Medication Use in the Management of Comorbidities Among Individuals With Autism Spectrum Disorder From a Large Nationwide Insurance Database.

Importance: Although there is no pharmacological treatment for autism spectrum disorder (ASD) itself, behavioral and pharmacological therapies have been used to address its symptoms and common comorbidities. A better understanding of the medications used to manage comorbid conditions in this growing population is critical; however, most previous efforts have been limited in size, duration, and lack of broad representation. Objective: To use a nationally representative database to uncover trends in the prevalence of co-occurring conditions and medication use in the management of symptoms and comorbidities over time among US individuals with ASD. Design, Setting, and Participants: This retrospective, population-based cohort study mined a nationwide, managed health plan claims database containing more than 86 million unique members. Data from January 1, 2014, to December 31, 2019, were used to analyze prescription frequency and diagnoses of comorbidities. A total of 26 722 individuals with ASD who had been prescribed at least 1 of 24 medications most commonly prescribed to treat ASD symptoms or comorbidities during the 6-year study period were included in the analysis. Exposures: Diagnosis codes for ASD based on International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Main Outcomes and Measures: Quantitative estimates of prescription frequency for the 24 most commonly prescribed medications among the study cohort and the most common comorbidities associated with each medication in this population. Results: Among the 26 722 individuals with ASD included in the analysis (77.7% male; mean [SD] age, 14.45 [9.40] years), polypharmacy was common, ranging from 28.6% to 31.5%. Individuals' prescription regimens changed frequently within medication classes, rather than between classes. The prescription frequency of a specific medication varied considerably, depending on the coexisting diagnosis of a given comorbidity. Of the 24 medications assessed, 15 were associated with at least a 15% prevalence of a mood disorder, and 11 were associated with at least a 15% prevalence of attention-deficit/hyperactivity disorder. For patients taking antipsychotics, the 2 most common comorbidities were combined type attention-deficit/hyperactivity disorder (11.6%-17.8%) and anxiety disorder (13.1%-30.1%). Conclusions and Relevance: This study demonstrated considerable variability and transiency in the use of prescription medications by US clinicians to manage symptoms and comorbidities associated with ASD. These findings support the importance of early and ongoing surveillance of patients with ASD and co-occurring conditions and offer clinicians insight on the targeted therapies most commonly used to manage co-occurring conditions. Future research and policy efforts are critical to assess the extent to which pharmacological management of comorbidities affects quality of life and functioning in patients with ASD while continuing to optimize clinical guidelines, to ensure effective care for this growing population.

Why Do Informal Sector Workers Not Pay the Premium Regularly? Evidence from the National Health Insurance System in Indonesia.

BACKGROUND: The challenges of universal health coverage (UHC) in developing countries with a significant proportion of the labor force that works in the informal sector include administrative difficulties in recruiting, registering and collecting regular contributions in a cost-effective way. As most developing countries have a limited fiscal space to support the program in the long run, the fiscal sustainability of UHC, such as that in Indonesia, relies heavily on the contributions of its members. The failure of a large proportion of voluntary enrollees/self-enrolled members/informal sector workers (Peserta Mandiri/Pekerja Bukan Penerima Upah [PBPU] members) to pay their premiums may lead to the National Health Insurance System (NHIS) in Indonesia being unable to effectively deliver its services. OBJECTIVE: This study aims at exploring the important factors that affect the compliance behavior of informal sector workers (PBPU members) in regularly paying their insurance premium. This analysis may be a basis for designing effective measures to encourage payment sustainability in informal sector workers in the NHIS. METHOD: This study utilizes the survey data collected from three regional offices of the Indonesian Social Security Agency for Health (SSAH), which cover approximately 1210 PBPU members, to understand the relationship between members' characteristics and their compliance behavior regarding the premium payment. We applied an econometric analysis of a logit regression to statistically estimate which factors most affect their compliance behavior in paying the insurance premium. RESULTS: This study reveals that almost 28% of PBPU members do not pay their insurance premiums in a sustainable way. Our logistic regression statistically confirms that the number of household members, financial hardship, membership in other social protection arrangements, and the utilization of health services are negatively correlated with the compliance rate of informal sector workers in paying their insurance premium. For instance, people who experience financial hardship tend to have a 7.7 percentage point lower probability of routinely paying the premium. In contrast, households that work in agricultural sectors and have income stability, the cost of inpatient care incurred before joining the NHIS, a comprehensive knowledge of the SSAH's services, and the availability of health professionals are all positively correlated with regular premium payment. CONCLUSION: Although there is no single policy that can ensure that informal sector workers (PBPU members) regularly pay their premiums, this study recommends some policy interventions, including (1) flexibility in applying for a government subsidy for premiums (Penerima Bantuan Iuran [PBI]), especially for people who have financial hardship; (2) an intensive promotion of insurance literacy; (3) expanding the quantity and quality of healthcare services; and (4) tailor-made policies for ensuring the sustainability of premium payments for each regional division.

