Kidney Transplantation Is Associated with Catastrophic Out of Pocket Expenditure in India

Kidney transplantation (KT) is only viable renal replacement option for most patients in India. Most patients do not have health insurance and meet treatment expenditure from their own resources. We prospectively evaluated the expenses associated with KT and its impact on the socioeconomic status of families in a public hospital. All direct and indirect expenses incurred by the patients from the time of diagnosis of chronic kidney disease to KT were recorded. Direct expenses included physician fees, cost of drugs and disposables, dialysis, and expenses on investigations and hospitalization. Indirect expenses included travel, food, stay, and loss of income suffered by the family. Educational dropout and financial loss were also recorded. There were 43 males and 7 females between the ages of 12 and 57 years. Direct expenses ranged from US$ 2,151–23,792 and accounted for two-thirds of the total expenses. Pre-referral hospitalization, dialysis and medication accounted for majority of direct expense. Indirect expenses ranged from US$ 226–15,283. Travel expenses and loss of income accounted for most of indirect expense. About 54%, 8%, and 10% of families suffered from severe, moderate, and some financial crisis respectively. A total of 38 families had job losses, and 1 patient and 12 caregivers dropped out of studies. To conclude, KT is associated with catastrophic out-of-pocket expenditure and pushes a majority of the patients who come for treatment to public hospitals into severe financial crisis. Educational dropout and loss of jobs are other major concerns. Systematic efforts are required to address these issues.     

Determinants of End-of-Life Expenditures in Patients with Oral Cancer in Taiwan: A Population-Based Study

BackgroundTo investigate the association of basic demographic data, socioeconomic status, medical services, and hospital characteristics with end-of-life expenditure in patients with oral cancer in Taiwan who died between 2009 to 2011.MethodsThis nationwide population-based, retrospective cohort study identified 5,386 patients who died from oral cancer. We evaluated medical cost in the last month of life by universal health insurance. The impact of each variable on the end-of-life expenditure was examined by hierarchical generalized linear model (HGLM) using a hospital-level random-intercept model.ResultsThe mean medical cost in the last six months of life was $2,611±3,329 (U.S. dollars). In HGLM using a random-intercept model, we found that patients younger than 65 years had an additional cost of $819 over those aged ≥65 years. Patients who had a high Charlson Comorbidity Index Score (CCIS) had an additional $616 cost over those with a low CCIS. Those who survived post-diagnosis less than 6 months had an additional $659 in expenses over those who survived more than 24 months. Medical cost was $249 more for patients who had medium to high individual SES, and $319 more for those who were treated by non-oncologists.ConclusionThis study provides useful information for decision makers in understanding end-of-life expenditure in oral cancer. We found significantly increased end-of-life expenditure in patients if they were younger than 65 years or treated by non-oncologists, or had high CCIS, medium to high individual SES, and survival of less than 6 months after diagnosis.     

Family configuration and family size

In a sample of 61,829 US families, the probability of having an additional child is higher in those families with all the children the same sex as compared to those families with children of both sexes. Data are from families of American high school students who took the National Merit Scholarship Qualifying test in 1965. All families with 3 or 4 children were selected. Families with only boys were more likely to have an additional child than families with all girls. Less than 1% of the variance in family size is explained by family configuration. Although the sample size makes these results unequivocal for the population involved, the population is clearly biased in favor of white middle class families.     

Household Expenditure for Dental Care in Low and Middle Income Countries

This study assessed the extent of household catastrophic expenditure in dental health care and its possible determinants in 41 low and middle income countries. Data from 182,007 respondents aged 18 years and over (69,315 in 18 low income countries, 59,645 in 15 lower middle income countries and 53,047 in 8 upper middle income countries) who participated in the WHO World Health Survey (WHS) were analyzed. Expenditure in dental health care was defined as catastrophic if it was equal to or higher than 40% of the household capacity to pay. A number of individual and country-level factors were assessed as potential determinants of catastrophic dental health expenditure (CDHE) in multilevel logistic regression with individuals nested within countries. Up to 7% of households in low and middle income countries faced CDHE in the last 4 weeks. This proportion rose up to 35% among households that incurred some dental health expenditure within the same period. The multilevel model showed that wealthier, urban and larger households and more economically developed countries had higher odds of facing CDHE. The results of this study show that payments for dental health care can be a considerable burden on households, to the extent of preventing expenditure on basic necessities. They also help characterize households more likely to incur catastrophic expenditure on dental health care. Alternative health care financing strategies and policies targeted to improve fairness in financial contribution are urgently required in low and middle income countries.     

