Perinatal risk factors and coeliac disease in children and young adults: a record linkage study.

BACKGROUND: Little is known about perinatal risk factors and coeliac disease. AIM: To investigate the relationship between perinatal risk factors and subsequent coeliac disease among offspring. METHODS: Record linked abstracts of birth registrations, maternity, in-patient and day case records in a defined population of southern England. RESULTS: Using univariate analysis, coeliac disease in the child was associated with maternal coeliac disease (odds ratio = 20.6; 95% CI = 5.04-84.0; based on two cases in both mother and child) and with social class, year of birth, maternal smoking and parity. Multivariate analysis confirmed an increased risk of coeliac disease of 3.79 (95% CI = 1.85-7.79) for classes IV and V compared with I and II, an increased risk of 1.92 (1.06-3.49) for births during 1975-1979 compared with 1970-1974 and an increased risk of 1.80 (1.05-3.09) for 'subsequent' compared with 'first' births. Smoking during pregnancy was no longer associated with coeliac disease. Because numbers were small, maternal coeliac disease was excluded from the multivariate analysis. CONCLUSIONS: This study shows increased risks of coeliac disease for manual social classes, births during the late 1970s and 'subsequent' births. Overall, perinatal risk factors seem to have a limited role in the aetiology of coeliac disease in children and young adults.

Incidence and case fatality for acute pancreatitis in England: geographical variation, social deprivation, alcohol consumption and aetiology--a record linkage study.

BACKGROUND: Regional studies in the UK indicate that the incidence of acute pancreatitis increased from the 1940s to the 1990s, while case fatality fell until the 1970s but has levelled-off since. AIMS: To establish incidence and case fatality for acute pancreatitis in England from 1998 to 2003, to study geographical variation and recent trends in incidence and to study associations with social deprivation and alcohol consumption. METHODS: Use of national record linkage of in-patient and mortality data for 52 096 people. RESULTS: Overall incidence was 22.4 per 100 000 population, increasing by 3.1% annually, with largest increases for women aged under 35 years (11% per year) and for men aged 35 to 45 (5.6%). Incidence was higher in northern regions than in southern regions and in areas with high social deprivation and binge drinking. Case fatality was 6.7% at 60 days, higher for alcoholic than gallstones aetiology and was associated with social deprivation and geography. CONCLUSIONS: Acute pancreatitis is a growing problem in England, particularly among younger women. The findings indicate strongly that alcohol consumption is the main reason for recent increases in incidence, the higher incidence in socially-deprived areas and for the lack of recent improvement in prognosis.

Use of case fatality and readmission measures to compare hospital performance in gynaecology.

OBJECTIVE: To identify suitable outcome measures for comparing gynaecology performance between hospitals. DESIGN: Analysis of routinely collected statistics. SETTING: England. POPULATION A total of 1.45 million gynaecology admissions in 1999/2001. METHODS: The database used was a linked file of English NHS hospital admission statistics and death certificate data. Case fatality rates (CFRs)and emergency readmission (ERA) rates were calculated for different components of gynaecology workload. Funnel plots, using age-sex standardised measures, were displayed to compare the outcomes. MAIN OUTCOME MEASURES: CFRs and ERA rates. RESULTS: The CFR within 30 days after admission for patients with cancer was 5.1%. These patients accounted for only 3% of all the admissions but for 73% of all 30-day deaths. All other 30-day CFRs were extremely low-below 0.5%. The 30-day ERA rates ranged from 1.8% after day case care to 17.4% after emergency admissions for people who did not have an operation. Funnel plots showed considerable variation between hospitals for ERA after day case care but not after elective abdominal hysterectomy. CONCLUSIONS: There are no measures of mortality that could be used routinely and meaningfully to compare the performance of gynaecology units. We suggest that two suitable comparative measures of outcome, derivable from routine hospital statistics, are 30-day ERA rates after day case admissions and after elective abdominal hysterectomy, excluding those records with a cancer diagnosis. These measures are relatively homogeneous with respect to their likely rates of adverse events and have sufficient numbers to produce potentially useful comparative results.