Analysis of Vascular Event Risk After Herpes Zoster From 2007 to 2014 US Insurance Claims Data.

OBJECTIVE: To estimate the risk of transient ischemic attack (TIA), stroke, and myocardial infarction in periods covering 4 weeks before to 52 weeks after herpes zoster (HZ) diagnosis in US adults. PATIENTS AND METHODS: This retrospective study (GSK study identifier: HO-15-15771) with matched cohorts used the Truven Health MarketScan Commercial and Medicare claims data set linked with obesity and smoking status information. Patients 18 years and older at the date of HZ diagnosis and 1-year pre- and post-HZ diagnosis continuous insurance enrollment (from January 1, 2007, through December 31, 2014) were propensity score matched to controls in terms of demographic characteristics, risk factors for vascular events, other comorbid disorders, general health, obesity, and smoking status. A post hoc sensitivity analysis was performed not matching for obesity and smoking status information. Adjusted incidence rate ratios (IRRs) were estimated using multivariate Poisson models during an aggregate period (1-month before and after the index date). RESULTS: A total of 23,339 patients with HZ were matched to 46,378 controls (mean age, 56 years; 45,173 [65%] women). During the aggregate period, patients with HZ were statistically significantly more likely to suffer a TIA: IRRs for all patients and patients aged 18 to 49 years were 1.56 (95% confidence interval [CI], 1.13-2.15) and 5.12 (95% CI, 1.37-19.10), respectively (P<.05); the respective IRRs for stroke were 1.40 (95% CI, 0.93-2.11) and 8.12 (95% CI, 0.93-71.27). In the sensitivity analysis, IRRs for TIA and stroke were statistically significantly increased regardless of age. CONCLUSION: Herpes zoster was associated with an increased risk of composite events, TIA, and stroke in adults in the period around diagnosis. More research on the HZ and vascular risk association is needed. GSK STUDY IDENTIFIER: HO-15-15771.

Robotic urologic surgery: trends in litigation over the last decade.

There is a lack of information regarding malpractice claims and indemnity payments associated with robotic cases in surgery. Malpractice claims and indemnity payouts will elucidate and mitigate harms of future adoption of new technology into surgery. We analyzed claims filed against Intuitive Surgical, Inc. from 2000 to 2017. A law librarian identified product liability claims from 2000 to 2017 with the defendant "Intuitive Surgical, Inc." using the Bloomberg Law database. We reviewed all available legal documents pertaining to identified claims, and extracted data points including filing date, surgery date, surgery type, robot type, instrument type, complications, and case outcomes. Since 2000, 123 claims were filed; 108 met criteria for inclusion. Gynecologic surgeries comprised the majority of claims (62%, 67 claims), followed by urologic surgeries (20%, 22 claims). Number of claims filed peaked in 2013 (30%, 32 claims) and then decreased each year, with 6% (7 claims) filed in 2016, and only 1% (1 claim) filed in 2017. Of the 22 claims regarding robotic urologic surgeries, 19 claims (86%) pertained to prostatectomy. Commonly alleged injuries in urologic cases were bowel injury (8 claims), erectile dysfunction (5 claims), bowel fistulas (4 claims), and incontinence (4 claims). Device failure was cited in only 2 claims. Early adopters of robotic surgery were at highest risk of litigation. This risk subsequently decreased despite the wide spread adoption of this technology. Almost all claims were secondary to surgical complications and not device failure, thus demonstrating a need for more systematic training for novel devices and early adopters.

Unemployment insurance and cigarette smoking.

