Reduction In Case Fatality Research Articles

Is Metformin Use Associated with a More Favorable COVID-19 Course in People with Diabetes?

Background: Diabetes Mellitus (DM) has been associated with a higher Coronavirus disease-19 (COVID-19) mortality, both in hospitalized patients and in the general population. A possible beneficial effect of metformin on the prognosis of COVID-19 has been reported in some observational studies, whereas other studies disagree. Methods: To investigate the possible effect of metformin on COVID-19 in-hospital mortality, we performed a retrospective study that included all SARS-CoV-2-positive patients with DM who were admitted to two Italian hospitals. In order to adjust for possible confounders accounting for the observed reduction of mortality in metformin users, we adopted the COVID-19 Mortality Risk Score (COVID-19 MRS) as a covariate. Results: Out of the 524 included patients, 33.4% died. A binomial logistic regression showed that metformin use was associated with a significant reduction in case fatality (OR 0.67 [0.45-0.98], p = 0.039), with no significant effect on the need for ventilation (OR 0.75 [0.5-1.11], p = 0.146). After adjusting for COVID-19 MRS, metformin did not retain a significant association with in-hospital mortality [OR 0.795 (0.495-1.277), p = 0.342]. Conclusions: A beneficial effect of metformin on COVID-19 was not proven after adjusting for confounding factors. The use of validated tools to stratify the risk for COVID-19 severe disease and death, such as COVID-19 MRS, may be useful to better explore the potential association of medications and comorbidities with COVID-19 prognosis.

Outcomes of pediatric community-acquired pneumonia before and after national pneumococcal immunization in Taiwan.

In Taiwan, the incidence of invasive pneumococcal disease (IPD) in children declined after the catch-up primary vaccination programs and the full national immunization program (NIP) with PCV13. The objective of the study was to investigate the clinical outcomes of pediatric community-acquired pneumonia (CAP) before and after the NIP. The study included patients aged 3 months to 17 years who were diagnosed with CAP and treated at the National Taiwan University Hospital between 2007 and 2019. Patients were assigned to three birth cohorts according to their birth years and vaccination eligibility: non-NIP, catch-up, and full NIP. We compared the rates of severe outcomes, including case fatality and pathogens. A total of 6557 patients who met the CAP criteria were enrolled during the study period. The case-fatality rate decreased from 3.2% (94/2984) in the non-NIP cohort to 0.3% (7/2176) in the catch-up cohort and 0.8% (11/1397) in the full NIP cohort (p < 0.001). Furthermore, there was a significant decrease in invasive ventilation from the non-NIP (17.9%) to both catch-up (6.8%) and full NIP cohorts (9.1%). The rate of IPD declined from the non-NIP cohort to the catch-up cohort (1.8% vs. 0.6%, p < 0.001) and from the catch-up to the full NIP cohort (0.6% vs. 0.07%, p = 0.014). In contrast, the rates of infections with other pathogens increased after NIP. The introduction of PCV13 showed significant reduction in case-fatality and IPD rates. The increasing rates of other pathogens warrant further surveillance for their clinical significance.

Relative contribution of trends in myocardial infarction event rates and case fatality to declines in mortality: an international comparative study of 1·95 million events in 80·4 million people in four countries