The Cost of Autism Spectrum Disorders

Objective

A diagnosis of an autism spectrum disorders is usually associated with substantial lifetime costs to an individual, their family and the community. However, there remains an elusive factor in any cost-benefit analysis of ASD diagnosis, namely the cost of not obtaining a diagnosis. Given the infeasibility of estimating the costs of a population that, by its nature, is inaccessible, the current study compares expenses between families whose children received a formal ASD diagnosis immediately upon suspecting developmental atypicality and seeking advice, with families that experienced a delay between first suspicion and formal diagnosis.

Design

A register based questionnaire study covering all families with a child with ASD in Western Australia.

Participants

Families with one or more children diagnosed with an ASD, totalling 521 children diagnosed with an ASD; 317 records were able to be included in the final analysis.

Results

The median family cost of ASD was estimated to be AUD $34,900 per annum with almost 90% of the sum ($29,200) due to loss of income from employment. For each additional symptom reported, approximately $1,400 cost for the family per annum was added. While there was little direct influence on costs associated with a delay in the diagnosis, the delay was associated with a modest increase in the number of ASD symptoms, indirectly impacting the cost of ASD.

Conclusions

A delay in diagnosis was associated with an indirect increased financial burden to families. Early and appropriate access to early intervention is known to improve a child''s long-term outcomes and reduce lifetime costs to the individual, family and society. Consequently, a per symptom dollar value may assist in allocation of individualised funding amounts for interventions rather than a nominal amount allocated to all children below a certain age, regardless of symptom presentation, as is the case in Western Australia.     

Nutritional status and mortality of refugee and resident children in a non-camp setting during conflict: follow up study in Guinea-Bissau

ObjectiveTo study the effects on children of humanitarian aid agencies restricting help to refugee families (internally displaced people).DesignFollow up study of 3 months.SettingPrabis peninsular outside Bissau, the capital of Guinea-Bissau, which has functioned as a refugee area for internally displaced people in the ongoing war, and the study area of the Bandim health project in Bissau.Participants422 children aged 9-23 months in 30 clusters.ResultsDuring the refugee situation all children deteriorated nutritionally, and mortality was high (3.0% in a 6 week period). Rice consumption was higher in families resident in Prabis than in refugees from Bissau but there was no difference in food expenditure. Nutritional status, measured by mid- upper arm circumference, was not associated with rice consumption levels in the family, and the decline in circumference was significantly worse for resident than for refugee children; the mid-upper arm circumference of refugee children increased faster than that of resident children. For resident children, mortality was 4.5 times higher (95% confidence interval 1.1 to 30.0) than for refugee children. Mortality for both resident and refugee children was 7.2 times higher (1.3 to 133.9) during the refugee’s stay in Prabis compared with the period after the departure of the refugees.ConclusionIn a non-camp setting, residents may be more malnourished and have higher mortality than refugees. Major improvements in nutritional status and a reduction in mortality occurred in resident and refugee children as soon as refugees returned home despite the fact that there was no improvement in food availability.

Key messages

• During the war in Guinea-Bissau, most of the population fled from the capital and moved in with relatives, friends, or strangers
• International agencies insisted on only providing help to refugees (internally displaced people)
• During the first month of conflict, there were already profound effects on the nutritional status and mortality of young children
• Food consumption was higher in resident families, but resident children were more malnourished and had higher mortality than refugee children
• Nutritional status and survival improved for both refugee and resident children once the refugees returned to Bissau

     

Bereavement counselling after sudden infant death.

Of 14 families who suffered a sudden infant death, eight were followed up intensively over several months and offered individual counselling, parents'' group meetings, and interviews with doctors as a way of helping them come to terms with their feelings of loss. Five couples accepted short term support from their health visitor, and one refused help. Many families experienced considerable stress including marital conflict, difficulties with surviving children, and anxiety about future children becoming victims of the sudden infant death syndrome. It was concluded that medical social workers, health visitors, hospital paediatricians, general practitioners, and parent self help groups are in key positions to help. The success of such help is likely to depend on the confidence that each helper has that his or her contribution will be valued by the bereaved family.     

Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study

The illness cost borne by households, known as out-of-pocket expenditure, was 74% of the total health expenditure in Bangladesh in 2017. Calculating economic burden of diarrhea of low-income urban community is important to identify potential cost savings strategies and prioritize policy decision to improve the quality of life of this population. This study aimed to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 17, 2015 to July 26, 2016. We used the World Health Organization (WHO) definition of three or more loose stool in 24 hours to enroll patients and enrolled 106 severe patients and 158 non-severe patients from Tongi General Hospital, local pharmacy and study community. The team enrolled patients between the first to third day of the illness (≤ 72 hours) and continued daily follow-up by phone until recovery. We considered direct and indirect costs to calculate cost-per-episode. We applied the published incidence rate to estimate the annual cost of diarrhea. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 [95% CI: 24.55, 30.23] (2,147 BDT), 17% of the average monthly income of the households. The average cost of illness for patient with non-severe diarrhea was US$ 6.36 [95% CI: 5.19, 7.55] (499 BDT), 4% of the average monthly income of households. A single diarrheal episode substantially affects financial condition of low-income urban community residents: a severe episode can cost almost equivalent to 4.35 days (17%) and a non-severe episode can cost almost equivalent to 1 day (4%) of household’s income. Preventing diarrhea preserves health and supports financial livelihoods.     

Cost Trend Analysis of Initial Cancer Treatment in Taiwan

Background

Despite the high cost of initial cancer care, that is, care in the first year after diagnosis, limited information is available for specific categories of cancer-related costs, especially costs for specific services. This study purposed to identify causes of change in cancer treatment costs over time and to perform trend analyses of the percentage of cancer patients who had received a specific treatment type and the mean cost of care for patients who had received that treatment.

Methodology/Principal Findings

The analysis of trends in initial treatment costs focused on cancer-related surgery, chemotherapy, radiation therapy, and treatments other than active treatments. For each cancer-specific trend, slopes were calculated for regression models with 95% confidence intervals. Analyses of patients diagnosed in 2007 showed that the National Health Insurance (NHI) system paid, on average, $10,780 for initial care of a gastric cancer patient and $10,681 for initial care of a lung cancer patient, which were inflation-adjusted increases of $6,234 and $5,522, respectively, over the 1996 care costs. During the same interval, the mean NHI payment for initial care for the five specific cancers increased significantly (p<0.05). Hospitalization costs comprised the largest portion of payments for all cancers. During 1996–2007, the use of chemotherapy and radiation therapy significantly increased in all cancer types (p<0.05). In 2007, NHI payments for initial care for these five cancers exceeded $12 billion, and gastric and lung cancers accounted for the largest share.

Conclusions/Significance

In addition to the growing number of NHI beneficiaries with cancer, treatment costs and the percentage of patients who undergo treatment are growing. Therefore, the NHI must accurately predict the economic burden of new chemotherapy agents and radiation therapies and may need to develop programs for stratifying patients according to their potential benefit from these expensive treatments.     

Do Children Lose and Maintain Weight Easier Than Adults: A Comparison of Child and Parent Weight Changes From Six Months to Ten Years

Recent research has shown weight maintenance for obese preadolescent children over 60 and 120 month intervals, while studies on adults consistently show they fail to maintain weight loss. This paper is designed to examine differences in percent overweight changes at 6, 60 and 120 months in obese parents and children from 113 families who participated in randomized controlled outcome studies evaluating family-based behavioral treatment. Analyses showed children had significantly greater changes in percent overweight than their parents at each time point. Chi-Square and Logistic Regression analyses showed children were more likely than their parents at each time point to have percent overweight decreases greater than 20%, with over 20% of the children and less than 1% of the parents showing changes this large. The implications of these results for weight control are discussed. These results suggest there may be differences in the efficacy of treating obesity in children versus adults.     

Assistance dog placement in the pediatric population: Benefits,risks, and recommendations for future application

Abstract

Assistance animals have long been recognized for their value in enhancing the lives of adults with disabilities by increasing the physical independence, confidence, and social lives of their handlers. Recently, this concept has been applied to the growing population of children with physical disabilities and developmental impairments, though the benefits and risks of these placements have not been thoroughly assessed. Our study used interviews to evaluate the outcome of placing assistance dogs in the pediatric population, looking specifically at the unique advantages and disadvantages of this application of the human–animal bond. We administered a structured interview assessing risks and benefits of assistance dog relationships to 17 families with a child under 18 years who graduated from a single provider (NEADS) over a five-year time period. Benefits were found in 88% of families, and were overwhelmingly social and cognitive, with additional physical and medical benefits for the pediatric client. However, risks, including behavioral, financial, and time/cost issues were significant, becoming a burden in 53% of families. Perhaps more than with adult placements, we found that it was of prime importance to understand the assistance animal in the context of the family, rather than just in relation to the individual with a disability. It is hoped that results of this and future studies will enhance the welfare of both client and assistance animal, as well as the overall success of this unique human–animal relationship.     

