The horizon of unintentional injuries among children in low-income setting: an overview from Bangladesh Health and Injury Survey.

INTRODUCTION: The paper aims to explore the magnitude and distribution of unintentional injuries among Bangladeshi children (<18 years). METHODOLOGY: A cross sectional survey was conducted during 2003 (January to December) in 12 randomly selected districts and Dhaka Metropolitan City of Bangladesh. Nationally representative data were collected from 171 366 households comprising of 351 651 children of under 18 years. Information includes the number of deaths and illness at the household in the preceding year. Verbal autopsy and verbal diagnosis form was used to determine the cause of mortality and morbidity respectively. RESULTS: There were 351651 children in the study, of which 5577 had one or more injuries in the past one year. Drowning and falls was the leading cause of injury mortality and morbidity in children over 1 year of age respectively. Incidence of unintentional injuries was significantly higher among boys (95% CI = -2157.8) than girls (95% CI = 968.7 - 1085.8) while rural children were the most vulnerable group. Home and its premises was the most common place for the injury incidence. CONCLUSION: The result of the study could be an insight to the policy makers to develop realistic and effective strategies to address the issue.

Impact of perioperative myocardial injury on early and long-term outcome after coronary artery bypass grafting.

AIMS: To establish the influence of perioperative myocardial injury on short- and long-term survival after coronary artery bypass grafting (CABG). METHODS AND RESULTS: The correlation of postoperative serum aspartate aminotransferase and creatine kinase MB to early cardiac-related death and to late survival was evaluated in 4911 patients who underwent CABG consecutively during a 6-year period. There were 93 early deaths (1.9%), 73 of them cardiac-related (1.5% of 4911). After a mean follow-up of 5 years, 409 additional deaths (8.5% of 4818) had occurred. Elevated enzyme levels on day 1 postoperatively highly increased the risk of early cardiac death (serum aspartate aminotransferase >or=2.35 microkat.l(-1): odds ratio 9.2; serum creatine kinase MB >or=61 microg.l(-1): odds ratio 6.0), and increased the risk of late death by approximately 50% (serum aspartate aminotransferase >or=2.35 microkat.l(-1): relative hazard 1.5; serum creatine kinase MB >or=61 microg.l(-1): relative hazard 1.4). This increased risk of death was independent of other risk factors and remained constant over time. CONCLUSIONS: Enzyme elevation after CABG implied an increased risk of both early and late death. The long-term effect persisted many years after surgery.

Outcome after lung cancer surgery. Factors predicting early mortality and major morbidity.

OBJECTIVE: This study was undertaken to assess mortality, complications and major morbidity during the first 30 days after lung cancer surgery and to estimate the significance of presurgical risk factors. METHODS: The study was based on all patients referred for surgery for primary lung cancer from 1 January 1987 to 1 September 1999. There were in total 616 patients with primary lung cancer. Three-hundred and ninety-four were men and 222 women. Postoperative events studied were divided into major and minor complications or death during the first 30 days after surgery. The significance of risk factors for an adverse outcome (defined as death or major complication in the first 30 days postoperatively) was assessed by uni- and multivariate logistic regression analyses. RESULTS: During the study period an increasing number of women and of patients older than 70 years underwent surgery. Overall 30-day mortality was 2.9, 0.6% after single lobectomy and 5.7% after pneumonectomy. Major complications occurred in 54 patients (8.8%). Fifty-eight patients (9.5%) had an adverse outcome during the first 30 days. Male gender, smoker, FEV(1)< or =70% of expected value, squamous cell carcinoma and pneumonectomy were risk factors predicting adverse outcome in the univariate model. Pneumonectomy and FEV(1)< or =70%, were the only independently significant factors for adverse outcome. Only pneumonectomy was independently associated with an increased risk for early death. CONCLUSION: Our results show low mortality and morbidity after lung cancer surgery. However, patients with reduced lung capacity and those undergoing pneumonectomy should be treated with great care, as they run a considerable risk of major complications or death during the first 30 days postoperatively. Older age (>70 years) does not appear to be a contraindication to lung cancer surgery, but patients in this group should undergo careful preoperative evaluation.

Night driving, season, and the risk of highway accidents.