We provide evidence for the causal relationship between unemployment insurance (UI) and individuals' smoking behavior using the 1995-2011 Current Population Survey-Tobacco Use Supplement data. Our identification relies on the exploitation of the exogenous variations of the maximum UI weekly benefits across states and over years. Instead of focusing on all unemployed people, we concentrate on those who are eligible for UI benefits. We find that when the maximum UI weekly benefit level increases by $100, smoking cessation increases by approximately 2.9 percentage points among the UI-eligible unemployed. The results are robust to various model specifications. We also explore the mechanism and find suggestive evidence that the increase in the maximum UI weekly benefit leads to a decrease in the probability of over-work of the respective spouse. Moreover, the unemployed who are less educated are more responsive to the increasing UI benefits.

A diagnosis of eosinophilic esophagitis is associated with increased life insurance premiums.

Eosinophilic esophagitis (EoE) is a chronic disease that can be diagnosed at any age, but is not associated with malignancy and does not shorten lifespan. It remains unknown whether an EoE diagnosis affects insurability or insurance premium costs. We therefore aimed to determine whether a diagnosis of EoE affects the costs of life insurance. Our investigation was a secret shopper audit study whereby we contacted national insurance companies in the United States to evaluate the effect of a diagnosis of EoE on life insurance premiums. We constructed standardized case scenarios for males and females, including a 25-year-old and a 48-year-old without other comorbid conditions, who either had or did not have a diagnosis of EoE. Companies were asked for their best estimate for a $100,000 whole life insurance policy. Comparisons between median premiums were made using the Mann-Whitney U test. There were 20 national life insurance companies contacted and a total of 73 quotes were obtained. The median premium rate was similar for EoE and non-EoE cases at the younger age ($828 [IQR $576-1,020] vs. $756 [IQR $504-$804]; P = 0.10). However, the premium for the older case without EoE was 19% less expensive compared to a case with EoE ($1990 [IQR $1,248-2,350] vs. $2,375 [IQR $2,100-2568; P = 0.02]. This finding was not explained by sex or state of residence. Based on these findings, we conclude that life insurance premiums are significantly more expensive in the older patient case with EoE when compared to the same case without EoE. Patients with EoE and their providers should be aware of the additional cost associated with this diagnosis.

EPIDEMIOLOGY OF GASTROINTESTINAL NEUROENDOCRINE TUMORS IN A U.S. COMMERCIALLY INSURED POPULATION.

OBJECTIVE: To estimate incidence and prevalence of gastrointestinal neuroendocrine tumors (GI NETs) in U.S. commercially insured patients. METHODS: This was a retrospective, cross-sectional study using 2009 to 2014 data from MarketScan and PharMetrics commercial claims databases. Patients were 18 to 64 years old, and had 1 inpatient or 2 outpatient claims with GI NET, identified by International Classification of Diseases, 9th Revision, Clinical Modification codes. Incidence was calculated as number of patients with NET who were disease-free for 2 years prior, divided by number of enrollees and reported as per million person-years (PMPY). Prevalence was calculated as the number of GI NET patients divided by the number of enrollees per year. RESULTS: The annual number of patients with GI NET ranged from 2,014 to 3,413 in MarketScan and 1,436 to 2,336 in PharMetrics. Incidence increased from 2011 to 2014: 67.0 to 79.1 PMPY in MarketScan and 47.4 to 58.2 PMPY in PharMetrics. Incidence increased by 24.3% in females and 10.7% in males in MarketScan, and by 17.6% in females and 29.3% in males in PharMetrics. Incidence increased with age and was highest in the 45 to 54 and 55 to 64 age groups. Prevalence increased from 77.9 to 131.2 per million per year (MarketScan) and 50.8 to 108.9 (PharMetrics) from 2009 to 2014. Prevalence was generally higher in females than males and highest in 55 to 64 year olds. These increases may be due to better diagnostics, increased awareness of NET among clinicians and pathologists, and/or actual increase in disease. CONCLUSION: Clinicians may see GI NET with increasing frequency and should become more familiar with its presentation and treatment. ABBREVIATIONS: GI = gastrointestinal; ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; NET = neuroendocrine tumor; PMPY = per million person-years; SEER = Surveillance, Epidemiology, and End Results.

