Matthew Tobey

Prevalence of and risk factors for chronic kidney disease in rural Nicaragua

BACKGROUND Mostly anecdotal reports describe a high prevalence of chronic kidney disease in northwestern Nicaragua, predominantly among younger men, resulting in substantial morbidity and mortality. The true prevalence, nature and aetiology of kidney disease in this region remain unknown. METHODS We performed a population-based prevalence study in Quezalguaque, Nicaragua to assess the frequency of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2), and compared the prevalence of reduced eGFR in Quezalguaque with the USA using the NHANES 1999-2006 data. We also conducted an embedded case-control study in a subset of participants to assess kidney disease risk factors. RESULTS From 1882 eligible households, 771 individuals from 300 households participated in the prevalence study, 98 (13%) of whom had reduced eGFR. Reduced eGFR was more common among older participants, men and participants living at lower altitudes. Among 18-29-year-old participants, 2.6% had reduced eGFR, and among 30-41-year-old participants, 7.4% had reduced eGFR; this compares with 0.2% and 0.8%, respectively, in NHANES. No individuals in these age groups were diabetic. Among cases, only 27% had dipstick proteinuria of 1+ or greater, compared with 7% of controls. Haematuria did not significantly differ between cases and controls (24% versus 18%). In age- and sex-adjusted models, hypertension and residence at lower altitude were independently associated with reduced eGFR, while occupational history was not associated with reduced eGFR. CONCLUSIONS Kidney disease appears common in residents of Quezalguaque, Nicaragua, particularly in younger men, with features most consistent with tubulointerstitial disease. Further research is needed to elucidate the causes of kidney disease in this region.

Tobacco Use among Homeless People — Addressing the Neglected Addiction

About three quarters of homeless adults in the United States smoke, but the coexisting psychiatric and addictive conditions and circumstances of homeless smokers fuel a fatalistic attitude among health professionals toward addressing tobacco use in this population.

Dental Student–Delivered Care at a Student–Faculty Collaborative Clinic in a Correctional Facility

The article discusses the implementation of a dental clinic in a city jail in tandem with medical and mental health care, during which dental students delivered dental care with a supervising dentist, provided patient oral health education, and trained other students to conduct oral screenings. Topics included the impact of incarceration on overall patient health, the benefits of interdisciplinary training of health professionals, and an increase in the availability of dental services for patients.

Rates of Criminal Legal System Involvement Among Patients Who Are Discharged Against Medical Advice

People with a history of incarceration have poorer health, are more likely to be hospitalized after release, and are more likely to utilize the emergency department for care. 5 Many patients with a history of incarceration report experiencing discrimination by healthcare workers, which may compound feelings of disempowerment and dissatisfaction with care that lead to DAMA. 6 The purpose of this study was to evaluate whether DAMA was associated with a history of criminal legal involvement (CLI) among patients at a large urban tertiarycare medical center in the northeastern USA.

Capsule Commentary on Winkelman et al., Health Insurance Trends and Access to Behavioral Healthcare Among Justice-Involved Individuals—United States, 2008–2014

T his analysis by Winkelman et al. 1 describes self-reported insurance status and utilization of certain care services among a sample of United States community-dwelling adults who reported recent involvement in the criminal justice system. The results, which offer insight into the effects of the Affordable Care Act (ACA), suggest important gains in insurance status from both the 2010 dependent coverage mandate and the 2014 reforms that included Medicaid expansion, subsidized insurance plans, marketplace implementation, and the individual coverage mandate. The ACA’s dependent coverage mandate of 2010 led 2.5 millionmore young adults to obtain insurance coverage. In this study, outsized gains were noted in justice-involved individuals in the eligible age range (19–25). This is an important subpopulation; in this analysis, 31 % of justice-involved individuals were 19–25, as are roughly 15 % of state prisoners. Insurance gains may have been reaped mostly by individuals with better socioeconomic profiles, given that the expansion applied only to dependents whose parents are privately insured. The ACA reforms of 2014 reached a near-full effect on insurance rates in 2015. Thus the study’s finding that the ACA increased coverage—relying on surveys administered in 2014—is unlikely to represent the full effect of the reforms. Despite improving, the rates of the uninsured among justiceinvolved individuals remained high, twice that of the general population, suggesting that barriers remain. Also, the study left unanswered the question of whether differential effects exist between states that did and did not expand Medicaid. The study demonstrated that uptake of some mental health and substance use disorder treatment was higher in insured groups over 2008–2014. One implication could be that the ACA’s effects on insurance coverage will generate increased uptake of services. Together, these findings offer important insight into how a uniquely vulnerable group has fared under the ACA. Strategies by which communities and health systems may best leverage ACA reforms for the justice-involved population were recently reviewed. The complexities of achieving health equity for these populations are likely to require targeted and comprehensive interventions. Nevertheless, the ACA appears to have loosened the shackles of the uninsured—communities and providers may take the next steps.

Global Health Systems

• Sustainable, ethical engagement begins with careful listening, cultural sensitivity, and responsiveness to local preferences and conditions. • Few, if any, health systems provide ideal care; there are useful frameworks for improvement. • Health systems built upon economic, social, public health, and primary carebased interventions at the community level have been the most consistently successful. • Some outside efforts to buoy health systems have caused harm. • There is growing access to information on health systems and understanding of routes to successful reform. Chapter 3 Global Health Systems