Changing patterns in the burden of paediatric injuries during the COVID-19 pandemic: a study in Mozambique's central hospitals.

INTRODUCTION: There is a substantial body of knowledge on the effects of the COVID-19 pandemic on injuries showing frequent but inconsistent reductions in both volume and pattern. Yet, studies specifically addressing children are less common, not least from low- and middle-income countries. This study investigated whether changes in the pattern and outcome of paediatric injury admissions to Mozambique's four regional referral hospitals during 2020. METHODS: Clinical charts of paediatric patients presenting to the targeted hospitals with acute injuries were reviewed using a set of child, injury, and outcome characteristics during each of two consecutive restriction periods in 2020 using as a comparator the same periods in 2019, the year before the pandemic. Differences between 2020 and 2019 proportions for any characteristic were examined using the t-test (significance level 0.05). RESULTS: During both restriction periods, compared with the previous year, reductions in the number of injuries were noticed in nearly all aspects investigated, albeit more remarkably during the first restriction period, in particular, greater proportions of injuries in the home setting and from burns (7.2% and 11.5% respectively) and a reduced one of discharged patients (by 2.5%). CONCLUSION: During the restrictions implemented to contend the pandemic in Mozambique in 2020, although each restriction period saw a drop in the volume of injury admissions at central hospitals, the pattern of child, injury and outcome characteristics did not change much, except for an excess of home and burn injuries in the first, more restrictive period. Whether this reflects the nature of the restrictions only or, rather, other mechanisms that came into play, individual or health systems related, remains to be determined.

Changes in trauma-related emergency medical services during the COVID-19 lockdown in the Western Cape, South Africa.

BACKGROUND: To limit virus spread during the COVID pandemic, extensive measures were implemented around the world. In South Africa, these restrictions included alcohol and movement restrictions, factors previously linked to injury burden in the country. Consequently, reports from many countries, including South Africa, have shown a reduction in trauma presentations related to these restrictions. However, only few studies and none from Africa focus on the impact of the pandemic restrictions on the Emergency Medical System (EMS). METHODS: We present a retrospective, observational longitudinal study including data from all ambulance transports of physical trauma cases collected during the period 2019-01-01 and 2021-02-28 from the Western Cape Government EMS in the Western Cape Province, South Africa (87,167 cases). Within this timeframe, the 35-days strictest lockdown level period was compared to a 35-days period prior to the lockdown and to the same 35-days period in 2019. Injury characteristics (intent, mechanism, and severity) and time were studied in detail. Ambulance transport volumes as well as ambulance response and on-scene time before and during the pandemic were compared. Significance between indicated periods was determined using Chi-square test. RESULTS: During the strictest lockdown period, presentations of trauma cases declined by > 50%. Ambulance transport volumes decreased for all injury mechanisms and proportions changed. The share of assaults and traffic injuries decreased by 6% and 8%, respectively, while accidental injuries increased by 5%. The proportion of self-inflicted injuries increased by 5%. Studies of injury time showed an increased share of injuries during day shift and a reduction of total injury volume during the weekend during the lockdown. Median response- and on-scene time remained stable in the time-periods studied. CONCLUSION: This is one of the first reports on the influence of COVID-19 related restrictions on EMS, and the first in South Africa. We report a decline in trauma related ambulance transport volumes in the Western Cape Province as well as changes in injury patterns, largely corresponding to previous findings from hospital settings in South Africa. The unchanged response and on-scene times indicate a well-functioning EMS despite pandemic challenges. More studies are needed, especially disaggregating the different restrictions.

Post-injury benzodiazepine and opioid use among older adults involved in road traffic crashes: A Swedish register-based longitudinal study.