Cost effectiveness of a latrine revision programme in Kabul, Afghanistan.

INTRODUCTION: We assessed a household latrine revision intervention implemented in Kabul, Afghanistan for evidence of a reduction in diarrhoeal disease. METHODS: A case-control design involving 1238 cases and 625 controls was used. Logistic regression modelling was performed both for children < 5 years and < or = 11 years, and the parameter estimates were later used with results from a stratified cluster sample survey. This survey used a verbal autopsy methodology to enable an estimation of the number of deaths averted over a 1-year period. A cost-effectiveness analysis using direct and indirect costs for the intervention was then conducted and the results compared with primary health care interventions identified from a Medline search. FINDINGS: Conditional logistic regression showed that patients were less likely than controls to live in households with revised latrines (odds ratio (OR) 0.57, 95% confidence interval (CI) = 0.42-0.77 for children < 5 years, and OR 0.53, 95% = CI 0.41-0.67 for children < or = 11 years). The results from the survey of cause-specific mortality by verbal autopsy enabled estimation of the number of deaths averted over a 1-year period due to the intervention; these estimations were 235 (95% CI = 109-360) for children < 5 years and 285 (95% CI = 180-397) for children < or = 11 years. Estimates of cost effectiveness ranged from approximately US dollars 1800 to US dollars 4100 per death averted depending on age and payer perspective. CONCLUSION: These estimates are conservative because only 1 year of effectiveness is considered, yet they compare favourably with a review of other paediatric interventions. These results are important because funding for sanitation interventions is often limited by the belief that the interventions are not cost-effective.

Civilians and war: a review and historical overview of the involvement of non-combatant populations in conflict situations.

The effects of light weapons are now regularly seen on television and are becoming an international issue, particularly regarding their impact on civilians. It is claimed that 80% or more of deaths and injuries in today's wars are civilian; there is no objective evidence for this as little accurate information is available. Recent surveys suggest, however, a proportion of between 35 and 65%--still far too high considering the protection to which civilians are entitled under international humanitarian law. It is proposed the problem arises from twentieth-century killing power in the hands of individuals with fifteenth-century discipline and organization. Recent systematic surveys distinguish between civilian deaths from light weapons in combat and non-combat situations. A high proportion of combat deaths is due to fragmenting weapons such as mortars targeted on populated areas. Many weapon-related deaths in non-combat situations are accidental (cleaning weapons, handling by children during play) and others are related to domestic disputes. The availability and use of weapons also affects civilians indirectly in many ways, such as ill-health in refugees, psychosocial effects on women and children, and economic and environmental consequences. A variety of schemes exist to reduce the availability of light weapons and reintegrate their users into society. The international community must extend and make better use of these measures.

Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review.

OBJECTIVE: To determine the implications of variation in mortality associated with use of weapons in different contexts. DESIGN: Literature review. SETTINGS: Armed conflicts and civilian mass shootings, 1929-96. MAIN OUTCOME MEASURE: Mortality from wounds. RESULTS: During the fighting of war the number of people wounded is at least twice the number killed and may be 13 times as high; this ratio of the number wounded to the number killed results from the impact of a weapon system on human beings in the particular context of war. When firearms are used against people who are immobilised, in a confined space, or unable to defend themselves the wounded to killed ratio has been lower than 1 or even 0. CONCLUSIONS: Mortality from firearms depends not only on the technology of the weapon or its ammunition but also on the context in which it is used. The increased mortality resulting from the use of firearms in situations other than war requires a complex interaction of factors explicable in terms of wound ballistics and the psychology of the user. Understanding these factors has implications for recognition of war crimes. In addition, the lethality of conventional weapons may be increased if combatants are disabled by the new non-lethal weapons beforehand; this possibility requires careful legal examination within the framework of the Geneva Conventions.

Circumstances around weapon injury in Cambodia after departure of a peacekeeping force: prospective cohort study.

