The life expectancy of profoundly handicapped people with mental retardation

Quality of dental treatments under intravenous sedation among patients with disability: A self-matching study

Background/purpose

Patients with disabilities usually have difficulties in communication and mobility, and the quality of the dental treatments are often inferior. This study uses the Taiwan National Health Insurance Database to analyze the quality of dental treatment for patients with disabilities who receive intravenous sedation (IVS).

Materials and methods

This study selected patients with disabilities who received dental treatment under IVS. Their oral cavity was divided into three major sections: anterior teeth, upper posterior teeth, and lower posterior teeth. Self-matching of the same section was conducted to observe whether operative dental treatment (OD) with or without IVS affected the occurrence of dental retreatment. This study observed the occurrence of refilling and the duration from the end of treatment until retreatment to compare treatment differences with or without IVS.

Results

After self-matching, this study found 158 patients who received dental treatment within the same section with and without IVS. During a follow-up period of 17 years, 75.18% of the patients who received OD treatment required refilling, 10.87% required endodontic treatment, and 5.67% required tooth extraction. After OD treatment with IVS, the risks of refilling, endodontic treatment, and tooth extraction were 0.71 (95% CI: 0.58-0.87, P < 0.001), 0.77 (95% CI: 0.48-1.23, P = 0.28), and 0.64 (95% CI: 0.32-1.27, P = 0.20), respectively.

Conclusion

For patients with disabilities, OD treatment with IVS significantly reduces the risk of refilling compared with OD treatment without IVS. IVS can be ideal for people with disabilities who receive dental treatment.

Phenotype assessment in neurologically impaired paediatric patients: Impact of a nutrition intervention protocol

BACKGROUND

Deficits in nutritional status and functional feeding disorders are common in Neurologically Impaired Paediatric Patients (NIPP). Interventions addressing these problems could offer better overall health status and quality of life in this group of patients, but the extent of their effectiveness is yet to be determined. Recent guidelines concerning the nutritional care of NIPP have been published from ESPGHAN but compliance to them has not been assessed.

AIM

The study aimed to assess the phenotypic profile of a group of NIPP attending the outpatient clinic of a pediatric department, and to implement, for the first time to our knowledge, an individualized nutritional intervention protocol following ESPGHAN guidelines 2017 as well as to assess the impact on phenotypic parameters and nutritional status.

PATIENTS AND METHODS

68NIPP and their caregivers aged 1m-17 years (83.8% suffering from cerebral palsy (CP) were invited to assess their phenotypic parameters and to implement in a nutrition intervention protocol in order to improve their dietary intake and nutritional status. Anthropometry (weight, height, triceps skinfold thickness, mid upper arm circumference) was expressed as z-scores for age and sex using WHO Anthro software and classified following the WHO criteria. Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Dysphagia Disorder Survey (DDS), Saliva Severity Scale (SSS), gastrointestinal complications, energy and nutrient intake were assessed at the beginning (zero point), after 6 (point 1) and 12 (point 2) months period. Intake to Requirement ratio (I/R) was derived. At zero point, following the baseline evaluation, caregivers were advised and educated on nutrition protocol and customized nutrition plans were handed out. The impact of the nutritional intervention on the phenotypic parameters was recorded on follow up visits (points 1, 2).The primary outcomes analyzed were anthropometric parameters (Waz), as indicators of nutritional status. GMFCS, MACS, DDS, SSS, FA were evaluated as possible predictors of this outcome. Secondary outcomes included the impact of the intervention protocol on the phenotypic parameters during the study period.

RESULTS

Based on weight for age z-score (Waz ≤ -2) (WHO) 17 patients (32.1%) were undernourished, 5/68 (10, 4%) were with triceps skinfold thickness z-score (TSTz) <-2 and 3/68 (7%) with mid upper arm circumference z-score (MUACz) <-2. Z-scores (WHO) for weight (p₁ = 0, 036) (p₂ = 0, 003), body mass index (BMI) (p₂ = 0,000), MUAC (p₁ = 0, 029) and TST (p₁ = 0, 021) (p₃ = 0, 044) were significantly improved in follow-up evaluations compared to the baseline. Less NIPP were found to be underweight according to Waz from point 1 to point 2 (p₃ = 0, 006), as well as stunding according to height for age z-score (Haz) from point 1 to point 2 (p ≤ 0,001). Patients with higher levels of GMFCS (p₁ = 0,040), MACS (p₁ = 0,028) DDS (p₁ = 0,001) and SSS (p₁ = 0,005) had significantly lower Haz. Patients with higher levels of SSS (p₁ = 0,002) had significantly lower TSTz scores. There were no significant changes in the classification of NIPP according to DDS or the patients' feeding ability. The energy (kcals) intake/kg of body weight (bw) was significantly higher at point 2 compared to point zero (p₃ = 0,028), protein intake/kg of body weight was significantly higher at points 1 and 2 compared to point zero (p₁ = 0,026, p₃ = 0,003), and fat intake/kg of body weight (bw) was significantly higher at point 2 compared to point zero (p₃ = 0,012). Intake of energy (kcals)/bw (p₁ = 0,026), (p₂ = 0,046), (p₃ = 0,048) carbs/bw (p₁ = 0,014) (p₂ = 0,042), I/R of pro (p₁ = 0,032), (p₃ = 0,013), and fat/kg (p₂ = 0, 033) (p₃ = 0,037) were found to be significantly lower in higher GMFCS levels. DQI did not improve during the study period nor correlated to any of the anthropometric parameters. Gastrointestinal complications correlated with Waz (r = -, 285 p₁ = 0, 011). Feeding Ability (FA) was found to be the only strong predictor for Waz at baseline evaluation (p = 0,012) when a multiple regression was run along with DDS.

CONCLUSION

Underweight was detected in one third of the patients, some degree of dysphagia in 69% and gastrointestinal complications in 58.8% of the sample. Height for age z-score (Haz) was the anthropometric parameter most sensitive to the changes in ranking on motor and functional feeding scores. The implementation of a customized nutrition intervention protocol in line with ESPGHAN's guidelines had a beneficial effect on improving dietary intake and nutritional status of NIPP after a 12 months period. Better results could be expected if dysphagia and feeding ability were also addressed by appropriate intervention protocols. Patients' feeding ability is of importance for predicting Waz.

