lateral movements of a patient with the sensitivity to monitor muscle group activity dynamically while filtering out positional changes.EFA can determine the approximate age of an injury by graphical interpretations of myoelectrical activity of muscle groups. Chronic Injuries are characterized by muscle compensation, bilateral changes, absence of the flexion-relaxation response, and bilateral vasoconstriction. Conversely, the presence of muscle spasms and hyperactivity is indicative of an acute injury. The ability to distinguish between acute and chronic pathology provides objective determinations of compensability and apportionment.EFA can objectively quantify effort and identify patient compliance, malingering, and in pain by recording presence or absence of type II motor recruitment when patient is instructed to perform isometric functional capacity component of the EFA.Many soft tissue injuries are reported as work related and, consequently, are submitted as worker's compensation claims. Occupational Medicine's (OM) primary goal of injury management is functional restoration and returning the patient to pre-injury status so that the patient is capable of returning to work. The OM physician is best served by treating the patient within EBM guidelines in order to achieve this outcome. Soft tissue injuries are poorly understood and accurate diagnosis has proved elusive. Therefore, correctly diagnosing the problem and its relation to the workplace is imperative. The Electrodiagnostic Functional Assessment (EFA) is an FDA registered diagnostic device specifically designed to objectively diagnose injuries to muscles and connective tissue.Over a three year period, 103 EFA tests were performed on 100 patients evaluated and treated at Occupational Medicine South, PC an occupational medicine facility in Southern New Jersey. Patients that presented with reported work related soft tissue injuries were initially managed by standard methods including work restrictions, physical therapy and medications. Patients were referred for EFA testing when their physical exam findings had normalized but still reported significant subjective complaints. Three patients that had prior EFA's were evaluated with the EFA at onset of new complaints to compare to baseline.Of the 100 injured workers that underwent EFA testing 56% were female and 44% male. Patient age ranged from 22 yrs to 66 years. The average age was 43 years. However, 68% of patients were 40 years of age or older. See Table The most common site of injury was low back. 65% of all study participants reported injury involving the lower back with over half experiencing pain exclusively at lumbosacral and the remaining involving multiple sites of injury to include low back. Approximately 20% of patients reported shoulder injuries.The most common source for injuries occurred in the Healthcare field. The vast majority were healthcare practitioners  and technical occupations. Most of the injuries were reported as the result of lifting and moving patients. Other common sources accounting for injuries included the Transportation category comprised primarily of drivers of trucks and buses. Cause of injury was either result of vehicular accident or exertional in nature during delivery of cargo followed by construction workers and trade professionals as well service technicians to include auto/boat mechanics, HVAC, utility and apartment superintendents.DOI to date of EFA evaluation ranged from one week to 90 weeks. The average time for EFA test was 16 weeks post injury however, after the removal of outliers, a more accurate average time was approximately 9 weeks. Soft tissue injuries were initially treated with conservative measures such as physical therapy, job modification and medications. The majority of work related soft tissue claims resolved within a 4 to 6 week period without need for further treatment or testing. Patients who did not respond to treatment as expected and/or had physical exam findings which had normalized but still reported significant subjective complaints, were then referred for EFA. The 9 weeks time period is realistic in these patients and practice pattern between initial reporting, treatment, referral for EFA, approval of testing and performance of test.73% of injured workers were found to have chronic, unrelated pathology, much of it age related degeneration. Since the injury was pre-existing the claim was non compensable and the worker was cleared to return to work. Virtually all of these same workers were found to be non-compliant as well meaning they did not cooperate or malingered when instructed to perform functional capacity and ROM during their EFA evaluation as evidenced by the limited/inappropriate recruitment of type II motor units. Patient Compliance, Malingering and Pain: these results corroborated with the treating physicians diagnosis during initial physical exam. Again, only patients with subjective complaints in the absence of objective findings were given EFA assessment. See Table In one instance, the EFA's objective and conclusive data altered the initial diagnosis that the patient did not have significant pathology. EFA results showed significant acute and chronic injury for the worker depicted in Figure Two patients on Temporary Total Disability (TTD) were stopped after their EFA found no acute compensable pathology. Both patients appealed to New Jersey Division of Workers' Compensation. One is pending and the other was recently settled:The claimant was involved in an auto accident in May 2008 while operating a school bus with an alleged injury to her cervical and lumbar spine. The MRI revealed positive findings and the claim was accepted as compensable and treatment was authorized. Epidural steroid injections after conservative care failed to alleviate symptoms. After the first injection In March 2009, the claimant alleged numbness and paralysis of the lower extremities and was hospitalized for almost a month as the doctors tried to confirm and diagnose the problem. On discharge, there were no objective findings noted and suggestions for possible psychiatric issues. An EFA was conducted in conjunction with an Independent Medical Evaluation (IME) and found:• Normal Evaluation• Inconsistency between the objective findings and subjective complaints• Objectively non compliant• Hospitalization not related to or aggravated by date of loss• Maximum Medical Improvement (MMI) pre injury status with no rateable impairmentBased on the findings of the EFA/IME the carrier denied any further medical or indemnity benefits. The claimant continued allegations for total disability. The claim went before New Jersey Division of Workers' Compensation Judicial Board and was settled for $16 K with a 55 percent savings on the reserve. Of note, all medical payments were prior to the EFA except for the EFA/IME charges.27% of patients had acute pathology and were prescribed site-specific physical therapy (PT) treatment regimen designed to return the worker to MMI with no rateable impairment status and full release to work duty. Recommended PT ranged from 2 to 12 sessions. The average treatment regimen prescribed was 6 PT sessions of muscle-specific therapy. At the conclusion of PT, all workers were released at MMI with no rateable impairment.According to the Bureau of Labour Statistics, most occupational injuries are "soft tissue" sprains/strains of the low back, shoulder, neck and knees. Physician directed care based on Evidenced Based Medicine should guide an accurate diagnosis as well as early aggressive conservative intervention. The EFA is an innovative diagnostic aid that is objective, reproducible, definitive, and evidence based. It is a significant in that it can assist an Occupational Medicine provider in objectively assessing the multiple varying subjective complaints and drill down to the soft tissue level to make an accurate diagnosis.EFA test results affected the course of treatment, improved clinical and functional outcomes, increased patient satisfaction, and decreased dispute litigation. In fact, 98 of the 100 cases resulted in return to maximum medical improvement with no rateable impairment and full release to active duty. Only two percent of the cases were challenged and 98% of the EFA control group returned to their pre-injury job. This paper is a case reference for 100 cases tracked over a three year time period and serves as an illustration of results utilising a new diagnostic aid.MR is the president of Insight Diagnostics Inc that provides EFA testing. There are no competing interests for JK.JK and MR carried out the patient selection, analysis of data and drafting of this manuscript. All authors have read and approved the final manuscript.