Determining the Effectiveness of Take Off Pounds Sensibly (TOPS), a Nationally Available Nonprofit Weight Loss Program

Obesity is a major public health issue in the United States. Many commercial weight loss programs are available, but their costs prohibit some people from participating. This study evaluated the effectiveness of Take Off Pounds Sensibly (TOPS), a low‐cost, nonprofit weight loss program. Longitudinal mixed‐effects repeated‐measures modeling of the TOPS national database was used to model changes in weight for TOPS participants who joined in 2005, 2006, and 2007 and had at least one annual renewal between 2006 and 2008. Separate analyses were performed on individuals with consecutive annual renewal and those with nonconsecutive annual renewal. During the study period, 42,481 individuals renewed their membership at least once, including 2,427 individuals with nonconsecutive renewals. Individuals with consecutive renewals in TOPS lost 5.9–7.1% of their initial weight over a period of 1–3 years. People who remained in the program lost ～6% of initial weight in the first year and maintained that weight loss for up to 3 years. TOPS participants with nonconsecutive renewal generally lost less weight than those with consecutive renewal. TOPS is associated with moderate weight loss among participants who remain in the program for at least 1 year. This degree of weight loss is likely to be clinically important for many individuals. TOPS is available at substantially lower cost than commercial weight loss programs, with similar results. Head‐to‐head trials of TOPS and popular commercial programs are needed.     

Variation in juvenile dependence

Notable in cross-cultural comparisons is the variable span of time between when children become economically self-sufficient and when they initiate their own reproductive careers. That variation is of interest because it shapes the age range of children reliant on others for support and the age range of children available to help out, which in turn affects the competing demands on parents to support multiple dependents of different ages. The age at positive net production is used as a proxy to estimate the close of juvenile economic dependence among a group of Maya subsistence agriculturalists. Maya children produce more than they consume by their early to mid teens but remain in their natal households for a number of years before leaving home and beginning families of their own. The Maya results contrast markedly with those from several groups of hunter-gatherers and horticulturalists for whom we have similar data. Even in the Maya case, where children are self-sufficient at a relatively young age, parents are unable to support their children without help from others. The production surplus of older children appears to help underwrite the cost of large Maya families and subsidize their parents’ continued reproduction.     

Impact of Increased Economic Burden Due to Human Echinococcosis in an Underdeveloped Rural Community of the People's Republic of China

Background

Ningxia is located in western People''s Republic of China, which is hyperendemic for human cystic echinococcosis (CE) throughout the entire area with alveolar echinococcosis (AE) hyperendemic in the south. This is in part due to its underdeveloped economy. Despite the recent rapid growth in P.R. China''s economy, medical expenditure for hospitalization of echinococcosis cases has become one of the major poverty generators in rural Ningxia, resulting in a significant social problem.

Methodology/Principal Findings

We reviewed the 2000 inpatient records with liver CE in surgical departments of hospitals from north, central and south Ningxia for the period 1996–2002. We carried out an analysis of health care expenditure of inpatient treatment in public hospitals, and examined the financial inequalities relating to human echinococcosis and the variation in per capita income between various socioeconomic groups with different levels of gross domestic product for different years. Hospital charges for Yinchuan, NHAR''s capital city in the north, increased approximately 35-fold more than the annual income of rural farmers with the result that they preferred to seek health care in local county hospitals, despite higher quality and more efficient treatment and diagnosis available in the city. Household income levels thus strongly influenced the choice of health care provider and the additional expense impeded access of poor people to better quality treatment.

Conclusions/Significance

Information on socioeconomic problems arising from echinococcosis, which adds considerably to the burden on patient families and communities, needs to be collected as a prerequisite for developing policies to tackle the disease in rural Ningxia.     