Myocardial infarction mortality has declined since the 1970s, but contemporary drivers of this trend remain unexplained. The aim of this study was to compare the contribution of trends in event rates and case fatality to declines in myocardial infarction mortality in four high-income jurisdictions from 2002-15. Linked hospitalisation and mortality data were obtained from New South Wales (NSW), Australia; Ontario, Canada; New Zealand; and England, UK. People aged between 30 years and 105 years were included in the study. Age-adjusted trends in myocardial infarction event rates and case fatality were estimated from Poisson and binomial regression models, and their relative contribution to trends in myocardial infarction mortality calculated. 1 947 895 myocardial infarction events from a population of 80·4 million people were identified in people aged 30 years or older. There were significant declines in myocardial infarction mortality, event rates, and case fatality in all jurisdictions. Age-standardised myocardial infarction event rates were highest in New Zealand (men 893/100 000 person-years in 2002, 536/100 000 person-years in 2015; women 482/100 000 person-years in 2002, 271/100 000 person-years in 2015) and lowest in England (men 513/100 000 person-years in 2002, 382/100 000 person-years in 2015; women 238/100 000 person-years in 2002, 173/100 000 person-years in 2015). Annual age-adjusted reductions in event rates ranged from -2·6% (95% CI -3·0 to -2·3) in men in England to -4·3% (-4·4 to -4·1) in women in Ontario. Age-standardised case fatality was highest in England in 2002 (48%), but declined at a greater rate than in the other jurisdictions (men -4·1%/year, 95% CI -4·2 to -4·0%; women -4·4%/year, -4·5 to -4·3%). Declines in myocardial infarction mortality rates ranged from -6·1%/year to -7·6%/year. Event rate declines were the greater contributor to myocardial infarction mortality reductions in Ontario (69·4% for men and women), New Zealand (men 68·4%; women 67·5%), and NSW women (60·1%), whereas reductions in case fatality were the greater contributor in England (60% in men and women) and for NSW men (54%). There were greater contributions from case fatality than event rate reductions in people younger than 55 years in all jurisdictions, with contributions to mortality declines varying by country in those aged 55-74 years. Event rate declines had a greater impact than changes in case fatality in those aged 75 years and older. While the mortality burden of myocardial infarction has continued to fall across these four populations, the relative contribution of trends in myocardial infarction event rates and case fatality to declining mortality varied between jurisdictions, including by age and sex. Understanding the causes of this variation will enable optimisation of prevention and treatment efforts. National Health and Medical Research Council, Australia; Australian Research Council; Health Research Council of New Zealand; Canadian Institutes of Health Research, Canada; National Institute for Health Research, UK.

Impact of Vaccination on COVID-19 case fatality in the United Kingdom

We examined trends and differences in the number of COVID-19 cases and deaths and corresponding estimates of case fatality in the United Kingdom (UK) during the 20-month period, 3/1/2020-10/31/2021. Three distinct stages of the epidemic in the UK population of 68.4 million were noted corresponding to successive surges in the number of cases and deaths. For these three successive time periods, crude case fatality rates (case fatality = number of deaths / number of cases) fell dramatically: 12.4% during the early months of the epidemic, (335,210 cases and 41,564 deaths during 3/1-8/31/2020), 2.08% during the autumn, winter and spring months of 2020 and 2021 (4,148,076 cases and 86,254 deaths during 9/1/2020-5/31/2021), and 0.28% during the summer and autumn months of 2021 (4,573,571 cases and 12,814 deaths during 6/1-10/31, 2021). A high proportion (80-90%) of the UK population was vaccinated against SARS CoV-2 during the latter stage when the dominant infection was due to the Delta variant of SARS CoV-2. Results suggest that COVID-19 vaccines did not prevent viral transmission in the UK but were associated with a marked reduction in case fatality.

Relative Contribution of Trends in Myocardial Infarction Event Rates and Case Fatality to Declines in Mortality: An International Comparative Study of 1.95 Million Events in 80.4 Million People in Four Countries