The Prevalence and Risk of Type 2 Diabetes in Adults with Disabilities in Korea

BACKGROUND

People with disabilities are at risk of secondary conditions such as diabetes. The aim of this study was to evaluate the prevalence and risk of type 2 diabetes in South Korea, especially among people with all types of disabilities.

METHODS

We conducted a cross-sectional study using data from the Korean National Health Insurance Service, with two disabilityfree controls matched for each participant with disabilities by age and sex. Information regarding the type, severity and grade of disabilities was obtained based on the National Disability Registry. Diagnosis of type 2 diabetes was defined according to the following criteria: presence of International Classification of Diseases, Tenth Revision, Clinical Modification codes E11, E12, E13, or E14 and claims for at least one oral anti-diabetic agent or insulin at baseline, or fasting glucose level ≥126 mg/dL.

RESULTS

We included 1,297,806 participants with disabilities and 2,943,719 control. Out of 4,241,525 participants, 841,990 (19.9%) were diagnosed with diabetes. The prevalence of diabetes was higher in the disability group compared with individuals without disabilities (23.1% vs. 18.4%). The odds of having diabetes was higher in the disability group compared with the control group (adjusted odds ratio, 1.34; 95% confidence interval, 1.33 to 1.34). The results showed higher prevalence of diabetes in the mildly disabled group (23.2%) than in the severely disabled group (22.7%).

CONCLUSION

The prevalence and risk of diabetes were higher in people with disabilities compared with the general population. Physicians and public health authorities should focus on people with disabilities for proper diabetes management.

Access to transplantation for persons with intellectual disability: Strategies for nondiscrimination

Disqualifying patients with intellectual disabilities (ID) from transplantation has received growing attention from the media, state legislatures, the Office of Civil Rights, and recently the National Council on Disability, as well as internationally. Compared with evidence-based criteria used to determine transplant eligibility, the ID criterion remains controversial because of its potential to be discriminatory, subjective, and because its relationship to outcomes is uncertain. Use of ID in determining transplant candidacy may stem partly from perceived worse adherence and outcomes for patients with ID, fear of penalties to transplant centers for poor outcomes, and stigma surrounding the quality of life for people with ID. However, using ID as a contraindication to solid organ transplantation is not evidence-based and reduces equitable access to transplantation, disadvantaging an already vulnerable population. Variability and lack of transparency in referral and evaluation allows for gatekeeping, threatens patient autonomy, limits access to lifesaving treatment, and may be seen as unfair. We examine the benefits and harms of using ID as a transplant eligibility criterion, review current clinical evidence and ethical considerations, and make recommendations for transplant teams and regulatory agencies to ensure fair access to transplant for individuals with ID.

An Examination of the Validity of the Health Risk Screening Tool: Predicting Mortality in People With Intellectual Disabilities

BACKGROUND AND PURPOSE

The Health Risk Screening Tool (HRST) is a 22-item instrument specifically designed to assess the health risk of persons with developmental disabilities. The predictive validity of the HRST was investigated by examining its ability to predict mortality.

METHODS

The sample consisted of 12,582 people with an intellectual or developmental disability residing in Georgia (U.S.). Data were analyzed using survival analysis (Kaplan-Meier estimate and Cox regression) and a binary logistic regression.

RESULTS

All models supported the prognostic value of the six-level health risk classification. The Kaplan-Meier procedure showed clear separation among functions. The Cox proportional hazard regression revealed that hazard is inversely related to the health risk level, even after controlling for potential confounding by gender, ethnicity, and race.

CONCLUSIONS

The HRST can predict mortality. Therefore, it can serve as a basis for establishing healthcare needs and determining nursing care acuity.

Rate and characteristics of urgent hospitalisation in persons with profound intellectual disabilities compared with general population

BACKGROUND

Little is known about the hospitalisation rate of adults with severe/profound intellectual disability (PID) presenting at emergency services or about the appropriateness of hospital admissions in this population. Examining the possible differences in the patterns of hospitalisation between people with PID and those without intellectual disability (ID) may shed light on aspects of health and illness in these patients and may in turn make it possible to differentiate more clearly between mild-moderate ID and PID.

METHODS

After an evaluation of the emergency visits made by adults with PID and by people without ID, patients in both groups requiring one or more hospitalisations were subsequently followed up for 18 months. The appropriateness of the decision to hospitalise was assessed using the ambulatory care-sensitive conditions index.

RESULTS

There were no differences in the proportion of people with PID and controls admitted to hospital after their emergency visit. The median hospital stay was higher for PIDs: 7.5 vs. 4 days for controls. People with PID were admitted more than controls for respiratory reasons and somewhat less for other somatic causes unrelated to the nervous system. There were no admissions for psychiatric causes in the group with PID other than unspecified conduct disorders. There were no differences in other diagnostic groups. The rate of inappropriate admissions was similar in the two study groups.

CONCLUSIONS

In contrast to previous results reported for the group with ID as a whole, patients with PID consulting the emergency service were not admitted to hospital more frequently than the general population nor did they present a higher rate of inappropriate admissions. These results support the utility of maintaining two distinct groups of people with ID: mild-moderate and severe-profound.

Health profile for Danish adults with activity limitation: a cross-sectional study

BACKGROUND

Studies have indicated that people with disabilities die earlier and may experience a poorer health than the general population. This study investigated 31 factors related to health and well-being, health behaviour and social relations among Danish adults with activity limitation (AL).

METHODS

This study was based on data from the Danish Health and Morbidity Survey (DHMS) 2013 where 25,000 men and women aged 16 years or older were selected randomly from the adult Danish population. A total of 14,265 individuals answered the self-administered questionnaire including 100 questions on health-related quality of life, health behaviour, morbidity, consequences of illness and social relations. Based on an international standard question on AL, 888 individuals (6%) were defined as having profound AL and 4180 (29%) as having some AL. Multiple logistic regression analyses were used to analyse the associations between activity limitation and 31 indicators of health. The results were presented as relative risks 95% confidence intervals.

RESULTS

Twenty-eight of 31 indicators showed consistently poorer health and well-being, health behaviour and social relations among individuals with AL as compared to individuals without AL. The increased relative risks were in a range of 7-661% the risk among individuals without AL. An example is obesity where RR (95% CI) was 2.07 (1.82-2.37). Only contact with internet friends was significantly higher among individuals with AL as compared to individuals with no AL. There was no association between alcohol and AL and no association between fast food and some AL.