Official accident and traffic density statistics on Swedish highways were used to compute the relative risk (Odds Ratio - OR) of being injured or killed in a traffic accident at different times of day. After removing accidents due to alcohol 10344 accidents remained for computations, and the period 10:00h-11:00h was used as the reference point. The highest total risk was seen at 0400h (OR=5.7, Confidence interval = 5.6-5.8), with an OR of 11.4 (Ci=10.3-12.5) for fatal accidents at the same point. The same pattern was exhibited by single vehicle, head-on, and "other" (e.g., turning off the road) accidents, whereas overtaking and rear-end accidents did not show clear 24 hour patterns. Retaining alcohol-related accidents approximately doubled the nighttime peak for total accidents. During the winter, the peak of total accidents occurred at 03:00h (OR=3.8, Ci=3.5-4.0), five hours before sunrise, whereas the summer peak occurred at 04:00h (OR=11.6, Ci=11.3-11.9), shortly after the early summer sunrise and with consistently higher nighttime risk than for winter driving. It was concluded that early morning driving is several times more dangerous than driving during the forenoon. Apart from alcohol the effect seems related to sleepiness, but not to darkness.

[Can asthma deaths in young people be predicted and prevented?]. / Kan astmadöd hos unga förutses och förebyggas?

UNLABELLED: In spite of increased asthma prevalence, the mortality in the disease has decreased during the last two decades in Sweden and in some other countries. However, in the age group 15-24 years an increased death rate was noted at the end of the 1980s. Therefore we started a prospective study from 1994 with the aim of trying to analyse the precipitating factors of all deaths in the ages 1-34 years in which the death certificate alleged asthma or anaphylaxis as the main or contributing cause of death. We conducted a confidential telephone enquiry of the next of kin of the deceased using a modified questionnaire developed by the British Thoracic Association. When available, patient records and post mortem protocols were obtained. RESULTS: The mortality in asthma in the ages 1-34 years has decreased from around 5 per million/year to 0.5/million/year over the period 1987-1998. The main preventable factors found in this analysis are undertreatment, non-compliance, psychosocial factors including alcohol/drug abuse, food allergy and inhalation allergy. Lacking awareness of the risks and underestimation of the severity of the asthma both by the physician and the patient seem to be dominating factors.

Observed and relative survival after aortic valve replacement.

OBJECTIVES: We sought to evaluate the effects of a number of factors that can potentially determine the optimal time for aortic valve replacement (AVR) and the observed and relative survival after the operation. BACKGROUND: Aortic valve replacement is performed in patients within a wide age span, but the proportion of elderly patients is increasing. In survival analyses, adjustment for the effects of age is therefore essential. Analysis of relative survival provides additional information on excess or disease-specific mortality and its risk factors. METHODS: Survival was analyzed in 2,359 patients (1,442 without and 917 with concomitant coronary artery bypass graft surgery) undergoing their first AVR. By relating observed survival to that expected among the general Swedish population stratified by age, gender and five-year calendar period, the relative survival and disease-specific survival were estimated. RESULTS: Early mortality after AVR (death within 30 days) was 5.6%. Relative survival rates (excluding early deaths) after 5, 10 and 15 years were 94.6%, 84.7% and 74.9%, respectively. There was an excess risk of dying during the entire follow-up period. Advanced New York Heart Association functional class, preoperative atrial fibrillation and pure aortic regurgitation were independent risk factors for observed and relative survival. Patients in the oldest age group showed decreased observed survival but excellent relative survival. CONCLUSIONS: Old age was not a risk factor for excess mortality after AVR, whereas atrial fibrillation decreased relative survival substantially.

Leukaemia, lymphoma, and multiple myeloma in seamen on tankers.

OBJECTIVES: To investigate the risk of lymphatic and haematopoietic malignancies in deck crew on tankers exposed to cargo vapours. METHODS: The study design was as a nested case-referent study in two cohorts of male Swedish seamen 20-64 years of age at the national census 1960 (n 13,449) and 1970 (n 11,290), respectively. Cases were detected by record linkage with the Swedish Cancer Register 1961-79 and 1971-87, respectively. For each case, three to five age matched referents from the population were selected. Exposure was assessed from data in the Swedish Registry of Seamen and from a register of Swedish ships. RESULTS: Seamen in the 1970 cohort, who had been exposed to cargo vapours for at least one month on chemical or product tankers, had an increased risk of lymphatic and haematopoietic malignancies (Mantel-Haenszel odds ratio (OR) 2.6, 95% confidence interval (95% CI) 1.1 to 5.9)) with a significant exposure-response relation (conditional logistic regression analysis, p = 0.04). The ORs were increased for both lymphoma (3.2), multiple myeloma (4.0), and leukaemia (1.6), but the increase was only significant for non-Hodgkin's lymphoma (OR 3.3, 95% CI 1.1 to 10.6). There were no significantly increased risks for the 1960 cohort or for seamen exposed only on crude oil tankers, but these groups had few exposed cases and low cumulative exposure to benzene and other light petroleum products. CONCLUSIONS: Seamen exposed to cargo vapours from gasoline and other light petroleum products on chemical or product tankers had an increased incidence of lymphatic and haematopoietic malignancies. One possible cause is exposure to benzene during loading, unloading, and tank cleaning operations.