AIM: Psychotropic drugs like opioids and benzodiazepines are prescribed for traumas resulting from road traffic crashes and the risk of developing an addiction deserves consideration. This study aims to shed light on how the consumption of those drugs evolves over time among older road traffic injury (RTI) victims. METHODS: We conducted a nationwide Swedish register-based longitudinal study to identify trajectories of post-RTI psychotropic drug use. All individuals aged 50 years and older who had a hospital visit for an RTI from 2007 to 2015 were followed up during a 2-year period; those who used the drugs prior to the RTI were excluded. Trajectories were identified by performing latent class trajectory analysis on drug dispensation data for opioids and benzodiazepines separately (66 034 and 66 859 adults, respectively, in total). RESULTS: Three trajectories were identified for opioids and four for benzodiazepines. The largest group in both instances included people with no-use/minimal use throughout the follow-up (81.3% and 92.8%). "Sporadic users" were more frequent among users of opioids (16.7%) than benzodiazepines (4.3%), whereas "chronic users" were found in similar proportions (2.0% and 1.8%). "Delayed chronic use" characterized the fourth group of benzodiazepine users (1.0%). CONCLUSION: Several trajectories of psychotropic drug use were identified after RTI, from limited to chronic. Although chronic use was uncommon, a better understanding of the factors likely to increase that risk is warranted given the seriousness of the problem.

Enablers of psychosocial recovery in pediatric burns: perspectives from the children, parents and burn recovery support staff.

BACKGROUND: Pediatric burn injuries are a major cause of death and injury, occurring mainly in resource poor environments. Recovery from burns is widely reported to be constrained by physical, psychological, relationship and reintegration challenges. These challenges have been widely described, but not the enablers of psychosocial recovery. This is especially true in pediatric burn research, with few multi- perspective studies on the recovery process. METHODS: This qualitative study involved 8 focus group discussions (four with 15 children post-burn injury, four with 15 caregivers) and 12 individual interviews with staff working in pediatric burns that explored the psychosocial needs of children after a burn and the enablers of their recovery. Purposive sampling was utilized and recruitment of all three categories of participants was done primarily through the only hospital burns unit in the Western Cape, South Africa. The interviews focused on factors that supported the child's recovery and were sequentially facilitated from the child and the family's experiences during hospitalization, to the return home to family and friends, followed by re-entry into school. Thematic analysis was used to analyze verbatim interview transcripts. RESULTS: The recovery enablers that emerged included: (i) Presence and reassurance; indicating the comfort and practical help provided by family and close friends in the hospital and throughout the recovery process; (ii) Normalizing interactions and acceptance; where children were treated the same as before the injury to promote the acceptance of self and by others especially once the child returned home; and (iii) Sensitization of others and protection; signifying how persons around the child had assisted the children to deal with issues in the reintegration process including the re-entry to school. CONCLUSIONS: This study indicates that the psychosocial recovery process of children hospitalized for burns is enabled by the supportive relationships from family members, close friends and burn staff, present during hospitalization, the return home, and school re-entry. Support included comfort and physical presence of trusted others and emotional support; affirmation of the child's identity and belonging despite appearance changes; and the advocacy and protection for the re-entry back into the school, and more generally the community.

Prevalence, trend and contributing factors of geriatric syndromes among older Swedes: results from the Stockholm County Council Public Health Surveys.

BACKGROUND: Evidence is scarce on the trend in prevalence of geriatric syndromes (GS). This study assesses how GS prevalence changes over time in Swedish older community-dwellers by socio-demography, and attempts to highlight factors that may contribute to explain the trend. METHODS: Data from Stockholm County Council Public Health Surveys in 2006, 2010 and 2014 were used. Old adults, aged 65-84 years, with measurements on GS items were identified. Thus, a total of 17,560 participants were selected in 2006 (n = 6295), 2010 (n = 6733) and 2014 (n = 4532). Data on socio-demographics, lifestyles and health status were collected through questionnaires. GS was defined as having at least one of the following: insomnia, urinary incontinence, severe hearing/vision problem, functional decline, fall and depressive disorder. Logistic regression was performed to assess the prevalence trend as well as the change in the associations of sociodemographic factors, health behaviors and chronic disease with GS. RESULTS: From 2006 to 2014, the prevalence of GS remained stable (Ptrend = 0.54). However, among old adults born outside Nordic countries, it increased significantly from 73.0% in 2006, 78.0% in 2010 to 83.0% in 2014 (Ptrend < 0.001). Furthermore, the association with GS became stronger for born outside Nordic counties (Ptrend < 0.001) and weaker for sedentary lifestyles (Ptrend = 0.004), whereas the association did not change for other sociodemographic factors, health behaviors and chronic disease (all Ptrend > 0.05). CONCLUSIONS: At population level, GS prevalence remained stable at a high level among Swedish old community-dwellers. There are noteworthy differences in GS trend between population groups, in particular to the detriment of older adults born outside Nordic countries.