Background: Myocardial infarction (MI) mortality has declined since the 1970s, but contemporary drivers of this trend remain unexplained. The aim was to compare the contribution of trends in event rates and case fatality to declines in MI mortality in four high-income jurisdictions from 2002-2015. Methods: Linked hospitalisation and mortality data were obtained from New South Wales (NSW), Ontario, New Zealand and England. Age-adjusted trends in MI event rates and case fatality were estimated from Poisson and binomial regression models, and their relative contribution to trends in MI mortality calculated. Findings: A total of 1,947,895 MI events were identified in ≥30 year olds. There were significant declines in MI mortality, event rates and case fatality in all jurisdictions. Age-standardised MI event rates were highest in New Zealand (men: 893/100,000 in 2002, 536/100,000 in 2015; women: 482/100,000 in 2002, 271/100,000 in 2015) and lowest in England (men: 513/100,000 in 2002, 382/100,000 in 2015; women: 238/100,000 in 2002, 173/100,000 in 2015). Annual age-adjusted reductions in event rates ranged from -2·6% (95% CI -2·7, -2·6) in men in England to -4·3% (95% CI -4·4, -4·1) in women in Ontario. Age-standardised case fatality was highest in England in 2002 (48%) but declined at a greater rate than in the other jurisdictions (men: -4·1%/year, (95% CI: -4·2, -4·0%); women: -4·4%/year, (95% CI: -4·5, -4·3%)). Declines in MI mortality rates ranged from -6.1%/year to -7.6%/year. Event rate declines were the greater contributor to MI mortality reductions in Ontario (69·4%), New Zealand (men 68·4%; women 67·5%) and NSW women (60·1%), while reductions in case fatality were the greater contributor in England (60% in men and women). There were greater contributions from case fatality reductions in younger age groups and event rate declines in older age groups. Interpretation: The contribution of trends in MI event rates and case fatality varied between jurisdictions, including by age and sex. Understanding the causes of this variation will enable optimisation of prevention and treatment efforts. Funding Information: NHMRC (Australia); Health Research Council New Zealand; Canadian Institutes for Health Research; National Institute for Health Research, Oxford. Declaration of Interests: None to declare. Ethics Approval Statement: This study was approved by the University of Toronto Health Sciences Research Ethics Board, NSW Population & Health Services Research Ethics Committee (reference 2016/09/654), the New Zealand Health and Disability Ethics Committees (reference number H13/049) and the Central and South Bristol Multi-Centre Research Ethics Committee (04/Q2006/176).

Modeling Mitigation Strategies to Reduce Opioid-Related Morbidity and Mortality in the US

The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it. To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden. A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029. The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo. Projected 10-year overdose deaths and prevalence of OUD. Under status quo, 484 429 (95% confidence band, 390 543-576 631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179 151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose. The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background:Sierra Leone was severely affected by the 2014/2015 Ebola outbreak which is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods:This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,250 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results:Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period. During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period ( P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions:Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background: Sierra Leone was severely affected by the 2014/2015 Ebola outbreak which is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods: This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,250 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results: Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period. During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period ( P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions: Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

The Rise of Colorectal Cancer in Asia: Epidemiology, Screening, and Management.

Colorectal cancer (CRC) remains the third most commonly diagnosed cancer globally, and its incidence and mortality rates have been on the rise in Asia. In this paper, we summarize the recent trends and screening challenges of CRC in this region. In 2018, Asia had the highest proportions of both incident (51.8%) and mortality (52.4%) CRC cases (all genders and ages) per 100,000 population in the world. In addition, there has been a rising trend of this disease across Asia with some regional geographic variations. This rise in CRC can be attributed to westernized dietary lifestyle, increasing population aging, smoking, physical inactivity, and other risk factors. In curbing the rising trend, Japan, South Korea, Singapore, and Taiwan have launched nationwide population-based screening programs. CRC screening across this region has been found to be effective and cost-effective compared with no screening at all. The emergence of new therapies has caused a reduction in case fatality; however, these new options have had a limited impact on cure rates and long-term survival due to the great disparity in treatment capacity/resources and screening infrastructures among Asian countries with different degrees of economic development. CRC is still rising in Asia, and implementation of screening is necessary for moderate- to high-incidence countries and construction of treatment capacity is the priority task in low-incidence and low-income countries. Unless countries in Asia implement CRC screening, the incidence and mortality rates of this disease will continue to rise especially with the rapidly rising population growth, economic development, westernized lifestyle, and increasing aging.

Paediatric morbidity and mortality in Sierra Leone. Have things changed after the 2014/2015 Ebola outbreak?