CONCLUSION

Danish adults with AL experience a poorer health and well-being, and have an unhealthier lifestyle and poorer social relations than adults without AL. People with activity limitation should be prioritized in public health and efforts done to secure availability and flexibility of health care services and primary prevention programs. Policies should address accessibility, availability and affordability of health care and health behaviour among people with activity limitation.

Severe intellectual disability is not a contraindication to kidney transplantation in children

Renal transplantation in children with ID is controversial. Acceptability of these children as candidates varies between programs. Limited outcome data in pediatric renal TXP recipients with cognitive impairment diminish their access to TXP. A retrospective chart review was performed of all children who underwent renal transplantation between January 1, 2002 and June 30, 2012 (N=72). Patients were divided into two groups, those with ID prior to transplantation (n=10) and those without (non-ID; n=62). Graft survival and BPAR episodes were compared between the two groups using Kaplan-Meier estimates. Graft survival rates at 3 years post-TXP were 100% in the ID group and 80% in the non-ID group (P=.13). Rates of BPAR at 3 years post-TXP were 10% in the ID group and 27% in the non-ID group (P=.29). Graft survival and acute rejection-free survival rates are similar between children with ID and those without. Based on midterm outcomes, there is no apparent contraindication to renal transplantation in pediatric patients with ID. Children with ID should be considered as TXP candidates provided that they have an adequate social support network.

Pain underreporting associated with profound intellectual disability in emergency departments

BACKGROUND

Little information is available regarding the visits made by persons with profound intellectual disability (PID) to general hospital emergency departments (ED). This study aims to know whether persons with PID who attend ED are given the same type of diagnoses as people with no such disability.

METHODS

Over a period of 18 months, we gathered data from all non-scheduled visits to an ED by persons with PID to identify the reason for consultation (according to the classification used by the Spanish Society for Emergency Nursing) and the final diagnosis upon discharge. The results were compared with data obtained from a control group of people with no ID who attended an ED for any reason during the same period.

RESULTS

Somatic complaints were the main reason for ED attendance among persons with PID (90% of consultations). These complaints were more often related to the central nervous system than was the case among non-ID patients (16 vs. 4.7%), whereas other kinds of non-central nervous system somatic complaint were less common among persons with PID (74 vs. 91%). A diagnosis implying physical pain was given less often to people with PID than to controls (3 vs. 20%).

CONCLUSIONS

The results suggest that persons with PID are less able to conceptualise and communicate information about their symptoms, especially as regards pain, and that this influences the diagnosis they are given when attending an ED. Professionals working in this environment need to be aware of this possibility so as not to underestimate or overlook such symptoms and the illnesses related to them.

An estimation of the prevalence of intellectual disabilities and its association with age in rural and urban populations in India

Background:

Intellectual disability (ID) is a global public health concern. Prevalence of ID and its association with age and other demographic factors is required for planning purposes in India.

Objective:

This study analyzed the age-adjusted prevalence of ID in rural and urban populations and its correlation with age in children and adults.

Materials and Methods:

Disability data published in the report (2002) of National Sample Survey Organization were analyzed, using Z-test to measure differences in age-adjusted prevalence. Spearman rho was calculated to determine strength and direction of the association, and regression analysis was used to predict prevalence rate, based on age in rural and urban population settings.

Results:

Overall, India has a prevalence of 10.5/1000 in ID. Urban population has slightly higher rate (11/1000) than rural (10.08/1000; P = 0.044). Age was found to be highly correlated with prevalence of ID in rural children (ϱ =0.981, P = 0.019) as well as in children (ϱ = −0.954, P = 0.000) and adults (ϱ = −0.957, P = 0.000) in urban population. The possibility of confounding or the existence of covariates for children in urban settings was noted.

Conclusion:

Results of this study match findings in other epidemiological studies. However, multistage, large-scale studies are recommended for investigating prevalence rates with different severity levels of ID.

Hand-held health records for individuals with intellectual disability: a systematic review

BACKGROUND

Hand-held health records (HHHRs) aim to empower individuals with intellectual disability (ID) and improve the communication between all those involved in their health care. HHHRs can be used to identify additional health needs and contribute to improved treatment for individuals with ID. This review summarises evidence concerning the use of HHHRs with individuals with ID.

METHODS

Systematic searching of electronic databases and email contact with established researchers in the field were used to identify relevant articles related to the use of HHHRs among individuals with ID.

RESULTS

Seven articles were identified and included for review. Studies involved the development, evaluation, acceptability and facilitators and barriers of implementation of HHHRs. HHHRs did not lead to improved short-term healthcare activity, but did lead to more discussion about health problems, increased health-related knowledge and awareness of personal health issues.

CONCLUSIONS

HHHRs are well accepted among users with ID. However, no short-term benefits were found and future research needs to examine the long-term effects of HHHRs.

Shared decision-making about assistive technology for the child with severe neurologic impairment

Shared decision-making is a process that helps frame conversations about value-sensitive decisions, such as introduction of assistive technology for children with neurologic impairment. In the shared decision-making model, the health care provider elicits family values relevant to the decision, provides applicable evidence in the context of those values, and collaborates with the family to identify the preferred option. This article outlines clinical, quality of life, and ethical considerations for shared decision-making discussions with families of children with neurologic impairment about gastrostomy tube and tracheostomy tube placement.

People with intellectual disability: what do we know about adulthood and life expectancy?

Increases in the life expectancy of people with Intellectual Disability have followed similar trends to those found in the general population. With the exception of people with severe and multiple disabilities or Down syndrome, the life expectancy of this group now closely approximates with that of the general population. Middle and old age, which until 30 years ago were not recognized in this population, are now important parts of the life course of these individuals. Older adults with Intellectual Disabilities form a small, but significant and growing proportion of older people in the community. How these persons grow older and how symptoms and complications of the underlying cause of the Intellectual Disability will influence their life expectancy is of the utmost importance.

The Confidential Inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study

BACKGROUND

The Confidential Inquiry into premature deaths of people with intellectual disabilities in England was commissioned to provide evidence about contributory factors to avoidable and premature deaths in this population.