While consensus on malaria vector control policy and strategy has stimulated unprecedented political-will, backed by international funding organizations and donors, vector control interventions are expansively being implemented based on assumptions with unequaled successes. This manuscript reports on the strategies, achievements and challenges of the past and contemporary malaria vector control efforts in Zambia.All available information and accessible archived documentary records on malaria vector control in Zambia were reviewed. Retrospective analysis of routine surveillance data from the Health Management Information System (HMIS), data from population-based household surveys and various operations research reports was conducted to assess the status in implementing policies and strategies.Empirical evidence is critical for informing policy decisions and tailoring interventions to local settings. Thus, the World Health Organization (WHO) encourages the adoption of the integrated vector management (IVM) strategy which is a rational decision making process for optimal use of available resources. One of the key features of IVM is capacity building at the operational level to plan, implement, monitor and evaluate vector control and its epidemiological and entomological impact. In Zambia, great progress has been made in implementing WHO-recommended vector control policies and strategies within the context of the IVM Global Strategic framework with strong adherence to its five key attributes.The country has solid, consistent and coordinated policies, strategies and guidelines for malaria vector control. The Zambian experience demonstrates the significance of a coordinated multi-pronged IVM approach effectively operationalized within the context of a national health system. Malaria remains a leading cause of morbidity and mortality in sub-Saharan Africa . Vector Indoor residual spraying (IRS) and insecticide-treated bed nets (ITNs) remain the frontline interventions for malaria vector control -16. In rEmpirical evidence is critical for informing policy decisions and tailoring interventions to local settings. Due to anecdotal data, vector control tools are often based on assumptions i.e.: the rapid and significant impact of IRS for suppressing unstable malaria; the amenability of ITNs in effectively targeting the most vulnerable subgroups within communities with stable transmission; and, the greater operational and logistical ease of building and sustaining an ITN programme compared to an IRS one . Thus, cAnopheles gambiae.s.s, Anopheles arabiensis and Anopheles funestus[In Zambia, the major malaria vectors are  funestus,30, with funestus,32. PoliThe study was a retrospective analysis of routine surveillance data from the Health Management Information System (HMIS), data from population-based household surveys and various operations research reports.The Zambian Ministry of Health (MoH) through the National Malaria Control Centre (NMCC) is responsible for the coordination and management of all vector control programs in the country. Transmission-reducing interventions ) are implemented and recorded at district level by the District Health Management Teams (DHMT) in collaboration with community health workers. All available information and accessible archived documentary records on malaria vector control in Zambia were reviewed to assess the status in implementing policies and strategies.A desk-based retrospective analysis was used to assess the progress in programmatic implementation, epidemiological and entomological impact of interventions. Programmatic progress and epidemiological impact was assessed through analysis of routine surveillance data from the HMIS, nationally representative cross-sectional population-based household surveys ,33 and D• Historical malaria vector control efforts. Malaria control in Zambia commenced in 1929 , and hasreducing malaria morbidity and mortality by 50%”. The policy emphasized prevention with ITNs [“A malaria-free Zambia”, a theme of “scaling-up for impact” and the main goal of “reducing malaria incidence by 75% and under-five mortality due to malaria by 20% by the year 2010”. This policy included vector control using ITNs and IRS supplemented with LSM [• Malaria vector control policy change. In 1992, Zambia began health reforms and malaria control was prioritized in the basic health care package . The NMCith ITNs . In 2000ith ITNs  resultinith ITNs . Malariaith ITNs . In 2005with LSM .“A malaria-free Zambia” and a theme of “consolidating malaria control gains, for higher impact” and three main goals “to reduce malaria incidence by 75% of the 2010 baseline, by 2015”, “to reduce malaria deaths to near zero and reduce all-cause child mortality by 20% of the 2010 baseline, by 2015” and “to establish and maintain five malaria-free areas in Zambia by 2015”[• Contemporary interventions. The current 2011–2015 NMSP seeks to provide the strategic framework for the NMCP, for the next five years. It has a vision of  by 2015”. Vector  by 2015”.In Zambia vector control is implemented within the context of the IVM Global Strategic framework with strong adherence to its five key attributes ,44. Prog2 ; and lambda cyhalothrin, (Syngenta), carbamates (Bayer), organophosphates (Syngenta) and DDT at 2 g/m2 (Avima). The spraying is carried out prior to the peak malaria transmission that coincides with the rainy season from November to April [• Indoor residual insecticide spraying. The operational design for IRS has an annual cycle . The intto April . Communito April ,48. Compto April .• Insecticide-treated bed nets. The distribution of ITNs strives towards attaining a goal of universal (100%) coverage with at least 85% utilization rates in all eligible areas . The covBacillus thuringensis israelensis (Bti) and Bacillus sphericus (Bs) and simple environmental modification and manipulation approaches i.e. canalisation, draining and land filling were reintroduced at programme level as supplementary tools to IRS and ITNs based on the stakeholders consensus meeting. This followed feasibility assessments for LSM conducted by Valent Biosciences Corporation, Durham university and the WHO [• Larval source management. Larviciding with  the WHO . The int the WHO , with fu• Environmental and personal safeguards. Insecticide-based vector control requires sound environmental and personal safeguards and development of strong stewardship, institutional strengthening of in-country regulatory bodies is pivotal for protecting health and environment. Insecticides for IRS are regulated by the Environmental Protection and Pollution Control Act of Zambia that defines and mandates sound management of pesticides. Internationally, Zambia is party to the Stockholm convention on Persistent Organic Pollutants (POPs), which it ratified in 2006 and National Implementation Plans (NIPs) exist to ensure adherence to the treaty. The MoH ensures safe distribution and storage of vector control commodities and equipment through standardized and stringent stock management and control. All storage facilities need to conform to the WHO standard and should be licensed by the Zambia Environmental Management Agency (ZEMA), the in-country regulatory body. In the face of increased population , strengt• Monitoring and evaluation. In order to make evidence based decisions for vector control, systematic and improved monitoring and evaluation for both programmatic progress and outcome and impact is critical. In Zambia, deployment of tools has been streamlined