Background:Sierra Leone was severely affected by the 2014/2015 Ebola outbreak and is likely to have had longer term repercussions on the health system including on paediatric morbidity and mortality. We thus assessed under-five morbidity and mortality for malaria, acute respiratory Infections (ARI)/pneumonia, watery diarrhoea and measles during the post-Ebola period in Sierra Leone and compared this with the pre- and intra-Ebola periods. Methods:This was a retrospective cross-sectional study using program data from the District Health Information system (DHIS2) and sourced from 14 districts in Sierra Leone. It included under-five children from 1,200 health facilities country-wide. Study periods included: before (June 1 st, 2013-April 30 th, 2014); during (June 1 st, 2014-April 30 th, 2015); and after Ebola (June 1 st, 2016-April 30 th, 2017). Results:Malaria, ARI/pneumonia and diarrhoea consultations declined during Ebola but recovered to pre-Ebola levels in the post-Ebola period. During the post-Ebola period, there was a highly significant reduction in case-fatality for the first three morbidities compared to the pre-Ebola period (P<0.0001). Average number of measles cases increased from 48/month in the pre-Ebola period to 568/month (12-fold increase) post-Ebola. Although there was no difference in measles case-fatality between the pre- and post-Ebola periods, case-fatality post-Ebola was significantly lower than during Ebola (Relative Risk: 0.05, 95% confidence interval 0.02-0.15, P<0.0001). Conclusions:Consultations for under-five children at health facilities in Sierra Leone recovered to pre-Ebola levels and case-fatality for common childhood illnesses declined significantly. This is a change for the better. However, the high level of reported measles cases in the post-Ebola period indicates gaps in immune status and needs focused attention.

Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults

ObjectivesTo study trends in stroke mortality rates, event rates, and case fatality, and to explain the extent to which the reduction in stroke mortality rates was influenced by changes in...

Estimating Case-Fatality Reduction from Randomized Screening Trials

Abstract In randomized cancer screening trials where asymptomatic individuals are assigned to undergo a regimen of screening examinations or standard care, the primary objective typically is to estimate the effect of screening assignment on cancer-specific mortality by carrying out an ’intention-to-screen’ analysis. However, most of the participants in the trial will be cancer-free; only those developing a genuine cancer that is screening-detectable can potentially benefit from screening induced early treatments. Here we consider measuring the effect of early treatments in this partially latent subpopulation in terms of reduction in case fatality. To formalize the estimands and identifying assumptions in a causal modeling framework, we first define two measures, namely proportional and absolute case-fatality reduction, using potential outcomes notation. We re-derive an earlier proposed estimator for the former, and propose a new estimator for the latter motivated by the instrumental variable approach. The methods are illustrated using data from the US National Lung Screening Trial, with specific attention to estimation in the presence of censoring and competing risks.

Neuroinflammation as a Target for Intervention in Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage (SAH) is a sub-type of hemorrhagic stroke associated with the highest rates of mortality and long-term neurological disabilities. Despite the improvement in the management of SAH patients and the reduction in case fatality in the last decades, disability and mortality remain high in this population. Brain injury can occur immediately and in the first days after SAH. This early brain injury can be due to physical effects on the brain such as increased intracranial pressure, herniations, intracerebral, intraventricular hemorrhage, and hydrocephalus. After the first 3 days, angiographic cerebral vasospasm (ACV) is a common neurological complication that in severe cases can lead to delayed cerebral ischemia and cerebral infarction. Consequently, the prevention and treatment of ACV continue to be a major goal. However, most treatments for ACV are vasodilators since ACV is due to arterial vasoconstriction. Other targets also have included those directed at the underlying biochemical mechanisms of brain injury such as inflammation and either independently or as a consequence, cerebral microthrombosis, cortical spreading ischemia, blood–brain barrier breakdown, and cerebral ischemia. Unfortunately, no pharmacologic treatment directed at these processes has yet shown efficacy in SAH. Enteral nimodipine and the endovascular treatment of the culprit aneurysm, remain the only treatment options supported by evidence from randomized clinical trials to improve patients’ outcome. Currently, there is no intervention directly developed and approved to target neuroinflammation after SAH. The goal of this review is to provide an overview on anti-inflammatory drugs tested after aneurysmal SAH.