METHODS

The population-based Confidential Inquiry reviewed the deaths of people with intellectual disabilities aged 4 years and older who had been registered with a general practitioner in one of five Primary Care Trust areas of southwest England, who died between June 1, 2010, and May 31, 2012. A network of health, social-care, and voluntary-sector services; community contacts; and statutory agencies notified the Confidential Inquiry of all deaths of people with intellectual disabilities and provided core data. The Office for National Statistics provided data about the coding of individual cause of death certificates. Deaths were described as avoidable (preventable or amenable), according to Office for National Statistics definitions. Contributory factors to deaths were identified and quantified by the case investigator, verified by a local review panel meeting, and agreed by the Confidential Inquiry overview panel. Contributory factors were grouped into four domains: intrinsic to the individual, within the family and environment, care provision, and service provision. The deaths of a comparator group of people without intellectual disabilities but much the same in age, sex, and cause of death and registered at the same general practices as those with intellectual disabilities were also investigated.

FINDINGS

The Confidential Inquiry reviewed the deaths of 247 people with intellectual disabilities. Nearly a quarter (22%, 54) of people with intellectual disabilities were younger than 50 years when they died, and the median age at death was 64 years (IQR 52-75). The median age at death of male individuals with intellectual disabilities was 65 years (IQR 54-76), 13 years younger than the median age at death of male individuals in the general population of England and Wales (78 years). The median age at death of female individuals with intellectual disabilities was 63 years (IQR 54-75), 20 years younger than the median age at death for female individuals in the general population (83 years). Avoidable deaths from causes amenable to change by good quality health care were more common in people with intellectual disabilities (37%, 90 of 244) than in the general population of England and Wales (13%). Contributory factors to premature deaths in a subset of people with intellectual disabilities compared with a comparator group of people without intellectual disabilities included problems in advanced care planning (p=0·0003), adherence to the Mental Capacity Act (p=0·0008), living in inappropriate accommodation (p<0·0001), adjusting care as needs changed (p=0·009), and carers not feeling listened to (p=0·006).

INTERPRETATION

The Confidential Inquiry provides evidence of the substantial contribution of factors relating to the provision of care and health services to the health disparities between people with and without intellectual disabilities. It is imperative to examine care and service provision for this population as potentially contributory factors to their deaths--factors that can largely be ameliorated.

FUNDING

Department of Health for England.

Behavioral management in children with intellectual disabilities in a resource-poor setting in Barwani, India

BACKGROUND

Management of behavioral problems in children with intellectual disabilities (ID) is a great concern in resource-poor areas in India. This study attempted to analyze the efficacy of behavioral intervention provided in resource-poor settings.

OBJECTIVE

This study was aimed to examine the outcome of behavioral management provided to children with ID in a poor rural region in India.

MATERIALS AND METHODS

We analyzed data from 104 children between 3 and 18 years old who received interventions for behavioral problems in a clinical or a community setting. The behavioral assessment scale for Indian children with mental retardation (BASIC-MR) was used to quantify the study subjects' behavioral problems before and after we applied behavioral management techniques (baseline and post-intervention, respectively). The baseline and post-intervention scores were analyzed using the following statistical techniques: Wilcoxon matched-pairs signed-rank test for the efficacy of intervention; χ(2) for group differences.

RESULTS

The study demonstrated behavioral improvements across all behavior domains (P < 0.05). Levels of improvement varied for children with different severities of ID (P = 0.001), between children who did and did not have multiple disabilities (P = 0.011).

CONCLUSION

The outcome of this behavioral management study suggests that behavioral intervention can be effectively provided to children with ID in poor areas.

Differences in muscle activation patterns during sit to stand task among subjects with and without intellectual disability

The aim of this study is to analyse the differences in muscle activity between subjects who have intellectual disability and healthy subjects when they make the transition from sitting to standing positions. A cross-sectional study. A group of adults was divided into two subgroups: with and without intellectual disability (ID). The means of the basic features in both groups were 22.13 and 22.83 for age, 66.38 and 67.67 for weight, and 173.38 and 174.33 for height, for the ID (n = 8) and without ID (n = 7) groups, respectively. Each subject performed three sets of five repetitions during which, starting from sitting, they had to get up and sit on the chair. The recording of muscle activity was performed using surface electromyography taking the measures of muscle activity of different muscles of the lower limbs. The results showed differences in the pattern of muscle activity between groups during sitting to standing movement.

Antireflux surgery in children with neurological impairment: caregiver perceptions and complications

OBJECTIVES

The aim of the present study was to report caregiver perceptions to antireflux surgery and gastrostomy in children with severe neurological impairment and to report the complications of the surgery.

METHODS

Children were identified from a clinic database and clinical information and surgical complications were extracted from the database and hospital medical records. A cross-sectional questionnaire addressing severity of symptoms was administered to parents/caregivers and scored with a 5-point Likert scale (1 is much better to 5, much worse).

RESULTS

A total of 122 children, median age 74 months (interquartile range 29-124), 63% spastic quadriplegic cerebral palsy, had antireflux surgery. Laparoscopic surgery was performed in 77 of 122 (63%) and 117 of 122 (96%) had gastrostomy insertion. Questionnaire was completed by 89 of 122 (73%) children; median duration of time from fundoplication to questionnaire was 77 months (43-89). The majority of caregivers indicated that surgery improved or greatly improved weight gain, chest infections, vomiting, and feeding tolerance. Only 2 caregivers reported that they regretted consenting to surgery. Serious surgical complications occurred in 10%.

CONCLUSIONS

Serious complications were uncommon in this series of antireflux surgery in neurologically impaired children. Although gagging and retching were common following surgery, a high percentage of caregivers reported improved nutrition, reflux-related symptoms, and high levels of satisfaction.

Costs of meningitis sequelae in children in Dakar, Senegal

BACKGROUND

Survivors of bacterial meningitis risk lifelong sequelae. In economic evaluations of vaccines protecting against meningitis, treatment and productivity costs due to meningitis sequelae are rarely included in studies from low-income countries, mainly due to lack of data. The aim of this study was to estimate the costs of meningitis sequelae in children in Senegal from the perspective of households.

