Mohammad M. Agha

Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection

BACKGROUND A decrease in risk of urinary-tract infection is one of the most commonly given reasons for circumcision of newborn boys. Previous studies have reported rates of UTI to be 10-20 times higher in uncircumcised than in circumcised boys. This population-based cohort study followed neonates in Ontario, Canada, prospectively to study the relation between circumcision and subsequent UTI risk. METHODS Eligible boys were born to residents of Ontario between April 1, 1993, and March 31, 1994. We used hospital discharge data to follow up boys until March 31, 1996. FINDINGS Of 69,100 eligible boys, 30,105 (43.6%) were circumcised and 38,995 (56.4%) uncircumcised. 888 boys circumcised after the first month of life were excluded. 29,217 uncircumcised boys were matched to the remaining circumcised boys by date of birth. The 1-year probabilities of hospital admission for UTI were 1.88 per 1000 person-years of observation (83 cases up to end of follow-up) in the circumcised cohort and 7.02 per 1000 person-years (247 cases up to end of follow-up) in the uncircumcised cohort (p<0.0001). The estimated relative risk of admission for UTI by first-year follow-up indicated a significantly higher risk for uncircumcised boys than for circumcised boys (3.7 [2.8-4.9]). 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life. INTERPRETATION Although our findings support the notion that circumcision may protect boys from UTI, the magnitude of this effect may be less than previously estimated.

Congenital abnormalities and childhood cancer

The examination of specific characteristics of neoplasms diagnosed in children have suggested that a significant proportion can be attributed to a genetic mutation or genetic predisposition. Although the study of a genetic predisposition to cancer in children remains in the early stages, congenital abnormalities could provide essential information for mapping predisposing lesions in children with cancer.

Universal Health Insurance and Equity in Primary Care and Specialist Office Visits: A Population-Based Study

PURPOSE Universal coverage of physician services should serve to reduce socioeconomic disparities in care, but the degree to which a reduction occurs is unclear. We examined equity in use of physician services in Ontario, Canada, after controlling for health status using both self-reported and diagnosis-based measures. METHODS Ontario respondents to the 2000–2001 Canadian Community Health Survey (CCHS) were linked with physician claim files in 2002–2003 and 2003–2004. Educational attainment and income were based on self-report. The CCHS was used for self-reported health status and Johns Hopkins Adjusted Clinical Groups was used for diagnosis-based health status. RESULTS After adjustment, higher education was not associated with at least 1 primary care visit (odds ratio [OR] = 1.05; 95% confidence interval [CI], 0.87–1.24), but it was inversely associated with frequent visits (OR = 0.77; 95% CI, 0.65–0.88). Higher education was directly associated with at least 1 specialist visit (OR = 1.20; 95% CI, 1.07–1.34), with frequent specialist visits (OR = 1.21; 95% CI, 1.03–1.39), and with bypassing primary care to reach specialists (OR = 1.23, 95% CI 1.02–1.44). The largest inequities by education were found for dermatology and ophthalmology. Income was not independently associated with inequities in physician contact or frequency of visits. CONCLUSIONS After adjusting for health status, we found equity in contact with primary care for educational attainment but inequity in specialist contact, frequent visits, and bypassing primary care. In this setting, universal health insurance appears to be successful in achieving income equity in physician visits. This strategy alone does not eliminate education-related gradients in specialist care.

Social disadvantage, air pollution, and asthma physician visits in Toronto, Canada.

BACKGROUND Previous research demonstrates that ambient air pollution exacerbates asthma. Asthma morbidity also varies with socioeconomic position (SEP). Few studies have examined if ambient air pollution has a differential impact on income subgroups of the population. This paper investigates socioeconomic variation in ambulatory physician consultations for asthma and assesses possible effect modification of SEP on the association between physician visits and air pollution for children aged 1-17 and adults aged 18-64 in Toronto, Canada, between 1992 and 2001. METHODS Generalized additive models and generalized linear models were used to estimate the adjusted risk of asthma physician visits associated with an interquartile range increase in sulfur dioxide (SO2), nitrogen dioxide (NO2), particulate matter (PM2.5), and ozone (O3). RESULTS A socioeconomic gradient in the number of physician visits was observed among children and adults and both sexes. SO2, NO2, and PM2.5 had positive associations with physician visits. The risk ratios for the low socioeconomic group were significantly greater than those for the high socioeconomic group in several of the models of SO2 and PM2.5. CONCLUSIONS These findings suggest increased ambulatory physician visits represent another component of the public health impact of urban air pollution. The burden of this impact may be borne disproportionately by those with lower SEP. Clarifying the role of SEP in altering susceptibility to the effects of air pollution is essential not only to inform revisions of ambient air quality standards, but also to design public health interventions to reduce health impacts on sensitive subgroups of the population.