Ecological study of road traffic injuries in the eastern Mediterranean region: country economic level, road user category and gender perspectives.

BACKGROUND: The Eastern Mediterranean region has the second highest number of road traffic injury mortality rates after the African region based on 2013 data, with road traffic injuries accounting for 27% of the total injury mortality in the region. Globally the number of road traffic deaths has plateaued despite an increase in motorization, but it is uncertain whether this applies to the Region. This study investigated the regional trends in both road traffic injury mortality and morbidity and examined country-based differences considering on income level, categories of road users, and gender distribution. METHODS: Register-based ecological study linking data from Global Burden of Disease Study with the United Nations Statistics Division for population and World Bank definition for country income level. Road traffic injury mortality rates and disability-adjusted life years were compiled for all ages at country level in 1995, 2005, 2015 and combined for a regional average (n = 22) and a global average (n = 122). The data were stratified by country economic level, road user category and gender. RESULTS: Road traffic injury mortality rates in the Region were higher than the global average for all three reference years but suggest a downward trend. In 2015 mortality rates were more than twice as high in low and high income countries compared to global income averages and motor vehicle occupants had a 3-fold greater mortality than the global average. Severe injuries decreased by more than half for high/middle income countries but remained high for low income countries; three times higher for males than females. CONCLUSION: Despite a potential downward trend, inequalities in road traffic injury mortality and morbidity burden remain high in the Eastern Mediterranean region. Action needs to be intensified and targeted to implement and enforce safety measures that prevent and mitigate severe motor vehicle crashes in high income countries especially and invest in efforts to promote public, active transport for vulnerable road users in the resource poor countries of the Region.

What do emergency medicine and burns specialists from resource constrained settings expect from mHealth-based diagnostic support? A qualitative study examining the case of acute burn care.

BACKGROUND: Traumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology. METHODS: This qualitative study investigated tele-experts' (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis. RESULTS: Experts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback. CONCLUSION: Experts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success - time pressure, intensity and the wide range of subspecialties to be considered.

Demographic and regional characteristics of road traffic injury deaths in Jiangsu Province, China.

Background: The study investigates the magnitude and distribution of fatal road traffic injuries (RTIs) in the Chinese province of Jiangsu by road user. Method: The 13 694 RTI deaths and years of potential life lost (YPLL) that occurred in 2012 were analysed; vulnerable and non-vulnerable road users were considered separately. Age-adjusted mortality and YPLL were compiled and the association between demographic characteristics and RTI mortality rate was analysed using negative binomial regression. Results: The age-adjusted RTI mortality and YPLL in Jiangsu in 2012 were 18.14 (95% CI: 17.84-18.45) and 494.3 (95% CI: 492.7-496.0) per 100 000 population. Half of the deaths were among pedestrians and for vulnerable road users as a whole, male fatalities were over three times that of female (adjusted incidence rate ratio = 3.26, 95% CI: 1.89-3.77). Fatalities in the oldest age group (80+ years) were over 14 times that of the youngest one (0-9 years) (adjusted incidence rate ratio = 14.13, 95% CI: 9.49-21.01). Fatality rates in the central and northern regions surpassed that of the south. Conclusion: As in the rest of the country, RTIs are a considerable public health problem in Jiangsu where fatality and YPLL rates fall heavily on pedestrians, men, and older persons and are more pronounced in the less developed regions.

Image-based teleconsultation using smartphones or tablets: qualitative assessment of medical experts.