Socioeconomic inequalities to accessing vaccination against human papillomavirus in France: Results of the Health, Health Care and Insurance Survey, 2012.

BACKGROUND: In France, human papillomavirus (HPV) vaccination coverage among adolescents and young women is low and decreasing. We analysed data from the 2012 Health, Health Care and Insurance Survey with the aim of identifying factors associated with this vaccination. We also compared the socioeconomic profile of unvaccinated young women to that of women who do not undergo cervical cancer screening (CCS). METHODS: Data were collected through interviews and self-administered questionnaires completed by a randomised sample of Health insurance beneficiaries. Two analyses were performed using Poisson regression: one to investigate the determinants of CCS uptake in women aged 25-65 years old (n=4508), the other to investigate the determinants of HPV vaccination in young women aged 16-24 years old (n=899). A sub-analysis was performed in 685 "daughter-mother" couples from the same household in order to analyse the association between participation to CCS in mothers and HPV vaccination in daughters. RESULTS: Factors significantly associated both to a lower CCS uptake and to an insufficient HPV vaccination were the lack of a complementary private health insurance (P=0.023 and P=0.037, respectively) and living in a family with a low household income (P<0.001 and P=0.005, respectively). A low education level was associated to a lower CCS uptake (P<0.001). The absence of CCS uptake in the last three years in mothers was associated to a lower level of HPV vaccination in their daughter (P=0.014). CONCLUSION: Women who do not undergo CCS and HPV unvaccinated young women tend to be of modest socioeconomic status. Unvaccinated young females tend to have mothers who do not undergo CCS and are therefore at risk of benefiting from none of the two cervical cancer preventive measures. The current implementation strategy concerning HPV vaccination in France may therefore increase inequalities regarding cervical cancer prevention.

A current life table and causes of death for insured dogs in Japan.

The life expectancies and causes of death were evaluated in 299,555 dogs insured in Japan between 1 April 2010 and 31 March 2011, of which 4169 dogs died during this period. The overall life expectancy of dogs was 13.7 years. The probability of death was high in the first year of life, lowest in the second and third years, and increased exponentially after 3 years of age. The life expectancy was 13.8 years in the <5 kg body weight group, 14.2 years in the 5-10 kg body weight group, 13.6 years in the 10-20 kg body weight group, 12.5 years in the 20-40 kg body weight group and 10.6 years in the ≥40 kg body weight group. As body weight increases, life expectancy tended to decrease except in the <5 kg body weight group. The probability of death increased as dogs got older for most potential causes of death. Neoplasia resulted in the highest probability of death, especially in the large and giant breed groups. Cardiovascular system disorders were the second major cause of death and the toy group had a probability of death significantly higher than the other breed groups at age 12+.

The risk of cancer in patients with rheumatoid arthritis taking tumor necrosis factor antagonists: a nationwide cohort study.

INTRODUCTION: The association between cancer and use of biologic therapy among rheumatoid arthritis (RA) patients remains controversial. We aimed to compare the relative risk of cancer development between RA patients taking tumor necrosis factor α (TNFα) antagonists and those taking nonbiologic disease-modifying anti-rheumatic drugs (nbDMARDs). METHODS: We conducted a nationwide cohort study between 1997 and 2011 using the Taiwan National Health Insurance Research Database. The risk of newly diagnosed cancer was compared between patients starting TNF-α antagonists (biologics cohort) and matched subjects taking nbDMARDs only (nbDMARDs cohort). Cumulative incidences and hazard ratios (HR) were calculated after adjusting for competing mortality. Standardized incidence ratio (SIR) was calculated for cancer risk. Multivariate analyses were performed using Cox proportional hazards model. RESULTS: We compared 4426 new users of TNF-α antagonists and 17704 users of nbDMARDs with similar baseline covariate characteristics. The incidence rates of cancer among biologics and nbDMARDs cohorts were 5.35 (95% confidence interval (CI) 4.23 to 6.46) and 7.41 (95% CI 6.75 to 8.07) per 1000 person-years, respectively. On modified Cox proportional hazards analysis, the risk of cancer was significantly reduced in subjects in biologics cohort (adjusted HR 0.63, 95% CI 0.49 to 0.80, P < .001), after adjusting for age, gender, disease duration, major co-morbidities, and prior use of DMARDs and corticosteroids. However, there was an increased risk for hematologic cancers in biologics cohort, yet without statistical significance. The effect of biologics was consistent across all multivariate stratified analyses and the association between biologics use and cancer risk was independent of dosage of concomitant nbDMARDs. CONCLUSION: These findings suggested that RA patients taking TNF-α antagonist are associated with a lower risk of cancer, but not for hematologic cancers, than RA patients taking nbDMARDs alone.