through a geographical information system (GIS) based decision support . PrimaryP = 0.938) [P = 0.003) and a decline in the percentage of children with severe anaemia from 13.8% to 4.3% between 2006 and 2008 and 16% in 2010  . The GIS= 0.938) . Since 2In view of the scaling up, logistical challenges include inadequate transport and storage capacity at district level that invariably deter efficient delivery of both IRS and ITNs. Delays in disbursement of funds for IRS affects timely procurement and implementation of interventions, resulting in IRS not covering 100% of the earmarked households. Challenges with ITNs still remains low utilization Table , lack ofVector control has a proven record for saving lives by preventing, reducing or eliminating the transmission of vector-borne diseases . As exemAdvocacy, social mobilization and legislation; Colla-boration within the health sector and with other sectors; Integrated approach; Evidence-based decision-making and Capacity-building[The deployment of an effective and evidence-based malaria vector control requires locally informed decisions as the epidemiology of the disease varies at a small scale, suggesting the need for precise targeting . To this-building,44. Zamb-building. In respProgrammatic scaling-up of WHO-recommended vector control tools have been intensified with substantial scores, as compared with set international targets. However, vector control is not a sole preserve of the ministry of health alone but requires involvement of various stakeholders including community engagement . The IVMIn the wake of scaled up transmission-interrupting strategies, monitoring and evaluation of the vector control interventions is an indispensable underpinning for rational and evidence based IVM approach. The historical vector control efforts where characterized with limited entomological monitoring and lack of comprehensive studies on impact of interventions on malaria vectors. Currently, there is strong evidence-based monitoring and evaluation to facilitate for the documentation of progress made towards the achievement of international goals and targets by 2015 Table . Over thWhile there is enough capacity for planning and deploying vector control tools at provincial and district level in Zambia, there is need to further strengthen capacity for entomological and epidemiological monitoring of interventions. Particularly, establishment of entomological capital equipment and infrastructure capacity at these levels, including increased human resource training to be able to drive forward the malaria vector control agenda. This will not only maintain the required capacity for implementation, given the high levels of human resource attrition, but facilitate for the tracking of primary entomological parameters which are critical for guiding deployment and impact assessment of interventions.Maintaining the momentum and the gains is critical as the programme strives to achieve universal coverage of evidence-based and proven interventions. With the development of insecticide resistance and the potential shift in malaria vector bionomics i.e. indoor biting to out door biting, the current vector control methods are not devoid of limitations. To sustain the efficacy of the vector control tools, commitment towards conservation of the limited arsenal of insecticides by their judicious use through a rational insecticide resistance management strategy guided by regular and expansive insecticide resistance surveillance and mapping together with increased monitoring of malaria vector bionomics is critical . There iIn light of the challenges of the dwindling financial resources that have followed in the wake of diminishing donor support and the limited Government funding for malaria control, streamlined uptake and purposeful deployment of key vector control tools requires efficient utilization of supportive strategies. To further improve coverage and utilization rates of interventions; a regularly updated, interactive, comprehensive and sustained national advocacy, IEC/BCC campaign, and a viable operations research feeding into and providing timely and sound evidence to guide implementation and inform policy decision-making are critical. To ensure and sustain adherence to high standards of supervision monitoring and evaluation, and adherence to personal and environmental safeguards, legal standards and guidelines is cardinal.The IVM strategy requires reconsidering the combination of vector control methods over time, as the environment, epidemiology and resources change . Even wiIn response to the increasing burden of malaria and the call by the WHO for scaled up implementation of proven vector control interventions, coupled with the unprecedented availability of resources for vector control, the Zambian NMCP has made progress in setting up strategies, scaling up programmatic implementation of interventions and monitoring their impact on malaria control. Sustained delivery of effective and evidence based vector control interventions has been informed by emerging evidence from ongoing operational research coupled with strengthened advocacy, social mobilization and political leadership. To attain the goal of elimination increased inter-sectoral collaboration and community involvement, strengthened supervision, technical and operational coordination and collaboration including cross boarder initiatives and resources mobilization is cardinal to reduce transmission. The Zambian experience demonstrates the significance of a coordinated multi-pronged IVM approach effectively operationalized within the context of a national health system.ACT: Artemisinin-based combination therapy; BCC: Behaviour Change Communication; CHW: Community Health workers; DDT: Dichloro Diphenyl Trichloroethane; DHMT: District Health Management Team; DHS: Demographic Health Survey; DSS: Decision Support System; EM: Environmental Management; GEF: Global Environment Facility; GFAT: Global Fund to fight AIDS/Tuberculosis and Malaria; GIS: Geographical Information System; HMM: Home Management of Malaria; HMIS: Health Management Information System; HSSP: Health Systems Strengthening Programme; IEC: Information Education and Communication; IRS: Indoor Residual Spraying; IVCC: Innovative Vector Control Consortium; IVM: Integrated Vector Management; JICA: Japanese International Corporation Agency; LLINs: Long-Lasting Insecticidal Nets; LSM: Larval Source Management; MACEPA: Malaria Control Evaluation Programme in Africa; MIS: Malaria Indicator Survey; NDP: National Development Plan; NHSP: National Health Strategic Plan; NHC: Neighbourhood Health Committees; NIP: National Implementation Plans; NMSP: National Malaria Strategic Plan; NMCC: National Malaria Control Centre; NMCP: National Malaria Control Programme; PMI: Presidents Malaria Initiative; POP: Persistent Organic Pollutants; RBM: Roll Back Malaria; RDT: Rapid Diagnostic Tests; SEA: Supplementary Environmental Assessment; UNEP: United Nation Environment Programme; USAID: United States Agency for International Development; WHO: World Health Organization; WHOPES: World Health Organization Pesticide Evaluation Scheme; ZEMA: Zambia Environmental Management Agency.The authors declare that they have no competing interests.EC: Conceived the idea, collected and analysed the data, and drafted the manuscript. VMM, MK and MBM: Critically reviewed the manuscript. UH: Guided data analysis and interpretation and contributed to the drafting of the manuscript. All authors read and approved the final manuscript.


