Regional Variation In Incidence Research Articles

Regional variation in incidence and prognosis of acute kidney injury.

Examining regional variation in acute kidney injury (AKI) and associated outcomes may reveal inequalities and possibilities for optimization of the quality of care. Using the Danish medical databases, we examined regional variation in the incidence, follow-up, and prognosis of AKI in Denmark. Patients with one or more AKI episodes in 2017 were identified using population-based creatinine measurements covering all Danish residents. Crude and sex-and-age-standardized incidence rates of AKI were estimated using census statistics for each municipality. Adjusted hazard ratios (aHR) of chronic kidney disease (CKD), all-cause death, biochemical follow-up, and outpatient contact with a nephrology department after AKI were estimated across geographical regions and categories of municipalities, accounting for differences in demographics, comorbidities, medication use, lifestyle and social factors, and baseline kidney function. We identified 63382 AKI episodes in 58356 adults in 2017. The regional standardized AKI incidence rates ranged from 12.9 to 14.9 per 1000 person-years. Compared with the Capital Region of Denmark, the aHRs across regions ranged from 1.04 to 1.25 for CKD, from 0.97 to 1.04 for all-cause death, from 1.09 to 1.15 for biochemical follow-up, and from 1.08 to 1.49 for outpatient contact with a nephrology department after AKI. Similar variations were found across municipality categories. Within the uniform Danish healthcare system, we found modest regional variation in AKI incidence. The mortality after AKI was similar; however, CKD, biochemical follow-up, and nephrology follow-up after AKI varied across regions and municipality categories.

Abstract 12799: Geographic Variation in Cardiac Amyloidosis in U.S. Veterans From 2012 to 2021

Background: Prior studies suggest variability in cardiac amyloidosis (CA) detection across the U.S. with underdiagnosis in some regions. Research Question: It is unknown whether geographic variation exists in the occurrence of CA amongst U.S. Veterans in a contemporary cohort. Method: This is a retrospective observational cohort study. CA was defined as ≥ 1 heart failure (ICD9/10) and ≥ 1 amyloidosis diagnosis. For geographic mapping the location was the state of the diagnosing Veterans Affairs (VA) facility. The population at risk was patients in each state with ≥1 VA encounter during the year. The outcomes were incidence and prevalence rates of CA at the state and U.S. Census regional level (per 100,000 patients). The data source was the VA Corporate Data Warehouse (MDClone ADAMS platform). Results: The incidence and prevalence rates of CA by region are shown in the Table, and by state in the Figure. There was an increase in incidence and prevalence in all regions in 2012 and 2021. In both years, incidence and prevalence were highest in the Northeast and lowest in the South. Conclusion: Despite increasing recognition of CA in the VA Health System, there is regional variation in incidence and prevalence in 2012 and 2021. VA facilities in the Midwest, West and especially the South may have differences in CA detection relative to those in the Northeast region. Further research into health system, provider, and patient factors leading to this variation is needed to ensure health equity and quality of care for patients with CA.

Hydatidiform Mole Types and Age Demographics in Sindh Province, Pakistan

Hydatidiform mole can be classified as partial and complete depending on the clinical and histopathological features. There is regional variation in incidence of hydatidiform mole with more cases seen in Asia, Africa and other developing countries. This cross-sectional descriptive study was done at the department of histopathology in Diagnostic and research laboratory Hyderabad Sindh. A total of 261 cases were added in the study including 251 cases of suction and evacuation and 10 cases of hysterectomy. The mean age was 27.16±6.66 with age range of 17-60 years. In our study out of 260 samples, 155(59.6%) were of complete mole while 105(40.4%) were of partial mole. The incidence of mole was highest in the age group 26-30 years. The prevalence of hydatidiform mole was notably higher in comparison to numerous other studies. In conclusion, it is recommended that all abortion specimens undergo evaluation to prevent misdiagnosis of gestational trophoblastic disease and to ensure appropriate treatment and follow-up, thereby minimizing the risk of complications. Keywords: Hydatidiform mole. Complete mole. Partial mole. Molar pregnancy.

Regional variation in the incidence of pseudo-exfoliation in the Andhra Pradesh Eye Disease Study (APEDS).