Causes of death among commercially insured multiple sclerosis patients in the United States.

BACKGROUND: Information on causes of death (CODs) for patients with multiple sclerosis (MS) in the United States is sparse and limited by standard categorizations of underlying and immediate CODs on death certificates. Prior research indicated that excess mortality among MS patients was largely due to greater mortality from infectious, cardiovascular, or pulmonary causes. OBJECTIVE: To analyze disease categories in order to gain insight to pathways, which lead directly to death in MS patients. METHODS: Commercially insured MS patients enrolled in the OptumInsight Research database between 1996 and 2009 were matched to non-MS comparators on age/residence at index year and sex. The cause most-directly leading to death from the death certificate, referred to as the "principal" COD, was determined using an algorithm to minimize the selection of either MS or cardiac/pulmonary arrest as the COD. Principal CODs were categorized into MS, cancer, cardiovascular, infectious, suicide, accidental, pulmonary, other, or unknown. Infectious, cardiovascular, and pulmonary CODs were further subcategorized. RESULTS: 30,402 MS patients were matched to 89,818 controls, with mortality rates of 899 and 446 deaths/100,000 person-years, respectively. Excluding MS, differences in mortality rate between MS patients and non-MS comparators were largely attributable to infections, cardiovascular causes, and pulmonary problems. Of the 95 excessive deaths (per 100,000 person-years) related to infectious causes, 41 (43.2%) were due to pulmonary infections and 45 (47.4%) were attributed to sepsis. Of the 46 excessive deaths (per 100,000 person-years) related to pulmonary causes, 27 (58.7%) were due to aspiration. No single diagnostic entity predominated for the 60 excessive deaths (per 100,000 person-years) attributable to cardiac CODs. CONCLUSIONS: The principal COD algorithm improved on other methods of determining COD in MS patients from death certificates. A greater awareness of the common CODs in MS patients will allow physicians to anticipate potential problems and, thereby, improve the care that they provide.

Insurance data for research in companion animals: benefits and limitations.

The primary aim of this article is to review the use of animal health insurance data in the scientific literature, especially in regard to morbidity or mortality in companion animals and horses. Methods and results were compared among studies on similar health conditions from different nations and years. A further objective was to critically evaluate benefits and limitations of such databases, to suggest ways to maximize their utility and to discuss the future use of animal insurance data for research purposes. Examples of studies on morbidity, mortality and survival estimates in dogs and horses, as well as neoplasia in dogs, are discussed.We conclude that insurance data can and should be used for research purposes in companion animals and horses. Insurance data have been successfully used, e.g. to quantify certain features that may have been hitherto assumed, but unmeasured. Validation of insurance databases is necessary if they are to be used in research. This must include the description of the insured population and an evaluation of the extent to which it represents the source population. Data content and accuracy must be determined over time, including the accuracy/consistency of diagnostic information. Readers must be cautioned as to limitations of the databases and, as always, critically appraise findings and synthesize information with other research. Similar findings from different study designs provide stronger evidence than a sole report. Insurance data can highlight common, expensive and severe conditions that may not be evident from teaching hospital case loads but may be significant burdens on the health of a population.

[The use of the Health Popular Insurance Program in pregnant women]. / Utilización del Seguro Popular de Salud en mujeres embarazadas.