METHODS

Children who had suffered from bacterial meningitis were identified from a database at Albert Royer Hospital in Dakar. Sixty-eight children were located at their home and caregivers interviewed about costs during the acute meningitis episode and due to meningitis sequelae, including productivity loss from caring for a disabled child. Lifetime costs were predicted by assuming a life expectancy of 30 years for disabled children.

RESULTS

Seventy-one percent of the children had either minor or major sequelae. Mean discounted lifetime sequelae costs amounted to US$ 34,895 (95% confidence interval: US$ 67-96,755) per child. Discounted childcare costs amounted to US$ 3158 (9%), treatment costs US$ 460 (1%) and productivity costs US$ 31,276 (90%). No children were receiving rehabilitation services by the time the study was conducted.

CONCLUSION

The present study is the first to present data on household costs from families with disabled children in a low-income country setting. Caring for a disabled child is a considerable financial as well as emotional burden for the individual family. None of the families could afford the treatment they desired for their child.

Prevalence of mental retardation among children in RS Pura town of Jammu and Kashmir

OBJECTIVE

To determine the Prevalence of mental retardation in children 3 to 10 years of age.

MATERIALS AND METHODS

The study was conducted in the framework of a population based, single centre, cross-sectional study at R.S.Pura town, 22 kms south- west of Jammu city.

RESULTS

A total of 61 (0.79 percent) of the 7,707 children surveyed had positive screening results on the Ten Questions instrument. 56 (0.72percent) children were diagnosed as suffering from mental retardation. Serious mental retardation was diagnosed in 48 children and mild mental retardation was diagnosed in 8 children. The combined prevalence estimates of mild and serious mental retardation were 7.2/1000. No notable sex differences were observed for either serious or mild retardation.

INTERPRETATION

The prevalence rates of mental retardation among children less than 19 years of age in R. S. town compares favorably with studies from developed world.

Longitudinal cohort protocol study of oropharyngeal dysphagia: relationships to gross motor attainment, growth and nutritional status in preschool children with cerebral palsy

INTRODUCTION

The prevalence of oropharyngeal dysphagia (OPD) in children with cerebral palsy (CP) is estimated to be between 19% and 99%. OPD can impact on children's growth, nutrition and overall health. Despite the growing recognition of the extent and significance of health issues relating to OPD in children with CP, lack of knowledge of its profile in this subpopulation remains. This study aims to investigate the relationship between OPD, attainment of gross motor skills, growth and nutritional status in young children with CP at and between two crucial age points, 18-24 and 36 months, corrected age.

METHODS AND ANALYSIS

This prospective longitudinal population-based study aims to recruit a total of 200 children with CP born in Queensland, Australia between 1 September 2006 and 31 December 2009 (60 per birth-year). Outcomes include clinically assessed OPD (Schedule for Oral Motor Assessment, Dysphagia Disorders Survey, Pre-Speech Assessment Scale, signs suggestive of pharyngeal phase impairment, Thomas-Stonell and Greenberg Saliva Severity Scale), parent-reported OPD on a feeding questionnaire, gross motor skills (Gross Motor Function Measure, Gross Motor Function Classification System and motor type), growth and nutritional status (linear growth and body composition) and dietary intake (3 day food record). The strength of relationship between outcome and exposure variables will be analysed using regression modelling with ORs and relative risk ratios.

ETHICS AND DISSEMINATION

This protocol describes a study that provides the first large population-based study of OPD in a representative sample of preschool children with CP, using direct clinical assessment. Ethics has been obtained through the University of Queensland Medical Research Ethics Committee, the Children's Health Services District Ethics Committee, and at other regional and organisational ethics committees. Results are planned to be disseminated in six papers submitted to peer reviewed journals, and presentations at relevant international conferences.

Subsequent, unplanned spine surgery and life survival of patients operated for neuropathic spine deformity

STUDY DESIGN

Retrospective study of a prospectively assembled cohort.

OBJECTIVE

To characterize the survival from subsequent spine surgery and the life survival of patients treated surgically for severe spinal deformity due to neuropathic diseases.

SUMMARY OF BACKGROUND DATA

Survivorship analysis is widely used to study the natural history of disease processes and of treatments provided, but has very seldom been used to study patients' course after surgery for spinal deformity associated with neuropathic diseases.

METHODS

Patients with neuropathic spinal deformity treated with primary posterior instrumentation and arthrodesis from 1989 through 2002 were identified and studied by review of charts and radiographs, and by mail survey. Subsequent spine surgery and death events, and the time interval from surgery were identified. Fifteen variables possibly influencing survivorship were studied.

RESULTS

There were no perioperative deaths, spinal cord injuries, or acute wound infections in the 117 eligible patients. Reoperation and life survival statuses were available for 110 patients (94%) at an average follow-up of 11.89 years (±5.3; range: 2-20.9 yr). Twelve patients (11%) had subsequent spine surgery. Survival from subsequent spine surgery was 91% at 5 years, 90% at 10 and 15 years, and 72% at 20 years. Proximal fixation problems occurred in 4 patients. Twenty-two patients (20%) had died from 4 to 20 years postoperative. Life survival was 98% at 5 years, 89% at 10 years, 81% at 15 years, and 56% at 20 years. The only variable associated with life survival was the occurrence of one or more perioperative complications, P = 0.0032. The younger half of the series at operation (<13.75 yr) was significantly more likely to have one or more perioperative complications, P = 0.0068. Spinal deformity type and magnitude were similar for the younger and older halves of the patients. Life survival of the patients with cerebral-palsy and not-cerebral-palsy upper motor neuron disease was not different. One-hundred-two of 105 were at least satisfied or would have the surgery again for the same condition.

CONCLUSION

Survival from subsequent spine operation was similar to adolescent idiopathic scoliosis series studied in the same manner. Life survival decline began at 4 years postoperative and was significantly associated with the occurrence of one or more perioperative complications. Even after successful spine deformity surgery, this population's health status is often precarious.

Postoperative adverse outcomes in intellectually disabled surgical patients: a nationwide population-based study

Background

Intellectually disabled patients have various comorbidities, but their risks of adverse surgical outcomes have not been examined. This study assesses pre-existing comorbidities, adjusted risks of postoperative major morbidities and mortality in intellectually disabled surgical patients.