BACKGROUND: Mobile health has promising potential in improving healthcare delivery by facilitating access to expert advice. Enabling experts to review images on their smartphone or tablet may save valuable time. This study aims at assessing whether images viewed by medical specialists on handheld devices such as smartphones and tablets are perceived to be of comparable quality as when viewed on a computer screen. METHODS: This was a prospective study comparing the perceived quality of 18 images on three different display devices (smartphone, tablet and computer) by 27 participants (4 burn surgeons and 23 emergency medicine specialists). The images, presented in random order, covered clinical (dermatological conditions, burns, ECGs and X-rays) and non-clinical subjects and their perceived quality was assessed using a 7-point Likert scale. Differences in devices' quality ratings were analysed using linear regression models for clustered data adjusting for image type and participants' characteristics (age, gender and medical specialty). RESULTS: Overall, the images were rated good or very good in most instances and more so for the smartphone (83.1%, mean score 5.7) and tablet (78.2%, mean 5.5) than for a standard computer (70.6%, mean 5.2). Both handheld devices had significantly higher ratings than the computer screen, even after controlling for image type and participants' characteristics. Nearly all experts expressed that they would be comfortable using smartphones (n=25) or tablets (n=26) for image-based teleconsultation. CONCLUSION: This study suggests that handheld devices could be a substitute for computer screens for teleconsultation by physicians working in emergency settings.

Accuracy of acute burns diagnosis made using smartphones and tablets: a questionnaire-based study among medical experts.

BACKGROUND: Remote assistance for burns by medical experts can support nurses and general physicians in emergency care with diagnostic and management advice. Previous studies indicate a high diagnostic accuracy based on images viewed on a computer screen, but whether image-based analysis by experts using handheld devices is accurate remains to be determined. METHOD: A review of patient data from eight emergency centres in the Western Cape, South Africa, revealed 10 typical cases of burns commonly seen in children and adults. A web-based questionnaire was created with 51 images of burns representing those cases. Burns specialists from two countries (South Africa and Sweden (n = 8 and 7 respectively)) and emergency medicine specialists from South Africa (n = 11) were contacted by email and asked to assess each burn's total body surface area (TBSA) and depth using a smartphone or tablet. The accuracy and inter-rater reliability of the assessments were measured using intraclass correlation coefficients (ICC), both for all cases aggregated and for paediatric and adult burn cases separately. Eight participants repeated the questionnaire on a computer and intra-rater reliability was calculated. RESULTS: The assessments of TBSA are of high accuracy all specialists aggregated (ICC = 0.82 overall and 0.81 for both child and adult cases separately) and remain high for all three participant groups separately. The burn depth assessments have low accuracy all specialists aggregated, with ICCs of 0.53 overall, 0.61 for child and 0.46 for adult cases. The most accurate assessments of depth are among South African burns specialists (reaching acceptable for child cases); the other two groups' ICCs are low in all instances. Computer-based assessments were similar to those made on handheld devices. CONCLUSION: As was the case for computer-based studies, burns images viewed on handheld devices may be a suitable means of seeking expert advice even with limited additional information when it comes to burn size but less so in the case of burn depth. Familiarity with the type of cases presented could facilitate image-based diagnosis of depth.

Using Mobile Apps to Communicate Vaccination Records: A City-wide Evaluation with a National Immunization App, Maternal Child Registry and Public Health Authorities.

Medicine is experiencing a paradigm shift, where patients are increasingly involved in the management of their health data. We created a mobile app which permitted parental reporting of immunization status to public health authorities. We describe app use as a proxy for feasibility and acceptability as well as data utility for public health surveillance. The evaluation period ran from April 27, 2015, to April 18, 2017, during which time 2,653 unique children's records were transmitted, containing 36,105 vaccinations. Our findings suggest that mobile immunization reporting is feasible and may be an acceptable complement to existing reporting methods. Measures of data utility suggest that mobile reporting could enable more accurate assessments of vaccine coverage.

New opioid analgesic use and the risk of injurious single-vehicle crashes in drivers aged 50-80 years: A population-based matched case-control study.