OBJECTIVE: To evaluate the use of the Popular Insurance of health (PIH) during the pregnancy and the factors associated with its adquisicition. METHODS: From November of 2006 to January of the 2007, women in puerperal immediate hospitalized in the General Hospital of Tijuana, BC were invited to participate in the study. A direct interrogation through a structured questionnaire was applied, exploring sociodemographic variables, variables related to the pregnancy, trimester in which SPS was acquired, consumption of tobacco and alcohol, drug use, prenatal control, complications during the pregnancy, childbirth and time of hospital stay. Descriptive and bivaried analysis was performed to identify association between variables and the use of PIH. RESULTS: 730 women where studied. The average age was of 23-6 +/- 6.3, schooling 7.4 +/- 2.8 years and 72 % cohabitated. Five hundred and forty women (74 %) acquired PIH during pregnancy, 36 women never assist to antennal visits despite to have PIH and only 15 % already had it from the first trimester of pregnancy. Women with SPS had statically significant higher levels of schooling (7.8 versus. 6.8 p = 0.003), minor smoker frequency during pregnancy (1.5 % versus 4.2 %, p = 0.002) and minor rate of premature childbirth (3.7 versus 8.9, p=. 005). The mean catasthropic expenditure in women with not PIH was 2546 +/- 131 Mexican pesos. CONCLUSIONS: Fifty per cent of women acquired the PIH in the third trimester of pregnancy this could be related more to protecting households during periods of financial crisis than for utilization of prenatal care services.

Bone tumors in a population of 400 000 insured Swedish dogs up to 10 y of age: incidence and survival.

The objectives of this study were to describe the incidence of, survival until, and survival after the diagnosis of canine bone tumors by breed, sex, age, and geographic location of residence. Dogs under 10 y old and insured by a Swedish insurance company between 1995 and 2002 were studied. In total, 764 dogs had claims for bone tumors, and the incidence rate was 5.5 cases per 10 000 dog-years at risk (DYAR). At ages 6, 8, and 10 y, the proportions of dogs with bone tumors were 0.13%, 0.30%, and 0.64%. The top 3 breeds at risk were Irish wolfhound, St. Bernard, and leonberger (incidence rates 99, 78, and 53 cases per 10 000 DYAR, respectively). Median survival time after diagnosis was 56 d in the 419 dogs that survived > or = 1 d. With a Cox regression model controlling for breed and age, females were shown to be at decreased risk of bone tumors, with a hazard ratio of 0.71 (99% confidence interval 0.58 to 0.87).

Increasing prevalence of gastroschisis repairs in the United States: 1996-2003.

PURPOSE: Local and state registries have shown recent increases in the prevalence of gastroschisis in the United States and abroad. The purpose of this study was to use a nationally representative database to identify national trends in the prevalence of gastroschisis repairs. METHODS: Records of infants undergoing gastroschisis repair were identified in the Nationwide Inpatient Sample from 1996 to 2003. Birth data were obtained from the National Center for Health Statistics and used to calculate the rate of procedures/live births stratified by US census region. Survey statistics were used to account for the sampling design of the Nationwide Inpatient Sample database. RESULTS: Between 1996 and 2003, a total of 9459 gastroschisis repairs were performed in the United States (3 procedures for every 10,000 births). A significant increase in the population-based rate of these procedures was observed in each census regions and nationwide. A twofold higher procedure rate was observed in 2003 than in 1996 (rate ratio, 2.0; 95% confidence interval, 1.1-2.9; P < .001). No significant change in unadjusted hospital mortality was observed regionally or nationally. CONCLUSIONS: The population-based rate of gastroschisis repairs significantly increased regionally and nationwide between 1996 and 2003, paralleling recent trends described at the local and state level.

[Malignant pleural cancers mortality and compensated cases for asbestos related diseases in Lazio municipalities (1980-2001)]. / Mortalità per tumore maligno della pleura e casi indennizzati di malattie asbesto correlate nei comuni del Lazio (1980-2001).