The effects of political and economic transitions on health and safety in Estonia: an Estonian-Swedish comparative study.

A general and dramatic deterioration of health in Estonia during the transition period 1990-1994 was analysed using Sweden as a comparative example. Though there were diverging trends between Estonia and Sweden in the leading cause of death, cardiovascular diseases, the gap in mortality from injury had increased most rapidly. While the injury mortality rate slightly decreased in Sweden from 1990 to 1994, it almost doubled in Estonia. In 1994, the total injury death rate for men was about 6 times higher in Estonia than in Sweden. The death rates for some types of injuries, such as alcohol intoxication and homicide, were many tenfolds higher in Estonia than in Sweden. Injury contributed the most to the widening health gap between the countries, especially in males. The mechanisms of this sudden health deterioration remain to be fully explained. It could be hypothesised that behind the traditional behavioural risk factors, the influence of socio-political factors related to economic and political reconstruction is present. A widespread risk-taking and unhealthy behaviour among Estonians can likely be partly explained as a way of coping with the distress created by the new demands of transition society. An important challenge on the way to improvement is creating the political will among policy-makers to confront the tremendous problems of controlling the factors in society that affect the population's health in Estonia.

Asthma mortality and occupation in Sweden 1981-1992.

The objective of the present study was to investigate mortality attributable to asthma in different occupations. The mortality from asthma among Swedish workers between 1981 and 1992 was investigated by a linkage between official mortality statistics and the occupational information in the 1980 National Census. For each occupation, a smoking-adjusted standardized mortality ratio (SMR) was calculated. The information about smoking habits was obtained from smoking surveys carried out from 1977 to 1979. Only occupations with more than five cases were considered in the analysis. Significantly increased mortality from asthma was found among male farmers (smoking-adjusted SMR = 146; 95% confidence interval [CI] 105-187) and male professional drivers (smoking-adjusted SMR = 144, 95% CI = 101-209) and female hairdressers (smoking-adjusted SMR = 332, 95% CI = 102-525). The increased mortality among three occupational groups (hairdressers, farmers, and professional drivers) out of 46 groups analyzed may be random occurrences. However, farmers and hairdressers are exposed to agents causing asthma, indicating that the increased mortality may be attributable to occupational exposure.

Risk of cancer and exposure to gasoline vapors.

Until the introduction of self-service around 1970, service station workers in the Nordic countries were exposed to gasoline vapors. Based on measurements reported in the literature, the 8-hour time-weighted average benzene exposure was estimated to be in the range of 0.5-1 mg/m3. We studied the cancer incidence in a cohort of 19,000 service station workers from Denmark, Norway, Sweden, and Finland. They were identified from the 1970 censuses and followed through 20 years, where 1,300 incident cancers were observed. National incidence rates were used for comparison. The incidence was not increased for leukemia (observed = 28, standardized incidence ratio (SIR) = 0.9, 95% confidence interval (CI) 0.6-1.3) not for acute myeloid leukemia (observed = 13, SIR = 1.3, 95% CI 0.7-2.1). The incidence was slightly elevated for kidney cancer observed = 57, SIR = 1.3, 95% CI 1.0-1.7) and for pharyngeal, laryngeal, and lung cancer. A 3.5-fold risk of nasal cancer was found (observed = 12, SIR = 3.5, 95% CI 1.8-6.1). This cohort exposed to gasoline vapors with benzene levels estimated to be 0.5-1 mg/m3 showed no excess risk of leukemia or acute myeloid leukemia, a 30% elevated risk of kidney cancer, and a previously unnoticed risk of nasal cancer.

Physical disease among 21 suicide cases: interviews of relatives and friends.

In an earlier study made in Uppsala, it was found that in 17% of suicide cases there was a correlation between the suicidal act and serious physical disease. To obtain a deeper knowledge of this, an interview study among relatives and/or friends of 21 patients who had committed suicide was performed. Variables studied were: demographic data, somatic diagnoses, psychiatric diagnoses, contact with the medical sector, earlier suicidal signals, and the correlation between the suicidal act and the physical disease. The provision of inadequate medical treatment was sought. The persons who had committed suicide were allocated to one of three groups according to the degree of correlation between suicidal act and physical disease. "Very strong" correlation was found for five persons, "rather strong" for nine persons, and "weak" for five persons. We found that physical disease was seldom decisive for the suicidal act. Medical treatment was experienced as inadequate in nine cases. Since there is reason to believe that physical disease is an important complicating risk factor for suicide, it is important to be aware of anxiety in patients and their relatives, give plenty of time for information, show empathy and give the care-providers a sense of security to avoid suffering and reduce suicidal acts.