Mobile phone ownership and use among school children in three Hungarian cities

In spite of rapid worldwide increase in mobile phone use and public concerns about associated potential health effects, little is known about patterns of mobile phone ownership and use in the general population and among children. In April 2005, we conducted a survey of mobile phone ownership and use among fourth grade school children in three Hungarian cities. From 24 schools, 1301 student filled out a short, self-administered questionnaire on basic demographics, mobile phone ownership, pattern of mobile phone use, and after-school activities. Overall, 989 students (76%) owned a mobile phone. Three hundred thirteen students (24%) used a mobile phone daily to make phone calls, and an additional 427 students (33%) used mobile phones for phone calls at least several times per week. Sixty-six students (5%) sent text messages daily and an additional 308 students (24%) sent text messages at least several times per week. Girls, children with no siblings, children who were members of a sport club, and children who played computer games daily were more likely to own and use mobile phones regularly. A higher number of socially disadvantaged children in a class predicted lower likelihood of regular mobile phone use among children. Our results suggest that mobile phone ownership and regular use is highly prevalent among school children in Hungary. Due to rapid changes in ownership patterns follow up surveys will be required to obtain information on temporal trends and changes in mobile phone ownership and pattern of use among school children.     

Adjuvant radiotherapy for early breast cancer: patterns of practice in Ontario.

OBJECTIVE: To determine the number of different radiation schedules used in Ontario to treat women with node-negative breast cancer after lumpectomy and axillary dissection. DESIGN: Retrospective survey. SETTING: Princess Margaret Hospital, Toronto, and regional centres of the Ontario Cancer Treatment and Research Foundation (in Hamilton, London, Ottawa, Windsor and Thunder Bay). PATIENTS: A total of 551 of 1624 consecutive patients with node-negative breast cancer having undergone lumpectomy and axillary dissection who were eligible but did not participate in the Ontario Clinical Oncology Group randomized clinical trial and who received adjuvant breast irradiation between April 1984 and February 1989. OUTCOME MEASURES: Schedules of radiotherapy received. RESULTS: Forty-eight different radiotherapy schedules were identified. Total doses ranged from 4000 to 6600 cGy and the number of fractions from 15 to 30. Several different schedules were preferred: 322 patients (58.5%) received 4000 cGy in 15 or 16 fractions to the whole breast over 3 weeks plus a local boost of 1250 cGy to the primary site in 5 fractions over 1 week; 66 patients (12.0%) received 4000 cGy in 15 or 16 fractions over 3 weeks to the whole breast plus a local boost of 1000 cGy to the primary site in 4 or 5 fractions over 1 week; and 63 patients (11.5%) received 5000 cGy in 25 fractions to the whole breast in 5 weeks, without a boost. CONCLUSIONS: The practice of adjuvant radiotherapy for early breast cancer in Ontario varies. The optimal radiation regimen for patients after lumpectomy should be determined through randomized clinical trials.     

First-line treatment of seasonal (ragweed) rhinoconjunctivitis: a randomized management trial comparing a nasal steroid spray and a nonsedating antihistamine

OBJECTIVE: To determine whether better health-related quality of life (HRQL) is achieved by initiating treatment of seasonal (ragweed) rhinoconjunctivitis (hay fever) with a nasal steroid (fluticasone) backed up by a nonsedating antihistamine (terfenadine) or whether it is better to start with the antihistamine and add the nasal steroid when necessary. DESIGN: Randomized, nonblind, parallel-group management study during the 6 weeks of the ragweed pollen season in 1995. PATIENTS: Sixty-one adults with ragweed pollen hay fever recruited from patients who had participated in previous clinical studies and from those who responded to notices in the local media. SETTING: Southern Ontario. INTERVENTIONS: Nasal steroid group: 200 micrograms of fluticasone nasal spray when needed (up to 400 micrograms/d) starting about 1 week before the ragweed pollen season and continued throughout, with 1 to 2 tablets of terfenadine daily (maximum 120 mg/d) if needed. Antihistamine group: 1 60-mg tablet of terfenadine when needed (maximum 120 mg/d) starting about 1 week before the ragweed pollen season and continued throughout, with 200-400 micrograms/d of fluticasone nasal spray (maximum 400 micrograms/d) if needed. OUTCOME MEASURES: HRQL before, at the height of and toward the end of the ragweed pollen season; HRQL was measured using the Rhinoconjunctivitis Quality of Life Questionnáire. RESULTS: Overall, HRQL tended to be better in the group of patients whose first-line treatment was with fluticasone (p = 0.052), but the difference between the 2 groups was small and not clinically important. Just over half (52% [16/31]) of the patients in the fluticasone group did not need additional help with terfenadine, whereas only 13% (4/30) of those in the terfenadine group did not need additional help with fluticasone (p = 0.002). CONCLUSIONS: There is little difference in the therapeutic benefit between the 2 approaches for the treatment of ragweed pollen hay fever. Therefore, the approach to treatment should be based on patient preference, convenience and cost. Regardless of the treatment, at least 50% of patients will need to take both types of medication in combination to control symptoms adequately.     