To report the 15-year incidence rate of pseudo-exfoliation (PXF), PXF glaucoma and regional variation among rural participants in the Andhra Pradesh Eye Disease Study (APEDS) III. This population-based longitudinal study was carried out at three rural study sites. Individuals of all ages who participated at baseline with amean 15-year follow-up visit were included. DetailedComprehensiveophthalmic examination was performed on all participants. The main outcome measure was development of PXF during the follow-up period in participants who were phakic in one or both eyeswithout PXF at baseline. Among 5395 participants, 5108 (94.6%) met the inclusion criteria. There were 93 (1.82%; 95% confidence interval (CI), 1.47-2.22) cases of incident PXF. Their median baseline age (1st, 3rd quartiles) was 51 (44, 59) years and the male: female ratio was 1.3:1. There was no case of incident PXF in participants aged <30 years at baseline. The incidence rate per 100 person years (95% CI) among all ages and those aged ≥30 years at baseline was 1.73 (1.64-1.82) and 3.73 (3.53-3.93), respectively. PXF material was located on iris as well as anterior surface of lens and itwas often bilateral. Participants living in two study sites and increasing age were associated with the incidence of PXF. The 15-year incidence of PXF glaucoma (95% CI) in participants ≥30 years of age at baseline was 0.33% (0.14-0.66). There is significant regional variation in incidence of PXF in south India which warrants further investigation.

Regional and hospital variation in commonly performed paediatric otolaryngology procedures in the Netherlands: a population-based study of healthcare utilisation between 2016 and 2019

ObjectiveIn the past few decades, there has been an increase in high-quality studies providing evidence on the effectiveness of commonly performed procedures in paediatric otolaryngology. We believe that now is...

Uncertainty in classification of death from fatal myocardial infarction: A nationwide analysis of regional variation in incidence and diagnostic support.

AimsThe usefulness of mortality statistics relies on the validity of death certificate diagnosis. However, diagnosing the causal sequence of conditions leading to death is not simple. We examined diagnostic support for fatal acute myocardial infarction (AMI) and investigated its association with regional variation.Methods and resultsFrom Danish nationwide registers, we identified the study population (N = 3,244,051) of whom 36,669 individuals were recorded with AMI as the underlying cause-of-death between 2002 and 2015. We included clinical diagnoses, procedures, and claimed prescriptions related to atherosclerotic disease to evaluate the level of diagnostic support for fatal AMI in three diagnostic groups (Definite; Plausible; Uncertain). Adjusted mortality rates, rate ratios, and odds ratios were estimated for each AMI category, stratified by hospital region using multivariable regression models. More than one-third (N = 12,827, 35%) of deaths reported as fatal AMI had uncertain diagnostic support. The largest regional variation in AMI mortality rate ratios, varying from 1.16 (95%CI:1.02;1.31) to 1.62 (95%CI:1.43;1.83), was found among cases with uncertain diagnostic supportive data. Substantial inter-regional differences in the degree to which death occurs outside hospital [OR: 1.01 (95%CI:0.92;1.12) - 1.49 (95%CI:1.36;1.63)] and general practitioners determining the cause-of-death at home were present. Minor regional differences [OR: 0.96 (95%CI:0.85;1.07) - 1.16 (95%CI:1.04;1.29)] in in-hospital AMI mortality were observed.ConclusionThere is significant regional variation associated with recording AMI as a cause-of-death. This variation is predominately based on death certificate diagnoses without diagnostic supportive evidence. Studies of fatal AMI should include a stratification on supportive evidence of the diagnosis.

Patterns of Presentation, Treatment, and Survival Rates of Gallbladder Cancer: a Prospective Study at a Tertiary Care Centre.

India has high incidence of gallbladder carcinoma with regional variation in incidence, the highest in Northern India. This study examines the patterns of presentation, treatment strategies, and survival rate of all patients with gallbladder cancer (GBC) evaluated at our tertiary academic hospital over a period of 2years. All patients presented to our institute with established tissue diagnosis of carcinoma gallbladder were accrued in our study over a time period of 2years. Presentation, treatment modalities, and survival rates were analyzed. One hundred six patients were included: 80 females and 26 males (F: M=3:1). Median age was 60years. Eighty patients (75%) had gallstones and 20 patients (21%) had typical history of chronic cholecystitis. The common symptom and sign at presentation were pain in the right upper abdomen (81%) and lump abdomen (49%), respectively. Overall resectability rate was 19.8% (21/106). Eighty-five patients were unresectable or metastatic and treated with palliative intent. Stagewise distribution at diagnosis was stage I (0%), stage II (4%), stage IIIA (10%), stage IIIB (8%), stage IVA (17%), and stage IVB (61%). Estimated 1-year survival for stages II, IIIA, IIIB, IVA, and IVB was 100, 76, 47.4, 26, and 10.6%, respectively. Significant difference in OS was observed among different stages of GBC (p value <0.001). If proper investigations are done, radical surgery including multi-organ resection can be curative with acceptable morbidity and mortality. Stage at presentation and ability to perform curative resection are the most important prognostic factors predicting survival. Palliative chemotherapy should be considered for metastatic GBC.