BACKGROUND: the increasing trend in opioid analgesic use among older drivers has raised concerns about their risk of being involved in car crashes. AIM: to investigate if older drivers who started using opioid analgesics have a higher probability of being involved in injurious crashes. METHODS: population-based matched case-control study. Data from population registers were merged using a personal identity number. Cases were drivers aged 50-80 years responsible for a single vehicle crash between 01.07.05 and 31.12.09 that led to at least one injured passenger (n = 4,445). Four controls were randomly matched to each case by sex, birth month/year, and residence area from persons holding a valid driving license who did not crash during the study period. New use was defined as at least one dispensation within 1-30 days prior to the crash, but none within the previous 31-180 days; frequent use when ≥3 dispensations were given within 0-180 days, with at least one within 31-180 days. Individuals using 1-2 non-opioid analgesic medications were used as reference category. Conditional logistic regression was used to estimate odds ratios (OR; 95% CI) adjusting for benzodiazepine use, co-morbidity, civil status and occupation. RESULTS: adjusted odds for new use were two-fold that of drivers using 1-2 non-opioid analgesics medications (2.0; 1.6-2.5). For frequent use, adjusted odds were also increased regardless of number of dispensations (3-4 = 1.7; 1.3-2.1, 5-6 = 1.6; 1.2-2.3, and ≥7 = 1.7; 1.3-2.1). CONCLUSION: new, but also frequent opioid analgesic use, resulted in an increased probability of single vehicle crashes. While more epidemiologic evidence is needed, patients could be advised to refrain from driving when using opioid analgesics.

Patterns in health-related behaviours and fall injuries among older people: a population-based study in Stockholm County, Sweden.

AIM: we identified clusters of older people with similar health-related behaviours and assessed the association between those clusters and the risk of injurious fall. METHODS: we linked self-reported and register-based data on the over-65s from the Stockholm public health cohort (N = 20,212). Groups of people with similar health-related behaviours were identified by cluster analysis using four measures of physical activity, two of smoking and alcohol habits and two individual attributes (age and type of housing). The association between clusters and falls leading to hospitalisation (422 cases) was studied using a nested case-control design. Odds ratios (ORs), crude and adjusted for health status, were compiled by cluster using the one with the most 'protective' health behaviour profile as the reference. RESULTS: five clusters were identified revealing a variety of combinations of health-related behaviours, all linked to specific age groups and types of housing and with a tendency towards higher levels of physical activity among the younger ones. The risk of injurious falls differed across clusters, and for three out of four, it was significantly higher than in the comparison cluster. Adjusting for health status only partially reduced the ORs for those clusters and this was observed both in men and women. CONCLUSION: health-related behaviours aggregate in different manners among older people. Some health-related profiles are associated with an excess risk of falls leading to hospitalisation. Although this is partly a reflection of age differences across clusters, health status alone cannot fully explain the association.

The risk of fall injury in relation to commonly prescribed medications among older people--a Swedish case-control study.

BACKGROUND: Older people not only consume more medication but they also represent a group at high risk for adverse effects such as injurious falls. This study examines the association between the medications most commonly prescribed to older people in Sweden and fall injuries. METHODS: This is a population-based, matched, case-control study of 64 399 persons aged ≥ 65 years in Sweden admitted to hospital because of a fall injury between March 2006 and December 2009, and four controls per case matched by gender, date of birth and place of residence. The prevalence of the 20 most commonly prescribed medications was compiled for the 30-day period before the index date. The association between those medications and injurious falls was estimated with odds ratios and corresponding 95% confidence intervals using conditional logistic regression. RESULTS: Ten of the top 20 most commonly prescribed medications, and in particular the three medications affecting the central nervous system (CNS), significantly increased the risk of fall injuries (highest for opioids and antidepressants) but not the seven cardiovascular ones, who had a protective effect (lowest for angiotensin converting enzyme inhibitors and selective calcium channel blockers). CONCLUSIONS: The adverse effect of several commonly prescribed medications may seriously threaten their positive effects on the well-being and quality of life of older people. Their association with injurious falls is of particular concern as falls are prevalent and often leading to severe consequences. This needs to be acknowledged so physicians and patients can make informed decisions when prescribing and using them.