Methods

A nationwide population-based study was conducted in patients who underwent inpatient major surgery in Taiwan between 2004 and 2007. Four controls for each patient were randomly selected from the National Health Insurance Research Database. Preoperative major comorbidities, postoperative major complications and 30-day in-hospital mortality were compared between patients with and without intellectual disability. Use of medical services also was analyzed. Adjusted odds ratios using multivariate logistic regression analyses with 95% confidence intervals were applied to verify intellectual disability's impact.

Results

Controls were compared with 3983 surgical patients with intellectual disability. Risks for postoperative major complications were increased in patients with intellectual disability, including acute renal failure (odds ratio 3.81, 95% confidence interval 2.28 to 6.37), pneumonia (odds ratio 2.01, 1.61 to 2.49), postoperative bleeding (odds ratio 1.35, 1.09 to 1.68) and septicemia (odds ratio 2.43, 1.85 to 3.21) without significant differences in overall mortality. Disability severity was positively correlated with postoperative septicemia risk. Medical service use was also significantly higher in surgical patients with intellectual disability.

Conclusion

Intellectual disability significantly increases the risk of overall major complications after major surgery. Our findings show a need for integrated and revised protocols for postoperative management to improve care for intellectually disabled surgical patients.

Aging with an Intellectual Disability: A Review of Canadian Literature

On constate une hausse de la longévité chez les personnes ayant des incapacités intellectuelles, due à la modification de leur encadrement — de la vie institutionnelle à la vie communautaire — et à l'amélioration de la nutrition et des soins de santé. Les individus nés avant 1945 au Canada, représentent le premier groupe d'importance à atteindre la vieillesse. Malgré la croissance de ce groupe d'individus, on sait très peu de choses sur leurs expériences de vie et leurs besoins. En grande partie, cette population demeure invisible, sous-évaluée et souvent oubliée, et n'est que rarement le point d'intérêt de nouvelles politiques ou de programmes d'initiatives. Cet examen des publications médicales canadiennes sur les sujets traitant de fréquence, de longévité et de vieillesse prématurée des personnes ayant des incapacités intellectuelles recouvre trois points. D'abord il expose l'impact des changements dans les politiques sociales sur leurs expériences de vie, ensuite il trace les grandes lignes des besoins et des attentes des personnes plus âgés ainsi que de leurs familles et finalement il suggère de nouvelles approches, dans l'avenir, des politiques de développement et de recherches au Canada.

The burden of inherited leukodystrophies in children

OBJECTIVES

Leukodystrophies are diseases of the white matter for which data concerning clinical characteristics, incidence, disease burden, and description of outcomes are sparse. The purpose of our study was to determine the incidence and most common types of inherited leukodystrophies in a population, the mortality and time course of deaths, common neurologic features in patients, and health care costs associated with leukodystrophies.

METHODS

We conducted a retrospective, hospital- and clinic-based surveillance of inherited leukodystrophies among children younger than 18 years presenting to a regional children's hospital. We enrolled children evaluated from January 1, 1999, through December 31, 2007; clinical information was obtained from medical records. We calculated incidence based on state birth rates.

RESULTS

A total of 122 children with an inherited leukodystrophy were identified; 542 patients were excluded. A total of 49% had epilepsy, 43% required a gastrostomy tube, and 32% had a history of developmental regression. Mortality was 34%; average age at death was 8.2 years. No final diagnosis was reported in 51% of patients. The most common diagnoses were metachromatic leukodystrophy (8.2%), Pelizaeus-Merzbacher disease (7.4%), mitochondrial diseases (4.9%), and adrenoleukodystrophy (4.1%). Endocrine abnormalities and hypoplastic cerebellum were noted in significant portions of patients (15% and 14%). Average yearly per-patient medical costs were $22,579. Population incidence was 1 in 7,663 live births.

CONCLUSIONS

Inherited leukodystrophies are associated with substantial morbidity and mortality in children. Overall population incidence is higher than generally appreciated (1 in 7,663 live births). Most leukodystrophies remain undiagnosed, but a logical algorithm based on prevalence could aid testing.

An analysis of ED utilization by adults with intellectual disability

OBJECTIVES

We sought to identify factors increasing the odds of ED utilization among intellectually disabled (ID) adults and differentiate their discharge diagnoses from the general adult ED population.

METHODS

This was a retrospective, observational open cohort study of all ID adults residing at an intermediate care facility and their ED visits to a tertiary center (January 1, 2007-July 30, 2008). We abstracted from the intermediate care facility database subjects' demographic, ID, health and adaptive status variables, and their requirement of ED care/hospitalization. We obtained from the hospital database the primary International Classification of Diseases 9 ED/hospital discharge diagnoses for the study and general adult population. Using multivariate logistic regression, we computed odds ratios (OR) for ED utilization/hospitalization in the cohort. Using the conditional large-sample binomial test, we differentiated the study and general populations' discharge diagnoses.

RESULTS

A total of 433 subjects met the inclusion criteria. Gastrostomy/jejunostomy increased the odds of ED utilization (OR, 4.16; confidence interval [CI], 1.64-10.58). Partial help to feed (OR, 2.59; CI, 1.14-5.88), gastrostomy/jejunostomy (OR, 3.26; CI, 1.30-8.18), and increasing number of prescribed medications (OR, 1.08; CI, 1.03-1.14) increased the odds of hospitalization. Auditory impairment (OR, 0.45; CI, 0.23-0.88) decreased the odds of hospitalization. For ED discharge diagnoses, ID adults were more likely (P < .05) than the general population to have diagnoses among digestive disorders and ill-defined symptoms/signs. For hospital discharge diagnoses, ID adults were more likely (P < .05) to have diagnoses among infectious/parasitic, nervous system, and respiratory disorders.

CONCLUSION

Among ID adults, feeding status increased the odds of ED utilization, feeding status, and increasing number of prescribed medications of that hospitalization. Intellectually disabled adults' discharge diagnoses differed significantly from the general adult ED population.