Variation in polyglutamine repeat number in the androgen receptor (AR CAGn) is negatively correlated with the transcription of androgen-responsive genes and is associated with susceptibility to an extensive list of human disease. Only a small portion of the heritability for many of these diseases is explained by conventional SNP-based genome-wide association studies, and the forces shaping AR CAGn among humans remains largely unexplored. Here, we propose evolutionary models for understanding selection at the AR CAG locus, namely balancing selection, sexual conflict, accumulation-selection, and antagonistic pleiotropy. We evaluate these models by examining AR CAGn-linked susceptibility to eight extensively studied diseases representing the diverse physiological roles of androgens, and consider the costs of these diseases by their frequency and fitness effects. Five diseases could contribute to the distribution of AR CAGn observed among contemporary human populations. With support for disease susceptibilities associated with long and short AR CAGn, balancing selection provides a useful model for studying selection at this locus. Gender-specific differences AR CAGn health effects also support this locus as a candidate for sexual conflict over repeat number. Accompanied by the accumulation of AR CAGn in humans, these models help explain the distribution of repeat number in contemporary human populations. An applied understanding of the evolutionary forces shaping human health and disease susceptibility has profound medical implications, providing clinical insights and suggesting novel, testable hypotheses (Di Rienzo Tandem-repeat polymorphisms can be key components of human phenotypic and disease-related variation (Ashley and Warren Two well-studied human tandem-repeat polymorphisms are situated within the X-linked androgen receptor (AR) gene, which codes for a transcription factor that mediates binding of the androgens testosterone (T) and dihydrotestosterone. Androgens play an integral role in the organizational and ontogenic processes involved in sexual differentiation and male-sexual development during embryogenesis  whose numbers vary both within and between human populations . IndepenFirst, balancing selection contributes to human illness when deleterious alleles are maintained in the population through heterozygote advantage or when disease risk results from extremes of bidirectional variation in gene expression , the online mendelian inheritance in man (OMIM) database , and the genetic association database . All phenotypes associated with polymorphisms in AR CAGn were initially included, but mutations or polymorphisms at other loci in the AR (e.g. AR GGNn) were discarded. Using phenotypes and references obtained from these databases, subsequent searches focused on disease phenotypes and risk associations, and studies investigating the molecular structure and function of the AR were included only for interpreting mechanisms of pathology or their role in selection on AR CAGn frequency in human populations. Additional literature was collected using Web of Science, Google Scholar, and PubMed databases using combinations of the search terms: ‘AR’ or ‘AR’, ‘CAG’, ‘CAG repeat’ or ‘Polyglutamine repeat’, and individual disease names (e.g. ‘Prostate Cancer’).We obtained data on the role of AR CAGn in human health and disease, using three online databases and one comprehensive review  mentioned above and that it be the subject of at least one large-scale (500+ participants) study or meta–analysis examining its relationship to AR CAGn. Diseases that matched these criteria and were the focus of ≥10 independent studies were considered, as was colorectal cancer, for which we deemed the relationship between this disease and AR CAGn to be well supported by two particularly large  case–control studies  shows an unequivocal relationship with AR CAGn. Patients with SBMA invariably have longer repeat number than is observed in the general population, typically between 38 and 62 repeats  are at a 20% increased risk of infertility  Adams , and bet2) with longer AR CAGn  and increase in osteoporosis  risk and progression. Castrated or hypogonadic men (including men suffering SBMA) rarely develop prostate cancer, and chronic exogenous androgen administration in rats can induce the disease  aggression, violence, and criminal activity; (ii) cognitive functioning and general intelligence; and (iii) depression. Other socio-behavioral traits, including social and sexual behavior, have been linked to AR CAGn as well as to other repeat polymorphisms in non-human mammals , which proposes that g increases with repeat length observed along the mammalian lineage is constrained in humans by the negative effects of SBMA and impaired sperm production. This ‘gain in function’ for general intelligence with longer AR CAGn has little empirical support, but given the highly expressed nature of the AR in areas of the brain associated with visual and verbal memory  of repeat length, or at least quantitative proxies for these metrics , the recent construction of a large-scale, annotated database of expressed trinucleotide repeats like the AR CAGn (Luo et al. Still, the challenge of testing evolutionary hypotheses is not restricted to hypotheses of human health and disease (Gluckman et al. These kinds of advances may also provide powerful insights into the role of the AR CAGn in the missing heritability of complex diseases and phenotypes modulated by androgens. Tandem repeats such as the AR CAGn may be more informative than SNPs at the individual level owing to their functional role and greater standing genetic variation in human populations, but have been largely neglected in GWA studies owing to the statistical power and high-throughput assays required to incorporate them (Ku et al. A more comprehensive picture of the heritability of human disease susceptibility must also account for interactions between genes and between genes and the environment (Eichler et al.


Patients with neurologic diseases often have neurogenic detrusor overactivity (NDO), which can result in a loss of voluntary bladder control and uncontrollable urinary incontinence (UI).The impact of UI due to NDO on patients’ lives has not been well studied. The objective of this review was to assess the health-related quality of life (HRQoL) and economic burden in patients with urgency UI due to NDO in select countries in North America, the European Union, Asia, and Australia.Systematic literature searches and reviews of articles published in English (January 2000 to February 2011) were conducted using MEDLINE®, EMBASE®, and the Cochrane Library. Studies assessing the impact of UI on HRQoL of patients with an underlying neurologic condition of interest  were included. Economic studies in urgency UI also were included.Of 876 citations generated in the initial search, a total of 27 articles were deemed relevant: 16 articles presented HRQoL data and 11 articles presented information on the economic burden of UI. Humanistic studies used a range of HRQoL instruments to measure HRQoL burden, and the economic studies included different cost components to quantify the economic burden, making meaningful comparisons challenging. Despite this heterogeneity, the literature suggests that HRQoL in patients with UI due to NDO is worse than patients with UI in general or those with the same underlying neurologic condition without UI. In addition, urgency UI also results in substantial economic costs.Incontinent patients with underlying neurologic conditions have impaired HRQoL as well as substantial economic burden attributable to UI due to NDO. There is a need for urgency UI treatments that improve HRQoL of these patients and alleviate the economic burden of this condition. Patients with neurologic diseases such as multiple sclerosis (MS) or spinal cord injury (SCI) often have a loss of bladder control. This may result from involuntarybladder contractions during the filling and storage phase of the urination process, which is referred to as neurogenic detrusor overactivity (NDO) ,2. SymptAlthough numerous studies have quantified both the economic and quality-of-life impact of OAB and general incontinence symptoms, the impact of UI specifically due to NDO has not been well characterized. Due to their underlying neurologic conditions, patients with UI and NDO may view their urinary symptoms differently than their otherwise healthy counterparts, and urgency UI due to NDO is secondary to numerous neurologic conditions that vary not only with respect to their presentation but also in the characteristics of affected patients. A better understanding of the negative effects of urinary symptoms on the economic outcomes and quality of life of patients with neurologic conditions is important in order to optimize treatment when potential pharmacologic therapies may be appropriate, as the utilization of outcomes