How Physician Obesity Specialists Use Drugs to Treat Obesity

Specialist physicians may have prescribing habits that are different from nonspecialist physicians. Little is known about the prescribing habits of physicians specializing in the treatment of obesity. An anonymous survey was given to the physician members of the American Society of Bariatric Physicians (ASBP). There was a 35% response rate (266 physicians) to the questionnaire that was represented nationally. Almost all prescribed medications and all of them recommended phentermine. The average maximal dose of phentermine was above that approved in the package insert, and these physicians disagreed with the National Institutes of Health (NIH) Obesity Treatment Guidelines. Phendimetrazine, metformin, and phentermine plus l ‐5‐hydroxytryptophan (5‐HTP) with carbidopa were all used more frequently than either orlistat or sibutramine. The combination of sibutramine and orlistat as well as 5‐HTP/carbidopa were prescribed by 14 and 20%, respectively. As 5‐HTP‐carbidopa was a combination not previously reported for the treatment of obesity, a retrospective chart review was performed in a single obesity practice, which may not be representative. Twenty‐two subjects had a 16% weight loss with phentermine over 6 months and an additional 1% weight loss with the addition of 5‐HTP/carbidopa for an additional 6 months. One subject who started on 5‐HTP/carbidopa alone lost 24.4% of initial body weight over 6 months. This questionnaire revealed that 20% of the obesity specialists responding to the survey used phentermine plus of 5‐HTP/carbidopa, an unreported combination. A controlled, randomized, clinical trial to evaluate the safety and efficacy of this combination in treating obesity should be considered.     

The Functional,Social and Economic Impact of Acute Encephalitis Syndrome in Nepal – a Longitudinal Follow-Up Study

Background

Over 133,000 children present to hospitals with Acute Encephalitis Syndrome (AES) annually in Asia. Japanese encephalitis (JE) accounts for approximately one-quarter of cases; in most cases no pathogen is identified and management is supportive. Although JE is known to result in neurological impairment, few studies have examined the wider impact of JE and AES on patients and their families.

Methodology/Principal Findings

Children (aged 1 month–14 years) with AES were assessed 5–12 months after discharge from two Nepali hospitals. Assessment included clinical examination, the Liverpool Outcome Score (LOS) - a validated assessment of function following encephalitis, questionnaires about the child''s social participation since discharge, and out-of-pocket costs to the family. Children were classified as JE or ‘other AES’ based on anti-JE virus antibody titres during acute illness. Contact was made with the families of 76% (73/96) of AES children. Six children had died and one declined participation. 48% (32/66) reported functional impairment at follow-up, most frequently affecting behaviour, language or limb use. Impairment was more frequent in JE compared to ‘other AES’ cases (68% [13/19] versus 40% [19/47]; p = 0.06). 49% (26/53) had improvement in LOS between discharge and follow-up. The median out-of-pocket cost to families, including medical bills, medication and lost earnings was US$ 1151 (10 times their median monthly income) for children with severe/moderate impairment and $524 (4.6 times their income) for those with mild/no impairment (P = 0.007). Acute admission accounted for 74% of costs. Social participation was limited in 21% of children (n = 14).

Conclusions/Significance

Prolonged functional impairment was common following AES. Economic impact to families was substantial. Encouragingly, almost half the children improved after discharge and most reported sustained social participation. This study highlights a need for long-term medical support following AES. Rationalisation of initial expensive hospital treatments may be warranted, especially since only supportive treatment is available.     

Pediatric obesity attitudes, services, and information among rural parents: a qualitative study

The objective of this study was to learn more about the attitudes concerning pediatric obesity among rural parents, the barriers these parents face in trying to help their children attain a healthy weight status, and the pediatric weight loss services currently available in small rural communities. A series of eight qualitative focus groups were conducted with 21 parents of overweight rural children in third through fifth grade. Eight saturated themes resulted indicating that parents (i) believe overweight children are lazy, (ii) are concerned about the weight of their children, (iii) believe that some individuals will be overweight no matter what they do, and (iv) have tried a variety of techniques to help their children lose weight. Barriers to helping their children lose weight unique to their rural status included lack of weight loss resources in their community, lack of exercise facilities, and lack of low-fat or low-calorie options in grocery stores. Rural families of overweight children encounter many barriers to healthier living, some of which are unique to their rural status.