Can We Trust the Use of Smartphone Cameras in Clinical Practice? Laypeople Assessment of Their Image Quality.

BACKGROUND: Smartphone cameras are rapidly being introduced in medical practice, among other devices for image-based teleconsultation. Little is known, however, about the actual quality of the images taken, which is the object of this study. MATERIALS AND METHODS: A series of nonclinical objects (from three broad categories) were photographed by a professional photographer using three smartphones (iPhone(®) 4 [Apple, Cupertino, CA], Samsung [Suwon, Korea] Galaxy S2, and BlackBerry(®) 9800 [BlackBerry Ltd., Waterloo, ON, Canada]) and a digital camera (Canon [Tokyo, Japan] Mark II). In a Web survey a convenience sample of 60 laypeople "blind" to the types of camera assessed the quality of the photographs, individually and best overall. We then measured how each camera scored by object category and as a whole and whether a camera ranked best using a Mann-Whitney U test for 2×2 comparisons. RESULTS: There were wide variations between and within categories in the quality assessments for all four cameras. The iPhone had the highest proportion of images individually evaluated as good, and it also ranked best for more objects compared with other cameras, including the digital one. The ratings of the Samsung or the BlackBerry smartphone did not significantly differ from those of the digital camera. CONCLUSIONS: Whereas one smartphone camera ranked best more often, all three smartphones obtained results at least as good as those of the digital camera. Smartphone cameras can be a substitute for digital cameras for the purposes of medical teleconsulation.

Number of medications and road traffic crashes in senior Swedish drivers: a population-based matched case-control study.

OBJECTIVE: This study investigated the relationship between the number of different medications dispensed (NDMD) to senior drivers and the risk of injurious road traffic crashes (RTCs). DESIGN: A matched case-control study with data from various population-based national registers was conducted. Cases were drivers aged 50-80 years involved in a crash in Sweden between 2005 and 2009. Only the first non-alcohol-related RTC was studied. Controls were residents with a valid license who did not crash. Four controls were matched by sex, age (year and month of birth), and place of residence. Exposure to NDMD prior to the crash date was assessed using four time periods: 1-8, 1-15, 1-30 and 1-90 days. Conditional logistic regression was used and analyses adjusted for civil status, occupation and dispensation of medications affecting the cardiovascular or nervous systems (C/N). RESULTS: ORs (95% CI) increased progressively with the NDMD. For 1-8 days the OR ranged from 1.15 (1.10 to 1.20) for 1-2 medications to 1.27 (1.13 to 1.42) for five or more medications. The magnitude of the effect declined gradually with longer exposure periods, but remained when five or more medications were used. Adjusting for C/N medications resulted in slightly higher effects; for 1-8 days it ranged from 1.16 (1.10 to 1.23) for 1-2 medications to 1.35 (1.17 to 1.56) for five or more, with similar trends by exposure period. The highest effects were seen for single crashes and for drivers aged 66-80 years. CONCLUSIONS: The NDMD was linked to the likelihood of a senior driver being involved in an injurious RTC. The strength of the association steadily increased with increased NDMD, especially when medications were taken closer to the index date, or when more than five medications were dispensed.

Young unlicensed drivers and fatal road traffic crashes in the USA in the past decade. A neglected public health issue.

It is unknown whether road traffic crashes (RTCs) involving young unlicensed drivers follow the downward trend of those involving licensed drivers. Our national register-based study from 2000 to 2011 indicates that the downward trend for young unlicensed drivers (<25 years) is significantly less pronounced. These drivers account for 10.7% to 11.5% of the fatal RTCs involving young drivers during that time period; this percentage is consistently higher in the Western and Southern states and has increased in recent years in the Midwest.

Medication and fall injury in the elderly population; do individual demographics, health status and lifestyle matter?