data together with clinical assessments best reflects the patients spectrum of disease . A systeLiterature searches were conducted using MEDLINE®, EMBASE®, and the Cochrane Library, which included Cochrane Reviews, the Database of Abstracts of Reviews of Effects (DARE), the Cochrane Central Register of Controlled Trials (CENTRAL), the Health Technology Assessment Database, and the National Institute for Health Research Economic Evaluation Database (NHS EED), to identify relevant articles that assessed the humanistic and economic burden of UI due to NDO. Relevant search terms for UI, such as incontinence, neurogenic bladder, detrusor overactivity, and urgency, were cross-referenced with outcome concepts (HRQoL burden of illness and economic burden of illness) as appropriate and with terms for the following underlying neurologic conditions: MS, SCI, Parkinson’s disease, stroke, and spina bifida. The search was limited to titles and abstracts of human studies conducted in the United States, the European Union 5 , Canada, Australia, Thailand, South Korea, and Taiwan that were published in English from January 2000 to February 2011. Selected studies were ranked and assigned levels of evidence in accordance with the 2011 Oxford Centre for Evidence-Based Medicine (CEBM) Levels of Evidence .The search failed to identify burden of illness studies in individuals with urodynamically confirmed NDO. Since the literature suggests that UI among patients with underlying neurologic conditions is attributable to detrusor overactivity in the majority of cases, ,11 the iIn addition, the search identified only one interventional study that assessed the economic burden of UI specifically resulting from NDO.assessed the economic burden specifically resulting from Therefore, these inclusion criteria were modified to include any economic studies that assessed the economic burden of UI in general and reported per-patient costs of care, as it was determined that costs associated with leakage of urine, irrespective of the underlying cause, would not differ substantially by UI etiology. Recognizing that the UI population is much larger and distinct from the NDO-related UI population, only studies that presented per-patient costs  were ultimately included to conservatively assess the economic impact of UI on patients with NDO.The selection and appraisal of the titles, abstracts, and literature were completed by two independent reviewers. The reviewers documented the reason for exclusion for every article that was not included in the analysis. Any discrepancies in the selection and appraisal of the articles were discussed between the reviewers and resolved with the help of a third reviewer, where necessary. Full articles were retrieved for the remaining documents from this round of review. The inclusion/exclusion criteria were applied to the review of full articles and key relevant articles were selected for data extraction. The key data, including a description of the study design, study population, baseline characteristics, and a summary of the economic and humanistic burden measures and related findings, were extracted from each publication. In order to compare costs related to the per-patient economic burden of UI reported across studies from different years and in various countries, all non-acute costs were annualized by multiplying weekly costs by 52 and daily costs by 365, and all costs were converted to US dollars for the year 2010, using consumer price indices for medical resources -14.The initial literature search generated 876 citations Figure . After tA total of 27 full text articles fulfilled all of the revised criteria and are summarized in this literature review. No studies assessing the HRQoL burden in patients with UI due to urodynamically confirmed NDO were identified. Sixteen references on the impact of UI on HRQoL in individuals with MS, SCI, Parkinson’s disease, stroke, or spina bifida were identified , Urogenital Distress Inventory (UDI-6), and American Urological Association (AUA) Symptom Index.  ApproximThe fourth study compared HRQoL of OAB patients with MS (OAB+MS group) versus OAB patients without MS (OAB group) using select domain scores of the Kings Health Questionnaire  and found that urinary symptoms had more impact on HRQoL in the OAB+MS group compared with the OAB group . KHQ scoFour studies were identified assessing the impact of UI among patients with SCI -24. The Similar results were reported in a separate cross-sectional study in 142 SCI patients in the UK . SF-36 sBaseline data from a recent interventional, randomized controlled trial in SCI patients with incontinence due to NDO further suggest that the HRQoL of these patients is greatly impaired . HRQoL wIn addition to physical, mental, and psychological impairments, the final study in SCI patients suggests that UI also negatively affects sexual life . Study pTwo relevant studies that assessed the impact of UI in people with Parkinson’s disease were identified. One study in Italy used the symptom bother component of the OAB questionnaire Short Form (OAB-Q SF) to assess the frequency and bother of frequency, urgency, nocturia, and incontinence symptoms in patients with Parkinson’s disease compared with healthy controls . Scores A study in Canada compared HRQoL of patients with Parkinson’s disease and UI versus Parkinson’s patients without UI . The stuFive studies in stroke patients with UI were identified, which suggest that incontinent stroke patients have impaired functioning, lower life satisfaction, and higher rate of institutionalization compared with stroke patients who are continent.et al. [Edwards et al.  intervieet al. , found tet al. [The remaining three studies assessed the impact of UI on long-term outcomes in stroke patients, including disability, rate of institutionalization, and mortality -31. Koloet al.  reportedThe rate of institutionalization among incontinent stroke patients ranged from 34% at 3 months post stroke  to 45% aet al. [The literature search identified two studies that assessed the impact of UI on HRQoL in people with spina bifida; however, neither study found a strong association between UI and HRQoL.The study by Valtonen et al.  , diagnostic procedures in Spain (27%), and health care provider visits in the UK/Ireland (27%) . In anotThe one study that assessed the economic impact of NDO suggests that direct costs of conservative care per patient in European countries may be higher in patients with UI due to NDO compared with patients with UI in general or due to other causes . In thiset al. [Irwin et al.  reportedet al. [et al. [When acute hospitalization and long-term care costs are added, the annual cost estimates increase further for patients with UI. A study evaluating the cost of UI in 54 subacute medical facilities in Australia and New Zealand found that stroke patients with high FIM motor scores were more expensive to treat if they were incontinent . Anotheret al.  reported [et al.  analyzedFew studies reported per-patient costs for UI from the societal or patient perspective. A study of costs associated with OAB, including UI, in Thailand reported that the weekly cost for pad usage was $4.45 for a patient with UI, which, if extrapolated to annual cost, could be as much as $232.20 per year . In the To our knowledge this is the first study to characterize the HRQoL and economic burden of UI in patients with different underlying neurologic conditions. We found that UI in individuals with MS, SCI, Parkinson’s disease, and stroke has a substantial negative impact on patients’ HRQoL. Physical, mental and psychological impairments were consistently observed, with patients reporting detriments in physical function, emotional well being, and social relationships. UI also had a negative effect on the sexual lives of patients with neurologic conditions, and may adversely affect long-term outcomes. Not surprisingly, we also found that incontinent individuals with underlying neurologic conditions also typically report worse HRQoL compared with their continent counterparts and the general population.Three studies suggested that UI has little or no impact on the HRQoL of patients with MS or spina bifida ,24,32. TEvaluating the economic impact of a disease or disease intervention is becoming increasingly important and is often one of the factors considered in determining access to treatment for patients. However, very little economic information regarding UI due to NDO or in patients with MS, SCI, Parkinson’s disease, stroke, or spina bifida was available, pointing to a need for further research to assess the economic burden of UI in these specific neurologic populations. Nevertheless, the results do suggest that the economic burden of UI due to NDO is substantial for patients, providers and payers, including direct medical costs, as well as costs for conservative care, physician/hospital/emergency room services, medication and