Demographic profile and pattern of fatal injuries in Nairobi, Kenya, January\u2013June 2014

BackgroundViolence and Injuries are a significant global public health concern characterized by marked regional variation in incidence. Approximately five million people die from injuries each year, accounting 9% of all deaths worldwide. In Kenya, injuries are increasingly becoming a cause of hospital admissions and mortality where they account for 10% of all the deaths. The objective of this study was to determine the magnitude, demographic profile and pattern of fatal injuries in Nairobi.MethodsRetrospective review of death certificates from the Department of Civil Registration was done for deaths caused by injuries that occurred in Nairobi during the period, January to June 2014. Data was collected using a standardized form. Data entry, cleaning and analysis was done using Epi info version 7.0.ResultsA total of 11,443 records were reviewed. From this data, deaths resulting from injuries were 1,208 accounting for 10.6% of all recorded deaths. Majority of the deaths resulting from injuries occurred in persons aged 25 to 44 years (48.1%). Males accounted for 85% of all the injuries. The leading cause of injury was assault by blunt force at 30.5%, followed by road traffic injuries at 25.9% and fire arm injuries at 15%. Pre-hospital deaths accounted for 51.4% of all the deaths. Nineteen percent of the deaths resulting from injuries had autopsies performed on them.ConclusionOur study found that injuries are an important cause of fatality in Nairobi, accounting for one in ten deaths. There is need for multisectoral collaboration as some of the preventive measures that target the most prevalent injuries such as assault and road traffic injuries lie outside the health sector. There exists information gaps on the death certificates hence there is need to adequately capacity build both clinicians and death certifiers. There is also a need to revise the death certificates and to improve the pre-hospital care system for the injured persons.

Regional incidence and outcome of out-of-hospital cardiac arrest associated with overdose

BackgroundThe frequency of lethal overdose due to prescription and non-prescription drugs is increasing in North America. The aim of this study was to estimate overall and regional variation in incidence and outcomes of out-of-hospital cardiac arrest due to overdose across North America. MethodsWe conducted a retrospective cohort study using case data for the period 2006–2010 from the Resuscitation Outcomes Consortium, a clinical research network with 10 regional clinical centers in United States and Canada. Cases of out-of-hospital cardiac arrest due to drug overdose were identified through review of data derived from prehospital clinical records. We calculated incidence of out-of-hospital cardiac arrest due to overdose per 100,000 person-years and proportion of the same among all out-of-hospital cardiac arrests. We analyzed the association between overdose cardiac arrest etiology and resuscitation outcomes. ResultsIncluded were 56,272 cases, of which 1351 were due to overdose. Regional incidence of out-of-hospital cardiac arrest due to overdose varied between 0.5 and 2.7 per 100,000 person years (p<0.001), and proportion of the same among all treated out-of-hospital cardiac arrests ranged from 0.8% to 4.0%. Overdose cases were younger, less likely to be witnessed, and less likely to present with a shockable rhythm. Compared to non-overdose, overdose was directly associated with return of spontaneous circulation (OR: 1.55; 95% CI: 1.35–1.78) and survival (OR: 2.14; 95% CI: 1.72–2.65). ConclusionsOverdose made up 2.4% of all out-of-hospital cardiac arrest, although incidence varied up to 5-fold across regions. Overdose cases were more likely to survive than non-overdose cases.

Abstract 236: Regional Incidence and Outcome of Out-of-Hospital Cardiac Arrest Associated with Overdose