BACKGROUND: The simultaneous use of several medications is an important risk factor for injurious falls in older people. The aim of this study is to investigate the effect of the number of medications dispensed to elderly persons on fall injuries and to assess whether this relationship is explained by individual demographics, health habits and health status. METHODS: A population-based, nested, case-control study on people 65 years and older (N = 20.906) was conducted using data from the Stockholm Public Health Cohort (SPHC) derived from self-administered surveys and linked at the individual level with various Swedish health registers. Fall injuries leading to hospitalization recorded in the Swedish National Patient Register (NPR) were considered as the outcome. The main exposure, obtained from the Swedish Prescribed Drug Register (SPDR), was the number of medications dispensed within 90 days prior to the injurious fall. The injury risk was estimated using adjusted odds ratios (ORs) from logistic regression. Results were adjusted by selected demographic, social circumstances, lifestyle and health status data extracted from the SPHC. RESULTS: After adjusting for common risk factors within demographics, lifestyle, social circumstances and health status, using more than one medication increased the risk of fall injury but no clear dose-response relationship was observed, with point estimates ranging from 1.5-1.7 for the use of two, three, four or five or more medications as compared to using none. An increased risk remained, and was even elevated, after adjusting for the use of fall-risk-increasing drugs (FRIDs). CONCLUSIONS: Using more than one medication affects the risk of injurious falls among older people. The effect of any given number of medications studied remains and is even strengthened after adjusting for individual demographics, health habits, health conditions and the use of FRIDs.

Serial QuantiFERON-TB Gold In-Tube assay and tuberculin skin test to diagnose latent tuberculosis in household Mexican contacts: conversion and reversion rates and associated factors using conventional and borderline zone definitions.

A cohort of 123 adult contacts was followed for 18-24 months (86 completed the follow-up) to compare conversion and reversion rates based on two serial measures of QuantiFERON (QFT) and tuberculin skin test (TST) (PPD from TUBERSOL, Aventis Pasteur, Canada) for diagnosing latent tuberculosis (TB) in household contacts of TB patients using conventional (C) and borderline zone (BZ) definitions. Questionnaires were used to obtain information regarding TB exposure, TB risk factors and socio-demographic data. QFT (IU/mL) conversion was defined as <0.35 to ≥0.35 (C) or <0.35 to >0.70 (BZ) and reversion was defined as ≥0.35 to <0.35 (C) or ≥0.35 to <0.20 (BZ); TST (mm) conversion was defined as <5 to ≥5 (C) or <5 to >10 (BZ) and reversion was defined as ≥5 to <5 (C). The QFT conversion and reversion rates were 10.5% and 7% with C and 8.1% and 4.7% with the BZ definitions, respectively. The TST rates were higher compared with QFT, especially with the C definitions (conversion 23.3%, reversion 9.3%). The QFT conversion and reversion rates were higher for TST ≥5; for TST, both rates were lower for QFT <0.35. No risk factors were associated with the probability of converting or reverting. The inconsistency and apparent randomness of serial testing is confusing and adds to the limitations of these tests and definitions to follow-up close TB contacts.

Changes in pregnancy and childbirth practices in remote areas in Lao PDR within two generations of women: implications for maternity services.

This paper sheds light on the inter-generational changes in pregnancy and childbirth practices in remote areas of Lao PDR over a period of 30 years. The study consisted of focus group discussions with pregnant women aged 14-30, mothers and fathers of small children, and older women aged 40+ in six rural communities in two districts. Childbirth practices were gradually evolving and changing - most dramatically illustrated by the transition from forest-based to home-based delivery, and a few health facility-based deliveries when complications occurred. Today's generation of women aged 40+ did not recommend all the practices of their mothers, but saw the need to adapt due to the social and medical risks they had experienced, especially high rates of neonatal death. Their daughters are doing the same. The increase in home-based deliveries should be regarded as significant progress in this setting in rural Laos. Understanding how young women interpret their options and incorporating that knowledge and the experience of successful local outreach programmes into health system policy and practice for maternity care, e.g. by strengthening the skills of community-based health workers, could contribute to improving maternal and neonatal survival and reducing health inequalities.