complications.Furthermore, existing studies that describe the economic burden of UI have mixed populations, where costs for UI are lumped with that for OAB as a whole. We were primarily interested in the economic impact of UI on an individual level rather than on a population level, recognizing that the general OAB population is substantially larger and distinct from patients with underlying neurologic conditions who experience bladder dysfunction. The studies that provided per-patient annual direct costs for UI from a payer perspective were mostly conducted in European countries, with annual costs ranging from $488 to $949 per patient . MeanwhiWe found a great deal of heterogeneity in the studies we identified with respect to study design, patient characteristics, and the types of outcome measures used to characterize the humanistic and economic burden of UI. This was true both within and across the neurologic conditions of interest. For example, studies examining the impact of UI on the HRQoL in MS patients often used different instruments than studies that assessed the impact of UI in SCI patients. Similarly, the economic studies that we identified and reviewed applied different cost components  when quantifying the economic burden of UI. As such, the ability to compare the humanistic and economic impact of UI across neurologic conditions and across countries was limited. Our results thus suggest the need for the medical community to reach a consensus on which tool(s) should be used to assess HRQoL in patients with neurologic diseases, so that researchers have a standard guideline to follow when designing clinical trials. Use of the same tool across studies will also facilitate future comparisons.et al. [Our search was limited by the inconsistent terminology used across the literature to describe this subset of patients with UI due to NDO. As such, studies that used terms different from ours may not have been generated in our search. No relevant studies were found in patients with UI due to urodynamically confirmed NDO, which is not surprising given that urodynamic evaluations are not routinely done in patients with urinary symptoms and that the terminology surrounding lower urinary tract function has constantly evolved in the last decade . Furtheret al. , not necImportant goals of therapy for neurogenic lower urinary tract dysfunction should focus on improving patient HRQoL by decreasing the most bothersome symptoms as much as possible ,47. FutuIncontinent patients with MS, SCI, Parkinson’s disease, stroke, or spina bifida have impaired HRQoL. In particular, detriments in physical function, emotional well being, and social relationships were generally noted across studies. HRQoL of incontinent patients with neurologic conditions is also significantly worse compared with patients with UI in general or patients with the same underlying neurologic condition without UI. Our results also suggest that the economic burden of UI due to NDO is substantial, and that there is a need for UI treatments that improve HRQoL and alleviate the economic burden of this condition.ACS: Activity Card Sort; ADL: Activities of daily living; AUA: American Urological Association; CI: Confidence interval; CIC: Clean intermittent cauterization; FAM: Functional Assessment Measure; FIM: Functional Independence Measure; HRQoL: Health-related quality of life; HUI3: Health Utilities Index Mark; IIQ-7: Incontinence Impact Questionnaire; I-QOL: Incontinence Quality of Life questionnaire; KHQ: Kings Health Questionnaire; MS: Multiple sclerosis; MCS: Mental component summary; NDO: Neurogenic detrusor overactivity; OAB: Overactive bladder; OAB-Q SF: Overactive Bladder Questionnaire Short Form; PCS: Physical component summary; RNL: Reintegration to Normal Living Index; SCI: Spinal cord injury; SIP: Sickness Impact Profile; SF-12: Medical Outcomes Study-12-Item Short Form Survey; SF-36: Medical Outcomes Study 36-Item Short Form Health Survey; UDI-6: Urogenital Distress Inventory; UI: Urinary incontinence; UTI: Urinary tract infection; VSP: Vecu et santé percuThis study was funded by Allergan, Inc. CI and KB declare that they are employees of Covance Market Access Services, Inc.; KK and DG declare that they are employees of Allergan, Inc.; Dr Chancellor declares that he is an advisor and consultant for Allergan, Inc. and has conducted studies funded by Allergan, Inc., and Dr Carr declares that she is a consultant for Allergan, Pfizer, Astellas, Triton, Watson, Cook Myosite, Gynecare and Ferring and has conducted studies funded by Cook Myosite, Allergan, Astellas and Pfizer.CT, KK, DG, KB, MC, and LC participated in the design of the study, including development of the literature search protocol. CT conducted the systematic literature review. DG and KK conceived of the study, and participated in its design and coordination. All authors helped to draft the manuscript, and all authors read and approved the final manuscript.Studies on the Impact of UI on the HRQoL of Patients with Underlying Neurological Conditions and Key Findings.Click here for file


Randomised controlled trials (RCTs) are perceived as the gold-standard method for evaluating healthcare interventions, and increasingly include quality of life (QoL) measures. The observed results are susceptible to bias if a substantial proportion of outcome data are missing. The review aimed to determine whether imputation was used to deal with missing QoL outcomes.A random selection of 285 RCTs published during 2005/6 in the British Medical Journal, Lancet, New England Journal of Medicine and Journal of American Medical Association were identified.QoL outcomes were reported in 61 (21%) trials. Six (10%) reported having no missing data, 20 (33%) reported ≤ 10% missing, eleven (18%) 11%–20% missing, and eleven (18%) reported >20% missing. Missingness was unclear in 13 (21%). Missing data were imputed in 19 (31%) of the 61 trials. Imputation was part of the primary analysis in 13 trials, but a sensitivity analysis in six. Last value carried forward was used in 12 trials and multiple imputation in two. Following imputation, the most common analysis method was analysis of covariance .The majority of studies did not impute missing data and carried out a complete-case analysis. For those studies that did impute missing data, researchers tended to prefer simpler methods of imputation, despite more sophisticated methods being available. Randomised controlled trials (RCTs) are perceived as the gold-standard evaluation method for evidence based medicine. Increasingly quality of life (QoL) outcomes are measured in clinical trials of new treatments, as this is becoming an important factor in decision making. Common QoL instruments include the generic questionnaires such as SF12/SF36  requires restrictive assumptions to produce valid statistical conclusions' . Carpentet al., [The results of this review support the conclusions of a review by Wood et al.,  which coet al.,  and recoet al., , the resResearchers involved with the design and analysis of clinical trials should take the following into consideration. Ideally one should aim to avoid missing data at the outset though often this is impossible. The data collection method should be chosen with the aim of reducing as far as possible missing data. The reasons why data are missing should be recorded where possible.There should be a clearer reporting of the methods used and the amount of missing data, which should be described separately for each treatment arm. The impact the missing data potentially has on results should always be discussed and a sensitivity analysis provided. Where imputation is chosen, the reason for the choice of method should be given. LVCF is usually not recommended, except in the generally implausible situation where outcome is not changing over time. Under MAR, it is desirable to include all longitudinal follow up data on the primary response, up to the end point analysis .http://www.lshtm.ac.uk/msu/missingdata/ and complementary monograph 'Missing Data in randomised controlled trials – a practical guide' [Resources that may assist researchers in deciding on appropriate action for missing data in RCTs include the recently published book by Molenberghs and Kenward (2007). The website l guide'  producedANCOVA: Analysis of covariance; ANOVA: Analysis of variance; AUC: Area under the curve; BMJ: British Medical Journal; CONSORT: Consolidated Standards of Reporting Trials; ESRC: Economic and Social Research Council; GHQ: General health questionnaire; JAMA: Journal of American Medical Association; LVCF: Last value carried forward; MAR: Missing at random; MCAR: Missing completely at random; MNAR: Missing not at random; NEJM: New England Journal of Medicine; QoL: Quality of life; RCT: Randomised controlled trial; WHOQOL: World Health Organisation quality of life questionnaire.The authors declare that they have no competing interests.SF conceived the review, participated in data extraction, summarizing the data and drafting of the manuscript. GM, CR and JC participated in data extraction and commented on drafts of the manuscript. All authors read and approved the final manuscript.Description of trials with imputation of quality of life outcomes.Click here for file