Introduction: The frequency of lethal overdose due to prescription and non-prescription drugs is increasing in North America. The contribution of drug overdose (OD) to regional variation in the incidence and outcome out-of-hospital cardiac arrest (OHCA) is unclear. Objective: To estimate overall and regional variation in incidence and outcomes of emergency medical services (EMS)-treated OD-OHCA cases across North America. Methods: The Resuscitation Outcomes Consortium (ROC) is a clinical research network with 10 regional clinical centers in United States (US) and Canada that uses uniform methods for surveillance of all EMS-treated OHCA in participating regions. Cases of OHCA from 2006 to 2010 were reviewed for evidence of association with or without OD. Incidence of OD-OHCA was calculated as the number of OD-OHCA in a region per 100,000 cumulative person-years, using 2000 US Census and 2006 Statistics Canada population counts. Patient and EMS characteristics as well as outcome were described. Multiple logistic regression was used to describe the association between OD status on return of spontaneous circulation (ROSC) and survival to hospital discharge, while adjusting for case characteristics and consortium center. Results: Included were 56,272 cases of OHCA. Regional incidence of OD-OHCA varied between 0.5 and 2.7 per 100,000 person years (p&lt;0.001), and proportion of OD-OHCA among all EMS-treated OHCA ranged from 0.9% to 3.8%. Table 1 shows outcomes and characteristics stratified by OD status; OD-OHCA were younger, less likely to be witnessed, and less likely to present with a shockable rhythm. Compared to non-OD, OD-OHCA was associated with ROSC (OR: 1.55; 95%CI: 1.35-1.78) and survival (OR: 2.14; 95%CI: 1.72-2.65). Conclusions: OD-OHCA are a small proportion of all OHCA, although incidence varied up to 5-fold across regions. OD-OHCA were more likely to survive than non-OD-OHCA.

Breast cancer in Wales: time trends and geographical distribution.

Breast cancer is the second commonest malignancy in the world. In 2012, approximately 522,000 women died of breast cancer across the world. The aim of this study is to provide an up-to-date analysis of time trends in incidence, geographical distribution, survival and mortality from breast cancer in Wales. Breast cancer cases registered between 1985 and 2012 were identified from the Welsh Cancer Intelligence and Surveillance Unit (WCISU). A Poisson regression model was fitted to assess temporal trends and rate ratios (RR) and 95% confidence intervals (CI) were determined and compared in relation to age, geographical distribution and mortality across time periods. A total of 60,227 women diagnosed with breast cancer were registered with the Welsh cancer registry between 1985 and 2012. The age-standardised incidence rate of breast cancer was 113.4 per 100,000 populations over the entire study period. There has been a significant increase in the incidence of breast cancer over the study period, although a slight decline was recorded towards the end of the study. There is a considerable regional variation in incidence, with a higher incidence rate in the rural areas compared to urban areas (P<0.001). One- and five-year relative survival improved from 83.3 and 64.2 respectively in 1985-1989 to 91.1 and 78.8 respectively in 2000-2004. There has also been a considerable improvement in relative survival across all age groups. Mortality has improved over the study period with the most dramatic decline in the age groups 45-54 and 55-64 years (P<0.001). There has been a significant increase in the incidence of breast cancer in Wales over the last three decades, which is likely to be partly due to the introduction of the National Health Service Breast Screening Programme. Breast cancer incidence is higher in rural areas than urban areas and lower incidence was seen in more deprived areas. There was a considerable decline in mortality rate across almost all age groups, especially in recent years. However, women over the age of 65 years had poorer outcome throughout the study period.

Regional variation in incidence for smoking and alcohol related cancers in Belgium

The prevalence of life habits may vary substantially within a country. Incidence maps of strongly related diseases can illustrate the distribution of these life style habits. In this study we explored the spatial variation in Belgium for different cancers related to alcohol and/or tobacco.From the Belgian Cancer Registry, municipality specific World Standardised incidence rates for the years 2004–2011 are used to create detailed smoothed cancer maps by subsite or histology for cancers of oral cavity, pharynx, larynx, oesophagus, liver and lung. Cancer incidence is compared both visually (from incidence maps) and with Poisson regression analysis using mortality from chronic liver disease and chronic obstructive pulmonary disease as a proxy for alcohol and tobacco prevalence, respectively.The incidence rates for oral cavity, pharyngeal and laryngeal cancer were comparable with the alcohol gradient. However, glottic cancer revealed a pattern that was more comparable with lung cancer. These two tumour types resembled more closely to the smoking pattern. Oesophageal cancer showed two patterns: squamous cell carcinoma was highly comparable with the background alcohol consumption, while adenocarcinoma was unrelated to one of our two proxies.Our approach and results are an encouraging example how data from a young cancer registry can be used in studies describing the regional cancer burden. The results can be useful for primary prevention to increase awareness for the public, authorities and health care professionals in specific subpopulations.

Clinical epidemiology of epithelial ovarian cancer in the UK.