OBJECTIVE: To examine the circumstances surrounding weapon injury and combatant status of those injured by weapons. DESIGN: Prospective cohort study. SETTING: Northwestern Cambodia after departure of United Nations peacekeeping force. SUBJECTS: 863 people admitted to hospital for weapon injuries over 12 months. MAIN OUTCOME MEASURES: Annual incidence of weapon injury by time period; proportions of injuries inflicted as a result of interfactional combat (combat injuries) and outside such combat (non-combat injuries) by combatant status and weapon type. RESULTS: The annual incidence of weapon injuries was higher than the rate observed before the peacekeeping operation. 30% of weapon injuries occurred in contexts other than interfactional combat. Most commonly these were firearm injuries inflicted intentionally on civilians. Civilians accounted for 71% of those with non-combat injuries, 42% of those with combat related injuries, and 51% of those with weapon injuries of either type. CONCLUSIONS: The incidence of weapon injuries remained high when the disarmament component of a peacekeeping operation achieved only limited success. Furthermore, injuries occurring outside the context of interfactional combat accounted for a substantial proportion of all weapon injuries, were experienced disproportionately by civilians, and were most likely to entail the intentional use of a firearm against a civilian.

Incidence of weapon injuries not related to interfactional combat in Afghanistan in 1996: prospective cohort study.

OBJECTIVE: To examine the descriptive epidemiology of weapon injuries not directly attributable to combat during armed conflict. DESIGN: Prospective cohort study. SETTING: Nangarhar region of Afghanistan, which experienced effective peace, intense fighting, and then peace over six months in 1996. SUBJECTS: 608 people admitted to Jalalabad hospital because of weapon injuries. MAIN OUTCOME MEASURES: Estimated incidence of injuries from combat or otherwise (non-combat injury) before, during, and after the fall of Kabul. RESULTS: Incidence of non-combat injury was initially 65 per 100 000. During the intense military campaign for Kabul the incidence declined dramatically, and then differentially increased dependent on injury subcategory-that is, whether injuries were accidental or intentional and whether they were inflicted by firearms or fragmenting munitions. Non-combat injuries accounted for 51% of weapon injuries observed over the study period. Civilians were more likely to have non-combat injuries than combat injuries. CONCLUSIONS: Weapon injuries that are not attributable to combat are common. Social changes accompanying conflict and widespread availability of weapons may be predictive of use of weapons that persists independently of conflict.

First-line tuberculosis therapy and drug-resistant Mycobacterium tuberculosis in prisons.

BACKGROUND: We assessed a programme of tuberculosis control in a prison setting in Baku, Azerbaijan. The programme used first-line therapy and DOTS (directly observed treatment, short course). METHODS: 467 patients had sputum-positive tuberculosis. Their treatment regimens followed WHO guidelines, and they had regular clinical examinations and dietary supplements. Isolates were tested by standard methods for resistance to isoniazid, rifampicin, ethambutol, and streptomycin in three laboratories. Treatment success was defined as three consecutive negative sputum smears at end of treatment. Factors independently associated with treatment failure were estimated by logistic regression. FINDINGS: Drug-resistance data on admission were available for 131 patients. 55% of patients had strains of Mycobacterium tuberculosis resistant to two or more antibiotics. Mortality during treatment was 11%, and 13% of patients defaulted. Overall, treatment was successful in 54% of patients, and in 71% of those completing treatment. 104 patients completed a full treatment regimen and remained sputum-positive. Resistance to two or more antibiotics, a positive sputum result at the end of initial treatment, cavitary disease, and poor compliance were independently associated with treatment failure. INTERPRETATION: The effectiveness of a DOTS programme with first-line therapy fell short of the 85% target set by WHO. First-line therapy may not be sufficient in settings with a high degree of resistance to antibiotics.

Mortality rates after cataract extraction.