Before the severe acute respiratory syndrome (SARS) outbreak, the Centers for Disease Control and Prevention’s (CDC) legal authority to apprehend, detain, or conditionally release persons was limited to seven listed diseases, not including SARS, and could only be changed using a two-step process: 1) executive order of the President of the United States on recommendation by the Secretary, U.S. Department of Health and Human Services (HHS), and 2) amendment to CDC quarantine regulations (42 CFR Parts 70 and 71). In April 2003, in response to the SARS outbreak, the federal executive branch acted rapidly to add SARS to the list of quarantinable communicable diseases. At the same time, HHS amended the regulations to streamline the process of adding future emerging infectious diseases. Since the emergence of SARS, CDC has increased legal preparedness for future public health emergencies by establishing a multistate teleconference program for public health lawyers and a Web-based clearinghouse of legal documents. Under our American constitutional structure, the “police power”  is reserved to the states by the 10th Amendment to the U.S. Constitution, while the federal government exercises authority to regulate interstate and foreign commerce  had administered the foreign quarantine regulations, while the U.S. Food and Drug Administration (FDA) had administered the interstate quarantine regulations. In addition to quarantine, these regulations authorize a variety of other public health measures, including reporting of ill passengers onboard international conveyances, sanitary inspection of arriving vessels and cargo, and restrictions on articles or imports that may be sources of infection to human beings. On August 16, 2000, FDA transferred a portion of its domestic quarantine authority  to CDC, while retaining its authority to control animals and other products that may transmit or spread communicable diseases ; in the introduction of monkeypox in the Western Hemisphere ; and during West Nile virus season (mosquito abatement/spraying programs), legal issues are nearly always intertwined with public health responses. During emergencies, communication among public health lawyers at all levels  is a crucial part of the “new normal” in public health. Until recently, however, there was no ready means for public health lawyers to communicate rapidly among themselves and quickly access relevant legal information.http://www.phppo.cdc.gov/od/phlp/. The addition of a Web-based clearinghouse and a teleconference capacity increases CDC’s effectiveness in responding to public health emergencies by more fully integrating lawyers into the public health response.During the SARS outbreak, CDC established a series of telephone conferences, whereby federal, state, and local public health lawyers could discuss important legal issues of the day and trade ideas about pending legal problems. These teleconferences were particularly useful in exchanging information concerning the interplay of quarantine authority at the federal, state, and local levels and discussion of procedural requirements involved in executing isolation or quarantine orders. These legal teleconferences were reinstituted and held daily during the peak of the monkeypox outbreak. Additionally, during the monkeypox outbreak, CDC developed a Web-based clearinghouse where just-issued legal documents such as gubernatorial executive orders and state and local health department rules could be posted. CDC, through its Public Health Law Program, plans to expand the scope of this clearinghouse to reduce the time required to identify relevant legal documents and disseminate them to public health legal counsels on a “real time” basis. The clearinghouse is available at:


More than 153 million children worldwide have been orphaned by the loss of one or both parents, and millions more have been abandoned. We investigated relationships between the health of orphaned and abandoned children (OAC) and child, caregiver, and household characteristics among randomly selected OAC in five countries.Using a two-stage random sampling strategy in 6 study areas in Cambodia, Ethiopia, India, Kenya, and Tanzania, the Positive Outcomes for Orphans (POFO) study identified 1,480 community-living OAC ages 6 to 12. Detailed interviews were conducted with 1,305 primary caregivers at baseline and after 6 and 12 months. Multivariable logistic regression models describe associations between the characteristics of children, caregivers, and households and child health outcomes: fair or poor child health; fever, cough, or diarrhea within the past two weeks; illness in the past 6 months; and fair or poor health on at least two assessments.Across the six study areas, 23% of OAC were reported to be in fair or poor health; 19%, 18%, and 2% had fever, cough, or diarrhea, respectively, within the past two weeks; 55% had illnesses within the past 6 months; and 23% were in fair or poor health on at least two assessments. Female gender, suspected HIV infection, experiences of potentially traumatic events, including the loss of both parents, urban residence, eating fewer than 3 meals per day, and low caregiver involvement were associated with poorer child health outcomes. Particularly strong associations were observed between child health measures and the health of their primary caregivers.Poor caregiver health is a strong signal for poor health of OAC. Strategies to support OAC should target the caregiver-child dyad. Steps to ensure food security, foster gender equality, and prevent and treat traumatic events are needed. Of 153 million children orphaned worldwide, 145 million reside in less wealthy nations where their number has increased dramatically because of HIV/AIDS and other causes Tragically, the countries with the highest rates of orphanhood are also among the economically poorest and most under-resourced Given the growing need for orphan support worldwide and funding constraints among international donors, increased efforts are required to understand the key determinants of orphan well-being and to target those determinants for resource allocation. Orphan well-being is multi-dimensional and encompasses several interlinked domains, including emotional health, economic and educational opportunities, social functioning, and physical health Numerous studies of varying quality and in disparate populations have examined associations of orphanhood with child mortality and poor health. One of the largest and most rigorously conducted studies used population surveillance data from Bangladesh to describe a striking association between the death of a mother and the survival of her child: only 24% of children whose mothers died were alive at age 10 versus 89% of those whose mothers remained alive To inform policy and resource allocation that promote the well-being of orphaned and abandoned children (OAC), a greater understanding is needed of the correlates and potential determinants of orphan health status. Using data from randomly selected, community-based OAC and their primary caregivers in five countries, we examined the relationship of many of the factors depicted in Written informed consent was obtained from each participating parent/guardian both for themselves and for each child participant under their care. In addition, each participating child gave written assent. Thus, informed consent was obtained for all children involved in the study. Ethical approval was obtained from the Duke University Institutional Review Board (IRB), the IRBs of Meahto Phum Ko’mah , SaveLives Ethiopia , Sharan , ACE Africa , and Kilimanjaro Christian Medical Centre , and from regulatory agencies in all participating countries: National Ethic Committee for Health Research (Cambodia), Ministry of Science and Technology (Ethiopia), Indian Council of Medical Research (India), Kenya Medical Research Institute (KEMRI), and the National Institute for Medical Research (Tanzania).As part of the Positive Outcomes for Orphans (POFO) study Interviews with children’s self-identified primary caregivers were conducted in their respective native language in the child’s residence. Six-month follow-up assessments were conducted in 5 of the 6 study sites and 12-months follow-up assessments in all sites. Interview windows for follow-up assessments were open from one month prior to two months after the scheduled follow-up date. Baseline data for children and caregivers were collected between May 2006 and February 2008. Follow-up data were collected from June 2007 through December 2008.At each interview caregivers were asked to rate the child’s