Work environment, skills utilization and health of Swedish nurses--results from a national questionnaire study.

Nurses make up a considerable proportion of the Swedish health care staff. Few nationally representative studies of their work environment and health, however, have been published. The present questionnaire study on work conditions, skill utilization, health and well-being of a national representative sample of 3,500 Swedish nurses, indicates a high degree of job satisfaction. Despite high satisfaction, 40% of the respondents felt too tired after work to socialize with family and 45% had seriously considered quitting their jobs. Factors such as improved work climate and development of supervisory skills were suggested as psychosocial interventions. Improvement in physical work environment factors had low priority. Medical care nurses perceive a higher work load and higher job demands in relation to decision latitude, and geriatric nurses report less work development. No differences between disciplines were found in work relations. In conclusion, there is a need to further develop skills development and utilization and work organization. Results will be used in interventions to enhance the work environment for nurses.

Are geographical differences in cardiovascular mortality due to morbidity differences or to methodological differences? The project "myocardial infarction in Mid-Sweden".

Geographical variations in cardiovascular mortality have been reported from Mid-Sweden. IHD mortality for men aged 45-64 was 60% higher in the western part than in the east. Mortality from stroke for men aged 45-74 was 73% higher on the west. Similar differences were found for women. One possible explanation could be that there are no incidence differences but that the mortality differences are due to different survival rates or to differences certifying the cause of death. These two possible explanations were tested in this study. Data for all patients hospitalised during the 10-year period 1972-1981 for myocardial infarction or stroke in a high mortality area, the County of Värmland in the west, and a low mortality area, the County of Uppsala in the east, were collected. In addition, a substudy was performed where the basis for the death certificate diagnosis was studied. The western area generally had a higher case fatality rate than the eastern. However, a larger proportion of the deaths the eastern area, occurred outside hospital, so that the net effect would be that the differences found were not large enough to explain the mortality differences. The autopsy rate in the western part was lower than in the east but since a larger proportion of the deaths occurred in hospital the rank order for IHD and stroke mortality between east and west was the same whether all IHD or stroke deaths were counted or only those considered the most well documented.

Occupation and smoking adjusted mortality due to asthma among Swedish men.

The study aims to survey the mortality from asthma in different occupations among Swedish men. The design was a register based cohort study where the smoking adjusted mortality due to asthma among Swedish men 1971-80 was investigated. For each occupation a smoking adjusted standardised mortality ratio (SMR) was calculated based on a linkage between official mortality statistics 1971-80 and occupational information in the 1970 national census. The information about the smoking habits among different occupations was obtained from a smoking survey carried out in 1963. In the statistical analysis only occupations with more than 10 deaths were considered. A significantly increased mortality from asthma was found among farmers (smoking adjusted SMR 137, 95% confidence interval (95% CI) 115-156), farm workers (smoking adjusted SMR 170, 95% CI 107-235), woodworking machine operators (smoking adjusted SMR 226, 95% CI 108-344), clerical workers (smoking adjusted SMR 161, 95% CI 102-220), packers and labellers (smoking adjusted SMR 144, 95% CI 100-188), and watchmen (smoking adjusted SMR 212, 95% CI 104-320). Exposure to organic dust, such as fresh wood dust and dusts in the farming environment, may cause increased mortality due to asthma.

Geographical variation of mortality from cardiovascular diseases. The Project 'Myocardial Infarction in mid-Sweden'.

In this study, the geographical variation of the mortality rate in mid-Sweden was studied. Data on mortality from all causes and mortality from cardiovascular diseases, cerebrovascular diseases, ischaemic heart disease (IHD) and non-cardiovascular diseases for men and women 45-74 years of age living in 76 communities in mid-Sweden were obtained from the National Bureau of Statistics. After age standardization, the rates for mortality from all causes and cardiovascular mortality were substantially higher in the Westernmost communities compared with those in the East, whereas for non-cardiovascular mortality there were no systematic differences. The county with the higher rate for IHD had a 60% higher rate for men aged 45-64 years and a 53% higher rate for women aged 45-64 years than the county with the lowest rate. The corresponding excess mortality rates from stroke were 73% for men aged 45-74 and 46% for women aged 45-74 years. The cause of this variation is not known. It is not due to the confounding effect of different age distributions in the communities, differences in the registration of causes of death, or differences in case fatality rate.

[Autopsies--necessary for medical services?]. / Obduktioner--nödvändiga för sjukvården?

The number of clinical autopsies has continuously declined in the last 20 years. The introduction of the new Swedish Autopsies Act is frequently mentioned as the principal reason for this development. This article presents an alternative explanatory model in which changes of attitudes within the medical services and the society appear as the major cause of the reduction in the number of autopsies. Some suggestions are offered with a view to breaking this trend.