Senile cataract may be a marker of generalized tissue aging. We examined this hypothesis using population-based linked health data. We hypothesized that any such association would diminish with increased use of cataract surgery. Mortality rates of those 50-95 years of age undergoing cataract surgery in British Columbia during either 1985 or 1989 were compared with the provincial population of comparable age who did not undergo cataract surgery during the study period. The 1985 cohort included 8,262 patients undergoing surgery and a comparison population of 804,303, and the 1989 cohort included 11,952 patients and a comparison population of 839,393. Using Cox regression, for the 1985 cohort, the hazard ratios for dying during follow-up were 3.2 for males 50-54.9 years of age [95% confidence limits (CL) = 2.0, 5.0] and 3.3 for females (95% CL = 1.9, 5.7). Hazard ratios for older age groups decreased with age. We also fit an additive risk model that produced excess mortalities that were less age dependent. In the 1985 analysis, these ranged from +7.1 per 1,000 (95% CL = +0.44, +13.76) to +20.3 (95% CL = +13.24, +27.36) for males and -17.5 (95% CL = -28.28, -6.72) to +2.0 (95% CL = -2.12, +6.12) for females. Findings for the 1989 analyses were similar, indicating that the association between cataracts and generalized aging remained constant despite a large increase in the use of cataract surgery.

Socioeconomic status, mortality, and the development of cataract at a young age.

It has been hypothesized that senile cataract may serve as a marker for generalised tissue aging, since structural changes occurring in the proteins of the lens during cataract formation are similar to those which occur elsewhere as part of the aging process. An earlier analysis we carried out to test this hypothesis revealed a strong age-dependent relationship between undergoing cataract surgery and subsequent mortality. Relative risks for dying over 9 yr of follow-up were particularly increased for individuals who had developed cataract requiring operation between the ages of 50-65. This finding prompted us to test the hypothesis that younger patients undergoing surgery for cataract (those in which surgery was undertaken at 50-65 yr of age) would tend disproportionately to be resident in areas of generally lower socioeconomic status. A population-based linked health data resource containing data on all hospital separations in the province of British Columbia was used to examine this hypothesis. Linkage to Canadian census data was used to assign a socioeconomic decile to the area of residence for all individuals in British Columbia who either did, or did not, undergo cataract surgery over a 3 yr period, and were aged 50-95. Relative to those who resided in the highest socioeconomic areas, odds ratios for undergoing cataract surgery between 50 and 65 yr of age were significantly greater than 1 for the four lowest socioeconomic deciles. This association was observed despite a conservative bias in our setting that favoured those of higher socioeconomic status tending to receive earlier treatment. The results of this ecologic study prompt consideration of whether factors which have the dual attributes of being correlates of socioeconomic status and implicated in the development of cataract may play a role in mediating the processes involved in the well known association of socioeconomic status and mortality.

Weapons injuries during and after periods of conflict: retrospective analysis.

OBJECTIVE: To assess the relative frequency of weapon injuries during conflict and after periods of conflict in the absence of disarmament. DESIGN: Retrospective analysis of a database of war wounds. SETTING: Region with a protracted conflict between rival combatant groups and a subsequent transition to the uncontested military authority of a single power. SUBJECTS: 2332 people who received weapons injuries during the conflict or post-conflict periods and were admitted to hospital within 24 hours of injury. MAIN OUTCOME MEASURES: Percentage change in mean monthly admission rate by weapon type between conflict and post-conflict periods; annual incidence of injury by weapon type during conflict and post-conflict periods; percentage change in annual incidence by weapon type between conflict and post-conflict periods. RESULTS: Mean monthly admission rates for injuries from fragmentation munitions decreased by 8% between conflict and post-conflict periods and by 23% for injuries from mines and 32% for gunshot injuries. The decline in admissions for all injuries was 23%. After adjustment for population growth over the study period, declines in annual incidence were 22% for fragmentation munitions injuries, 34% for mine injuries, and 40% for gunshot injuries. The decline in incidence for all injuries was 33%. In-hospital mortality from weapons related injuries increased from 2.5% to 6.1% (P < 0.001) between conflict and post-conflict periods. CONCLUSIONS: In this setting, continued availability of weapons is associated with increased mortality and a level of injuries from weapons that is only somewhat reduced from that observed during a period of conflict.