Segmented regression analysis of emergency departments patient visits from Septicemia in Taiwan

BackgroundThe protocol for early goal-directed therapy (EGDT) is effective for improving both the costs and outcomes of septicemia treatment, including a significant reduction in case fatality. However, this complicated protocol may have a downside. Furthermore, the Joint Taiwan Critical Care Medicine Committee has launched a nationwide educational program after the publication of the Surviving Sepsis Campaign (SSC) to improve the overall survival rate from septicemia in the emergency care system of Taiwan. ObjectivesTo assess the impact of the EGDT protocol and SSC education programs on island-wide septicemia-related emergency department (ED) visits. MethodsSegmented regression techniques were utilized to assess the differences in annual rates and changes in septicemia-related ED visits between 1998 and 2012. We considered annual incidence of two medical comorbidities as potential confounders: metastatic malignant neoplasms and malignant neoplasms of the lymphatic and hematopoietic tissues. ResultsThe EGDT protocol was associated with decreased septicemia-related ED visits in 2002 (level change; p < 0.001), while the SSC education program led to a slight increase in septicemia-related ED visits in 2007 (slope change; p < 0.001). For the EGDT protocol, the number of patient visits decreased by 32.9% after the protocol was implemented in 2002 compared with the expected number without the intervention. For the SSC education program, the number of patient visits increased by 20.2% (compared with the predicted number) in 2007 after the education program was implemented. ConclusionsThe EGDT protocol and SSC education program were associated with significant immediate changes and lagged intervention effects on island-wide septicemia-related ED visits.

Preventing deaths from pesticide self-poisoning-learning from Sri Lanka's success.

Preventing deaths from pesticide self-poisoning-learning from Sri Lanka's success.

The Tromsø study 1974–2016: 40 years of cardiovascular research

The rapid increase of coronary heart disease mortality in Northern Norway during 1951–1970 was why the newly established University of Tromsø decided to start a study to identify major operating cardiovascular risk factors. The first Tromsø survey in 1974 suggested that the relatively high cardiovascular mortality was associated with elevated cholesterol levels and high prevalence of smoking, while high-density-lipoprotein-cholesterol (HDL-C) was identified as a preventive factor. After 1974, six more surveys including both genders (aged 20–89 years) were undertaken. The second survey (1979) revealed the cholesterol increasing effect of coffee. Echocardiographic examinations, ECG, and ultrasound of carotid arteries were introduced in later surveys, and intervention studies were established. Repeated carotid measurements showed that inflammation was involved in novel plaque formation, while HDL-C was protective. Moderate physical activity protected against atrial fibrillation but hard exercise increased the risk. Obesity, hypertension and smoking increased the risk of aortic stenosis, and diastolic dysfunction predicted development of atrial fibrillation. Dilated left atria predicted stroke, especially for individuals without known atrial fibrillation. Total cholesterol, blood pressure and smoking declined after 1974, corresponding to the subsequent decline in coronary heart disease mortality. Reduced incidence accounted for 40% of the mortality decline, while a substantial reduction in case fatality explained the remaining 60%.

Cervical cytology and the diagnosis of cervical cancer in older women.

ObjectivesMost non-screen-detected cervical cancers are advanced stage. We assess the potential for cytology to expedite diagnosis when used outside of routine call and recall screening for cervical cancer.MethodsTwo cohorts of women with cytology that did not appear to have been taken as part of routine screening, nested within a census of cervical cytology, in England between April 2007 and March 2010 were studied: 93,322 women aged 40–69 at first cytology, and 14,668 women aged ≥70. The diagnostic performance of high grade cervical squamous intraepithelial lesion (HSIL) or worse cytology was estimated. We also estimated case-fatality from stage distribution in women aged ≥66 with and without cytology in the year prior to diagnosis.ResultsThere were 259 cancers diagnosed in women aged 40–69 at first cytology, and 78 in women aged ≥70. The sensitivity of cytology ≥ HSIL for cancer was 89% and 83% respectively, and the number of women needed to test to identify one cancer was 404 (95% confidence interval [CI]: 355–462) and 226 (95% CI: 177–292) respectively. Women aged ≥66 with cytology within a year of diagnosis had earlier stage cancers than those without, corresponding to a 17–22% reduction in case fatality.ConclusionsCervical cytology is an excellent identifier of cancer among women tested outside routine screening call and recall. Its use as a triage tool, for instance in women with vague gynaecological symptoms, could facilitate earlier stage diagnosis and reduce cervical cancer mortality.