The effect of basketball training on the muscle strength of adults with mental retardation

The purpose of this study was to evaluate the effect of basketball training on the muscle strength of adults with mental retardation (MR). Twenty-four adults with and without MR were separated into 3 groups. Eight adults (mean age 25.4 years) with normal IQ constituted the control group (NIQ). Eight adults (mean age 26.5 years) with MR and all participating in a 4-year systematic basketball exercise program constituted the trained group (MR-T), and 8 adults (mean age 25.3 years) with MR exercised occasionally for recreational reasons formed the MR-R group. Parameters measured were isometric and isokinetic concentric and eccentric muscle strength. All subjects performed a leg strength test on a Cybex Norm isokinetic dynamometer. Analysis of variance was used to examine mean differences between the values of the 3 groups. A significance level of 0.05 was used for all tests. The NIQ group showed a statistically significant difference in all measured values compared to the MR groups. The MR-T group presented higher absolute and relative torque scores for both knee extensors and flexors than the MR-R group, whereas the MR-R group presented statistically higher antagonistic activity for both knee extensors and flexors than the MR-T group. In addition, both MR groups presented statistically higher antagonistic activity for both knee extensors and flexors compared to the NIQ group. Data support participation on a systematic and well-designed basketball training program to improve muscle strength levels of adults with MR. Participation in basketball without necessarily focusing on developing specific fitness components may be an effective training strategy for the promotion of strength of adults with MR.

Residential characteristics, social factors, and mortality among adults with intellectual disabilities: transitions out of nursing homes

The present study examined the degree to which residential characteristics and social factors are associated with mortality, after controlling for personal characteristics, among adults with intellectual disabilities who have resided in nursing homes (facilities providing skilled care and related services) at baseline in the Chicago area. Initial assessments were conducted on 330 residents, and 2 follow ups were performed over 10 years. Seventy-one residents had died by the end of the study. The variables examined included personal characteristics of age, gender, intellectual level, health, and adaptive behavior; residential characteristics of type of residence, size of facility, attractiveness of physical environment (cleanliness, conditions, and aesthetic appeal), and diversity of physical environment (personalization of residents' rooms and distinctiveness of all living spaces); and social factors of family involvement and community integration. The results indicated, beyond age, adaptive behavior, and health, that size of residences, residential characteristics, and social factors are related to mortality.

Health, mortality, and wellness issues in adults with cerebral palsy

For many years, children with cerebral palsy (CP) and their parents have been told that health and functional status stabilize by early adulthood. However, adults with CP report ongoing health conditions and aging and secondary conditions that are not always recognized or managed by their healthcare providers. There is a growing body of literature to better define the health, mortality, and wellness of those aging with CP. In general, adults with CP report good health, although health outcomes appear to be linked to the severity of CP and to increasing age. Studies reporting on lifespan warrant caution in interpretation because of biases in the survey and surveillance systems. It appears that lifespan of persons with CP is at or close to that of the typical population. The most commonly reported age-related changes and secondary conditions involve pain/fatigue, physical performance, and the musculoskeletal system. Not all adults have serious health problems, and many now recognize the aging process as a natural course of events. Few adults with CP engage in typical screening and health promotion activities due to a variety of barriers. There continues to be much to be learned and disseminated, in order to improve the care of adults with CP.

Gastrointestinal and nutritional problems in severe developmental disability

The aim of this study was to describe the experience of 452 children and adults with a severe developmental disability who presented to a multidisciplinary clinic with swallowing, nutritional, and gastrointestinal problems. Data were obtained by chart review. Two hundred and ninety-four children (age range 7 mo-19 y, 173 males, 121 females) and 158 adults (age range 18-53 y; 90 males, 68 females) were assessed over 5 years. One hundred and eighty-two children and 86 adults had cerebral palsy. Approximately 90% were wheelchair dependent and totally dependent on caregivers for feeding; 60% had epilepsy. Pulmonary aspiration was identified by oesophageal videofluoroscopy in 41% of 174 children and 47% of 34 adults. Chronic oesophagitis and Helicobacter pylori were found in 57% of 182 children and 76% of 66 adults undergoing endoscopy. Chronic suppurative lung disease was identified by computerized axial tomography in 94% of 62 children and all six adults studied. Most patients improved with simple interventions. However, gastrostomy was recommended in 140 children and performed in 91, and in 10 adults but performed in seven, whereas fundoplication was recommended in 111 children and performed in 74, and in six adults but performed in two. In conclusion, chronic oesophagitis, pulmonary aspiration, and chronic lung disease were identified in many patients with a severe developmental disability.

Predictive factors of early mortality in children with developmental disabilities: a case-comparison analysis

The aim of this study was to identify the risk factors for early mortality in children with neurodevelopmental disabilities. Of 1000 children who were sequentially referred to the same child developmental center over the period 1975-1985, 81 children died between the ages of 6 months and 22 years (mean, 8.04 years; 6.1 SD). A group of 81 age-matched children and another group of 81 developmentally and age-matched children also referred to the center served as comparison groups. Following multivariate analysis, low developmental quotient, restricted mobility, assisted feeding, and genetic etiology were risk factors for early mortality when compared to the age-matched group (P < .01). In comparison to the developmentally matched group, restricted mobility, genetic etiology, and hearing deficit were identified as significant risk factors (P < .01). Comprehensive treatment at the child development center was demonstrated to be a significant protective factor (P = .004). Socioeconomic variables were not significant in predicting an increased mortality risk in disabled individuals. In conclusion, in addition to mobility and feeding skills, a genetic etiology and hearing deficit are risk factors for early mortality, whereas socioeconomic variables are not. A comprehensive treatment program was found to be a protective factor.

Surgical correction of scoliosis in pediatric patients with cerebral palsy using the unit rod instrumentation

STUDY DESIGN

Retrospective clinical and radiographic consecutive case series of 2 surgeons.

OBJECTIVE

The purpose of this study was to present a large consecutive series of patients with cerebral palsy who were treated with the Unit rod instrumentation at a single institution. The goal was to report the incidence of surgical complications, degree of deformity correction, reoperation rate, prevalence of pseudarthrosis, and the caretakers' perceived outcome.

SUMMARY OF BACKGROUND DATA

Children with cerebral palsy frequently develop scoliosis that requires surgical correction. Segmental instrumentation has been the primary mode of treatment. There are no reported large series with long-term follow up.

METHODS

This study was a retrospective review of 287 children treated with the Unit rod instrumentation. This instrumentation with fusion included the whole spine (between C7 and T3 into the pelvis) with 242 posterior-only and 45 anterior-posterior procedures. Of this group, 241 patients were observed for more than 2 years. This review focused on the rate of complications and radiographic outcome of the treatment. Parent and caretaker interviews were conducted to define perceived functional outcome after surgery.