current health as “very good”, “good”, “fair”, “poor”, or “very poor”. Caregivers were also asked whether the child had experienced fever, cough and/or diarrhea during the previous two weeks and whether the child had been sick during the previous 6 months. Children’s fair or poor health, any symptoms during the past 2 weeks, and any illness during the past 6 months were the primary child health outcomes of interest for this analysis. In addition, a “persistent fair or poor health” variable was constructed to describe whether a child was reported to be in fair or poor health during at least two of the three possible assessments.At the 12 month follow-up interview the same measures were asked of caregivers to describe their own health; and the SF-8™ Health Survey that includes one question from each of the 8 domains of the SF-36 v.2 health survey was given to each caregiver Additional questions assessed children’s age, gender, orphan status , whether a child had tested HIV-positive, and whether potentially traumatic events had been experienced by the child . CaregivMultivariable logistic regression models were used to describe associations of child characteristics, caregiver characteristics, caregiving, and household characteristics with child health outcomes, specifically current fair or poor health, symptoms in the past two weeks, illness in the past 6 months, and persistent fair or poor health. In alternative specifications, caregiver health was described by measures equivalent to the respective child health measures  or the summary score derived from the SF-8 questions. To assess between-site variation in the associations between child and caregiver health measures, random slope models estimated site-specific random intercepts and slopes for caregivers’ self-reported health. In all models, observations were weighted to adjust for differences in the number of children and their age and gender distributions across study sites. To account for error correlation among children within sampling clusters and study areas, models were estimated with robust standard errors. All analyses were conducted using Stata version 11.2 .The performance characteristics of caregiver health as a binary classification test for “fair or poor” child health, symptoms in the past two weeks, and persistent fair or poor child health were described using sensitivity and specificity calculations with the SF-8 as the classification variable. In this context, sensitivity refers to the proportion of OAC with poorer health correctly identified as such on the basis of poorer health of their caregiver. Specificity refers to the proportion of OAC in good health, so identified based on the good health of their caregivers.The sample was evenly split between boys and girls, and the median age at enrolment was 10  years . Fifty-sNearly one in four children were reported by their caregivers to be in fair, poor, or very poor health; a similar number were reported to have persistently fair, poor, or very poor health . More thShown in Households were composed of a mean of 2.9 (s.d. 1.6) children and 2.4 (s.d 1.6) adults, and had a mean of 2.1 (s.d. 1.6) persons per bedroom . SlightlSeveral child characteristics were associated with poor health outcomes . Being fAmong caregiver characteristics, highly significant and consistent associations were observed between poorer caregiver health, as measured by the SF-8, and three of the four measures of child health . Greater caregiver involvement was negatively correlated with persistent fair/poor child health , and a higher child to adult ratio was associated with illness in the past 6 months . Among the household and community characteristics evaluated, having fewer than 3 meals per day was associated with symptoms in the past two weeks  and persistent fair/poor health .Random coefficients models (not shown) suggest that associations between child and caregiver health measures varied across study sites. The study was not sufficiently powered to provide conclusive site-level estimates, however, the association between the caregiver’s SF-8 health measure and fair or poor child health was significant in 4 of the sites; associations with child symptoms and illness in the past 6 months were positive in 5 of the 6 study sites and significant in 2 sites each.Shown in Among more than 1,300 randomly selected orphaned and abandoned children in six diverse settings, one in five were reported to be in fair or poor health, and one in four had experienced symptoms of illness in the past two weeks. In multivariable logistic regression models including child and caregiver characteristics, caregiving characteristics, and household and community factors as covariates, strong associations were observed between child health and the health of their caregivers. Children who were female, experienced more categories of potentially traumatic events, received fewer than 3 meals per day, and lived in urban settings were more likely to be in poorer health; whereas children whose caregivers demonstrated greater involvement were less likely to be in persistent fair/poor health.The strongest and most consistent predictor of poor child health in this study was the health of the caregiver. Although poor health among caregivers of orphans has been described elsewhere It is also possible that economic consequences of poor caregiver health may contribute to poor child health. Orphans are frequently cared for in households headed by females or the elderly; these households may have fewer economic resources  and may be less likely to absorb income shocks and medical expenses associated with caregiver illness, further diminishing their ability to provide adequate nutrition and access to health care for OAC Regardless of the mechanism, the close association between caregiver and OAC health has practical, even diagnostic, significance in that the poor health of adult caregivers may signal poor health of the OAC under their care. ROC curves highlight the diagnostic trade-offs of sensitivity and specificity of caregiver health for predicting varied OAC health measures . In our Policy makers and health economists might judge that the greater misclassification error would be to not identify children in fair or poor health; therefore, we propose that the fair or poor health of a caregiver should prompt an evaluation of the health status of OAC in her/his care. Our data also support the potential utility of adding caregiver health assessments to instruments such as the Orphans and Vulnerable Children Wellbeing Tool Several other findings highlight potential determinants of poor child health within each of the domains examined. Among the child characteristics examined, female gender and exposure to multiple types of traumatic events were independently correlated with two of the four measures of poor health. Some Within the domain of caregiver characteristics, it is not surprising that caregiver involvement was inversely  correlated with persistent fair/poor health, indicating that the more involved a caregiver was with the child, the better the health of the child. Finally, within the domain of household and community characteristics, we identified an association of food insecurity  with both illness in the past 6 months and persistent/fair poor health. That food insecurity correlates with poor health is an expected finding The study has several limitations. First, self-reported data are subject to respondent biases, especially recall biases. In this case, proxy reports of children’s health by their caregivers may have introduced additional biases. In particular, it is possible that caregivers consider their own health when reporting on a child’s health, thereby biasing the estimated relationships. To assess this possibility, we used data on 893 children from 5 study sites, collected at a later interview round, to estimate three logistic regression models with caregiver-reported child health measures as dependent variables, and children’s and caregivers’ self-reports of their own health as explanatory variables . If no bWith fewer resources to care for OAC in less wealthy countries it is increasingly important to identify determinants of poor health among OAC and to consider the efficiencies and trade-offs inherent in any method for identifying children who need care for poor health. In this study of more than 1,300 OAC from six diverse settings, we examined an array of child, caregiver, caregiving, and environmental factors potentially associated with poor health. The strong associations between caregiver health and the health of OAC suggest that poor caregiver health is predictive of poor health of OAC and provides further support for health interventions that target the caregiver-child dyad. Steps to ensure food security, foster gender equality, and prevent and treat traumatic events may also be important for the health of orphaned and abandoned children.