Recognizing true H5N1 infections in humans during confirmed outbreaks

The goal of this study was to evaluate whether any characteristics that are evident at presentation for urgent medical attention could be used to differentiate cases of H5N1 in the absence of viral testing. Information about exposure to poultry, clinical signs and symptoms, treatments, and outcomes was abstracted from existing data in the global avian influenza registry (www.avianfluregistry.org) using standardized data collection tools for documented and possible cases of H5N1 infection who presented for medical attention between 2005-2011 during known H5N1 outbreaks in Azerbaijan, Indonesia, Pakistan and Turkey. Demography, exposure to poultry, and presenting symptoms were compared, with only the common symptoms of fever and headache presenting significantly more frequently in confirmed H5N1 cases than in possible cases. Reported exposure to infected humans was also more common in confirmed cases. In contrast, unexplained respiratory illness, sore throat, excess sputum production, and rhinorrhea were more frequent in possible cases. Overall, oseltamivir treatment showed a survival benefit, with the greatest benefit shown in H5N1 cases who were treated within two days of symptom onset (51% reduction in case fatality). Since prompt treatment with antivirals conferred a strong survival benefit for H5N1 cases, presumptive antiviral treatment should be considered for all possible cases presenting during an outbreak of H5N1 as a potentially life-saving measure.

Heart failure in young adults: 20-year trends in hospitalization, aetiology, and case fatality in Sweden

AimsTo describe trends in incidence and case fatality among younger (18–54 years) and older (55–84 years) Swedish patients with heart failure (HF).Methods and resultsThrough linking the Swedish national hospital discharge and the cause-specific death registries, we identified patients aged 18–84 years that were discharged 1987–2006 with a diagnosis of HF. Age-specific mean incidence rates per 100 000 person-years were calculated in four 5-year periods. Kaplan–Meier survival curves were plotted up to 3 years. From 1987 to 2006, there were 443 995 HF hospitalizations among adults 18–84 years. Of these, 4660 (1.0%) and 13 507 (3.0%) occurred in people aged 18–44 and 45–54 years (31.6% women), respectively. From the first to the last 5-year period, HF incidence increased by 50 and 43%, among people aged 18–34 and 35–44 years, respectively. Among people ≥45 years, incidence peaked in the mid-1990s and then decreased. Heart failure in the presence of cardiomyopathy increased more than two-fold among all age groups. Case fatality decreased for all age groups until 2001, after which no further significant decrease <55 years was observed.ConclusionIncreasing HF hospitalization in young adults in Sweden opposes the general trend seen in older patients, a finding which may reflect true epidemiological changes. Cardiomyopathy accounted for a substantial part of this increase. High case fatality and lack of further case fatality reduction after 2001 are causes for concern.

Effects of a provincial ban of two toxic organophosphorus insecticides on pesticide poisoning hospital admissions

Background. Pesticide self-poisoning causes one third of global suicides. Sri Lanka halved its suicide rate by banning WHO Class I organophosphorus (OP) insecticides and then endosulfan. However, poisoning with Class II toxicity OPs, particularly dimethoate and fenthion, remains a problem. We aimed to determine the effect and feasibility of a ban of the two insecticides in one Sri Lankan district. Methods. Sale was banned in June 2003 in most of Polonnaruwa District, but not Anuradhapura District. Admissions with pesticide poisoning to the district general hospitals was prospectively recorded from 2002. Results. Hospital admissions for dimethoate and fenthion poisoning fell by 43% after the ban in Polonnaruwa, while increasing by 23% in Anuradhapura. The pesticide case fatality fell from 14.4% to 9.0% in Polonnaruwa (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.41–0.84) and 11.3% to 10.6% in Anuradhapura (OR 0.93, 95%CI 0.70–1.25; p = 0.051). This reduction was not sustained, with case fatality in Polonnaruwa rising to 12.1% in 2006–2007. Further data analysis indicated that the fall in case fatality had actually been due to a coincidental reduction in case fatality for pesticide poisoning overall, in particular for paraquat poisoning. Conclusions. We found that the insecticides could be effectively banned from agricultural practice, as shown by the fall in hospital admissions, with few negative consequences. However, the ban had only a minor effect on pesticide poisoning deaths because it was too narrow. A study assessing the agricultural and health effects of a more comprehensive ban of highly toxic pesticides is necessary to determine the balance between increased costs of agriculture and reduced health care costs and fewer deaths.