BACKGROUND: Occupational exposure to asbestos has been widely reported in the Region, but a high risk for non-occupational and environmental contaminations have also been documented. OBJECTIVES: To describe the geographical distribution ofpleural cancer deaths and compensated asbestosis cases from 1980 to 2001 in the Lazio Region. METHODS: For each municipality Standardized Mortality Ratios (SMRs) for pleural cancer and Standardized Incidence Ratios (SIRs) for asbestosis were estimated. Expected cases were estimated from age and gender specific rates in Lazio. SatScan software was used to identify clusters and to verf;j their statistical significance. RESULTS: 789 deaths from pleural cancer (495 males and 294 females) occurred in Lazio from 1980 to 2001. The standardized mortality rate per 100.000 inhabitants is 0,74 (0,95 for males and 0,54 for females). The main excess mortality from pleural cancer occurred in the municipalities of Civitavecchia (SMR: 269,9; 95% CI: 164,9 - 416,8), Colleferro (SMR: 304,9; 95% CI: 139,4-578,8) and Rocca Priora (SMR: 379,2; 95% CI: 103,3-970,9). Significant SIRs for compensated asbestosis cases were found in the industrial areas of the Naples-Rome highway and in the shipyard area of Civitavecchia. Nofemale compensated cases were found. The most important clusters were identified in the municipality of Civitavecchia for pleural cancer (p-value = 0,117) and in the Colleferro industrial area for compensated asbestosis cases (p-value = 0,001). CONCLUSIONS: Epidemiological surveillance of incident cases of malignant mesothelioma in the Lazio Region and the investigation of modalities of asbestos exposure are urgently needed for prevention of occupational diseases.

Incidence and breed predilection for dystocia and risk factors for cesarean section in a Swedish population of insured dogs.

OBJECTIVES: To estimate the incidence and breed predilection for canine dystocia using data from insurance claims. The risk factors for cesarean section (CS) were assessed for bitches with dystocia. STUDY DESIGN: Retrospective, longitudinal study. SAMPLE POPULATION: Insurance claims records (1995-2002) from a Swedish animal insurance database (Agria), including approximately 200,000 bitches. METHODS: The overall incidence rate of dystocia in insured bitches was calculated by dividing the number of reimbursed dystocia claims with the number of dog years at risk. Subsequently, incidence rates were stratified by breed, region, and habitat. The proportion of bitches with a dystocia claim that had CS were calculated, and risk factors for CS were assessed using a logistic regression model. RESULTS: Between 1995 and 2002, 3894 (2%) of 195,931 Swedish bitches included in the study had a reimbursed insurance claim for dystocia. The overall incidence rate of dystocia was 5.7 cases/ 1000 dog years at risk. Some breeds like the Scottish terrier were at increased risk of dystocia. Among bitches with dystocia, 63.8% were treated by CS. CONCLUSION: Dystocia in the bitch is more common than reported earlier. The risk of developing dystocia varies by breed, and a high percentage (63.8%) of affected bitches undergo CS. Clinical Relevance- Breeders and veterinarians could use this information to better predict which bitches are likely to experience dystocia and/or CS.

Mefloquine increases the risk of serious psychiatric events during travel abroad: a nationwide case-control study in the Netherlands.

BACKGROUND: Psychiatric events during travel abroad account for a large percentage of medical repatriations arranged by insurance companies. Several risk factors have been proposed for such events, one of these being use of mefloquine. We investigated the risk of psychiatric events during use of mefloquine. METHOD: We performed a nationwide case control study using medical records from 4 large alarm centers in the Netherlands. Cases were patients contacting the alarm centers because of psychiatric events, according to International Code Primary Care code P (all psychiatric symptoms) or International Classification of Diseases, Ninth Edition, codes 290-319 (all psychiatric syndromes). To every case we matched up to 6 controls by alarm center, calendar time, and continent of travel. All controls had contacted the alarm centers because of nonpsychiatric medical reasons. Shortly after the anticipated day of return, cases and controls received a questionnaire regarding travel characteristics, gender, age, marital status, education, weight, height, general health, history of psychiatric diseases, use of medicines, smoking status, alcohol intake, coffee intake, and use of malaria prophylaxis. Dates of travel for the source population were between September 1, 1997, and June 1, 2000. RESULTS: The study population consisted of 111 cases and 453 controls. The risk of psychiatric events during the use of mefloquine was 3.5 (95% CI = 1.4 to 8.7). In females, the risk was strongly increased, with an odds ratio of 47.1 (95% CI = 3.8 to 578.6). Stratification for history of psychiatric diseases showed that the risk of psychiatric events during use of mefloquine in cases without a history of psychiatric diseases was 3.8 (95% CI = 1.4 to 10.1), whereas the risk in cases with a history of psychiatric diseases was 8.0 (95% CI = 1.8 to 35.8). CONCLUSION: The use of mefloquine is associated with an increased risk of psychiatric events in females and in patients with a history of psychiatric diseases.