RESULTS

Scoliosis was corrected from a mean of 76 degrees to 25 degrees (68%). Pelvic obliquity was corrected from a mean of 17 degrees to 5 degrees (71%). In posterior-only procedures the average blood loss was 2.8 L, ICU stay was 4.9 days, and the hospital stay was 19.6 days. In combined procedures, the average blood loss was 3.4 L, ICU stay was 6.7 days, and the hospital stay was 24.5 days. Major complications included 3 perioperative deaths, 18 deep wound infections [12 early deep infections in a total of 287 patients (4.2%); 6 late deep infections in a total of 236 patients (2.5%)], and 2 patients with septicemia who recovered after prolonged antibiotic management. Caretakers' survey reported a 96% satisfaction rate.

CONCLUSION

The Unit rod instrumentation is a common standard technique and the primary instrumentation system for the treatment of pediatric patients with cerebral palsy and neuromuscular scoliosis because it is simple to use, it is considerably less expensive than most other systems, and can achieve good deformity correction with a low loss of correction, as well as a low prevalence of associated complications and a low reoperation rate.

New strategies and decision making in the management of neuromuscular scoliosis

The outcome of spinal fusion in neuromuscular scoliosis demonstrates a consistently high satisfaction rate among parents and caretakers. It is somewhat more difficult to determine the functional benefits in individual patients, especially in those with the most severe involvement. Even in those children, a predicted 70% survival rate at 11 years has been documented following surgery. Scoliosis is common in children with neuromuscular diseases, especially cerebral palsy. Most of these children need stabilization to enhance their quality of life by improving sitting ability. Studies continue to show a high family satisfaction and caregiver satisfaction following spine reconstructive surgery for neuromuscular scoliosis and other spine deformities.

Compliance with Dysphagia Recommendations by Carers of Adults with Intellectual Impairment

Health risks associated with dysphagia in adults with intellectual impairment are well documented. There is little research into compliance with dysphagia recommendations in environments where care is provided for adults with intellectual impairment. This is a pilot study into carer compliance with Speech-Language Pathology recommendations. We aimed to investigate the level of compliance with dysphagia recommendations in day centers and the factors that might affect compliance using a questionnaire. Twenty-seven clients were observed. Results showed an overall high level of compliance with recommendations (82%), with figures ranging from 64% compliance with appropriate utensils to 100% with direct support recommendations. Areas of noncompliance were evident, with level of dependence of clients and training of carers being key issues. Implications for practitioners are discussed.

Policy, service pathways and mortality: a 10-year longitudinal study of people with profound intellectual and multiple disabilities

BACKGROUND

One hundred and forty-two children and adults with profound intellectual and multiple disabilities were identified in 1993 in a single Scottish region on whom detailed information was collected via a postal questionnaire survey.

METHODS

They were followed up in 2003. The time spanned represented a period of significant policy change in which community care and inclusive policies were implemented.

RESULTS

Of the original population of 142, 30 (21.1%) had died in the intervening period and two had left the area, allowing follow-up information to be collected on 110 individuals. While in line with policy, all those living in hospital and hostels in 1993 had been relocated by 2003 to community settings, a substantial proportion had moved into other forms of congregate care, notably nursing homes. Overall, the proportion in congregate care increased from 38% in 1993 to 43% in 2003. The second principal providers were family carers, with the proportion of those living at home also increasing from 33% to 40%. Provision in group houses increased from 6.3% to 15.5%. Day service provision remained based on a traditional centre-based model. The principal cause of death was respiratory disease. Survivors in 2003 were in 1993 more competent in personal self-help and motor abilities and were less likely to have epilepsy.

CONCLUSIONS

The findings are considered with respect to the extent to which they realize policy aspirations.

Age at death of people with an intellectual disability in Ireland

This study examined the age at death of people with an intellectual disability in Ireland. Using data from the National Intellectual Disability Database, the average age at death of 1120 people who died between 1996 and 2001 was 45.68 years, with no difference in lifespan between men and women. A more severe level of intellectual disability predicted shorter lifespan. In general, those requiring lower levels of day-to-day support and supervision had a longer lifespan. Those living in the family home had the shortest lifespan while those in hospital residential environments had the longest lifespan. Those not attending any day service had a longer lifespan than those attending a range of day services. There were also differences in age at death across different health board regions. These findings are discussed in light of their implications for service planning.

Cerebral palsy life expectancy

The life expectancy of people who have perinatally acquired cerebral palsy can be similar to that of the general population, or it can be reduced substantially. The most important factors that are associated with reduced survival are disabilities of motor, cognitive, or visual functions. Prematurity and low birth weight are associated with lower rates of disability, and better survival. A 2-year-old who has severe cerebral palsy has about a 40% chance of living to age 20, in contrast to a child who has mild cerebral palsy, for whom the chance is 99%. Cerebral palsy, respiratory diseases, epilepsy, and congenital malformation are the most commonly recorded causes of early death.

Does gastrostomy tube feeding in children with cerebral palsy increase the risk of respiratory morbidity?

BACKGROUND

Children with severe neurological impairment may have significant oral motor dysfunction and are at increased risk of nutritional deficiencies, poor growth, and aspiration pneumonia. Gastrostomy tube feeding is increasingly being used for nutritional support in these children.

AIM

To examine the occurrence of respiratory morbidity before and after gastrostomy feeding tube insertion in children with severe neurological disabilities.

METHODS

This study was nested in a longitudinal, prospective, uncontrolled, multicentre cohort study designed to investigate the outcomes of gastrostomy tube feeding in 57 children with severe neurological disabilities. Parents completed a questionnaire prior to (visit 1) and 6 and 12 months (visits 2 and 3) following the gastrostomy, detailing number of chest infections requiring antibiotics and/or hospital admission.

RESULTS

Mean number of chest infections requiring antibiotics was 1.8 on visit 1 and 0.9 on visit 3. Hospital admissions for chest infections fell significantly from 0.5 to 0.09.

CONCLUSION

This study provides no evidence for an increase in respiratory morbidity following insertion of a feeding gastrostomy in children with cerebral palsy.