Socioeconomic status and prevalence of congenital heart defects: does universal access to health care system eliminate the gap?

BACKGROUND A twofold increase in the prevalence of congenital heart defects (CHDs) has been reported since the early 1970s with higher rates among children from low socioeconomic status (SES). This increase and the observed SES gap are postulated to be reflective of higher ascertainment, especially increased use of ultrasound and echography. The purpose of this study was to examine if trends over time in the prevalence of CHD were the same for high and low SES groups. METHODS Using the childs health number as a unique identifier and through record linkage, children born in Ontario between 1994 and 2007 were followed for the diagnosis of CHD. Using postal codes and census information, SES quintiles were assigned to each child. We used adjusted rates and used multivariate models to compare trends in the prevalence rate among children born in different SES groups. RESULTS Children born in low SES areas (23% of all births) had significantly higher rates of CHDs (rate ratio = 1.20; 95% confidence interval [CI] = 1.15-1.24). While prevalence of nonsevere CHDs declined in all SES groups since 2000, severe CHDs, especially atrial septal defects were on the rise during the study period. DISCUSSION It is assumed that increased ascertainment is responsible for observed increase in the prevalence of CHD, especially minor defects. While the trend and pattern over time changed for severe and nonsevere CHDs, the SES gap remained consistent during the study period. Our results indicate that even free and universal access to a health care system does not eliminate the SES gap observed in the prevalence of CHD.

Determining the costs of families' support networks following a child's cancer diagnosis.

Background: Cancer in children may place considerable economic burden on more than individual family members. The costs incurred to families’ support networks (FSNs) have not been previously studied. Objectives: The study objectives were to (a) identify and determine independent predictors of the direct and time costs incurred by the FSN and (b) explore the impact of these cancer-related costs on the FSN. Methods: A prospective mixed-methods study was conducted. Representing the FSN, parents recorded the resources consumed and costs incurred during 1 week per month for 3 consecutive months, beginning 1 month following their child’s diagnosis. Descriptive statistics, multiple regression modeling, and descriptive qualitative analytical methods were used to analyze the data. Results: In total, 28 fathers and 71 mothers participated. The median total direct and time costs for the 3 months were CAN

Which Siblings of Children with Cancer Benefit Most from Support Groups

154 and

Food fortification and decline in the prevalence of neural tube defects: does public intervention reduce the socioeconomic gap in prevalence?

2776, respectively, per FSN. The largest component of direct and time costs was travel and foregone leisure. Direct and time costs were greatest among those parents who identified a support network at baseline. Parents relied on their FSN to “hold the fort,” which entailed providing financial support, assuming household chores, maintaining the siblings’ routines, and providing cancer-related care. Conclusions: Families’ support networks are confronted with a wide range of direct and time costs, the largest being travel and foregone leisure. Implications for Practice: Families’ support networks play an important role in mitigating the effects of families’ costs. Careful screening of families without an FSN is needed.

Monitoring mental health reform in a Canadian inner city.

This study asks which siblings of children with cancer (SCC) benefit most from a group intervention specifically designed for them. One hundred and eleven SCC (aged 8–17) participated in eight weekly, two-hour, manualized group sessions. Changes in anxiety and depression symptoms were used as outcome measures. Anxiety and depression scores improved more for siblings who were initially most depressed and, thus, considered “less resilient” (p < 0.0001). Within this group, males improved more than females, and siblings of children with brain tumors improved less than SCC with other cancers, (p = 0.05), with female siblings of children with brain tumors improving the least (p = 0.0397).

Congenital abnormalities in newborns of women with pregestational diabetes: A time-trend analysis, 1994 to 2009.

Objective: A significant decline in the prevalence of neural tube defects (NTD) through food fortification has been reported. Questions remain, however, about the effectiveness of this intervention in reducing the gap in prevalence across socioeconomic status (SES). Study Design: Using health number and through record linkage, children born in Ontario hospitals between 1994 and 2009 were followed for the diagnosis of congenital anomalies. SES quintiles were assigned to each child using census information at the time of birth. Adjusted rates and multivariate models were used to compare trends among children born in different SES groups. Results: Children born in low SES areas had significantly higher rates of NTDs (RR = 1.25, CI: 1.14–1.37). Prevalence of NTDs among children born in low and high SES areas declined since food fortification began in 1999 although has started rising again since 2006. While the crude decline was greater in low SES areas, after adjustment for maternal age, the slope of decline and SES gap in prevalence rates remained unchanged overtime. Conclusions: While food fortification is successful in reducing the prevalence of NTDs, it was not associated with removing the gap between high and low SES groups.