Epithelial ovarian cancer is the fifth commonest cancer among women and the leading cause of gynecological cancer death in the UK. Most women present with advanced disease, mainly because the nonspecific nature of the symptoms lead to diagnostic delays. Recent data have shown a fall in ovarian cancer mortality rates in the UK, but rates are still higher when compared to other European countries or the USA. In addition, surgeons in the UK achieve on average lower optimal surgical cytoreduction rates in patients with advanced ovarian cancer. Despite a wealth of information on epidemiological risk factors, the pathogenesis of epithelial ovarian cancer remains largely unknown. This review presents the most recent data on incidence, mortality, and survival for epithelial ovarian cancer in the UK. Time trends, trends by age, international comparisons, and regional variation in incidence, survival, and mortality are presented within the context of a major reorganization of cancer services that took place in the UK over 10 years ago. Centralization of cancer services has meant that women with ovarian cancer receive treatment in specialist Cancer Centers.

Incidence of type 1 diabetes in Norway among children aged 0–14 years between 1989 and 2012: has the incidence stopped rising? Results from the Norwegian Childhood Diabetes Registry

Our study aimed to describe the incidence of type 1 diabetes in children below 15 years of age in Norway during the period 1989-2012 and to assess the regional variation during 2004-2012. We further set out to estimate the completeness of ascertainment in the Norwegian Childhood Diabetes Registry (NCDR). Incident cases of type 1 diabetes were registered in the NCDR and incidence rates were modelled using Poisson regression. Ascertainment for 2005-2008 was estimated using capture-recapture methodology by using data from the Norwegian Prescription Database (NorPD), a nationwide register established in 2004, which included insulin prescribed and dispensed at pharmacies to individual patients. Population data were obtained from Statistics Norway. Observed incidence rates for 1989-2012 suggested three distinct time segments: in 1989-1996, the average incidence rate was 22.6 per 100,000 person-years (95% CI 21.4, 23.7); in 1996-2004, the average incidence rate was 28.4 per 100,000 person-years (95% CI 27.3, 29.6); and from 2004 to 2012, the average incidence rate per 100,000 person-years was 32.7 (95% CI 31.5, 34.0). After adjustment for age and sex, the estimated change per year was 1.8% for 1989-1996 (95% CI -0.07, 3.6; p = 0.059), 3.4% for 1996-2004 (95% CI 2.2, 4.7; p < 0.0001) and 0.3% for 2004-2012 (95% CI -0.9, 1.6; p = 0.64). The highest incidence was in the age group 10-14 years for both sexes. A significant regional variation in incidence was observed (p < 0.001). Completeness of ascertainment in the NCDR was estimated to be 91%. The previously observed increase in incidence of type 1 diabetes has levelled off and remained essentially constant at 32.7 per 100,000 person-years during 2004-2012. There is a significant variation in type 1 diabetes incidence within Norway.

Epidemiological factors in gall bladder cancer in eastern India-a single centre study.

India has high incidence of Gallbladder carcinoma with regional variation in incidence possibly due to environmental factors. Prospective study of all the gall bladder cancer in our hospital over 18months analysing how the epidemiological factors are influencing the disease. Incidence-Four cases per 100,000 populations per year. The peak incidence was in 41 to 50years group (49.20%). Male to female ratio was 1:3.8. Majority (69.84%) were in lower socio-economic group. 61 out of 63 patients (96.62%) were non-vegetarians. 60.34% and 19.04% patients weighed between 50 and 55kg and 55and 60kg respectively (p = 0.003). Male smokers had significantly higher risk (p = 0.000 1). Gall stones were present in 45 out of 63 cases(71.42%).45 out of 63 patients were typhoid carriers (p < 0.05). Pain abdomen was the commonest complaint (87.30%), followed by pallor, lump in right upper quadrant, nausea & vomiting and jaundice in 71.42%, 69.84%, 66.66%, 31.74% patients respectively. This data highlights high prevalence of gall bladder carcinoma in Eastern India. Better hygiene and water supply to prevent typhoid carriers, prevention of malnutrition, early intervention for cholelithiasis, importance of balanced diet, increase in awareness about risk of tobacco and alcohol consumption-all are highlighted as significant modifiable factors.

Getting to the heart of the matter: cardiac involvement in transthyretin-related amyloidosis

This editorial refers to ‘Disease profile and differential diagnosis of hereditary transthyretin-related amyloidosis with exclusively cardiac phenotype: an Italian perspective’, by C. Rapezzi et al. , doi:10.1093/eurheartj/ehs123 Transthyretin-related amyloidosis (ATTR) was originally called familial amyloidotic polyneuropathy (FAP) by Andrade based on the predominant features of a length-dependent axonal neuropathy seen in affected Portuguese patients.1 With positive identification of transthyretin (TTR) as the precursor protein, and a growing number of new forms of systemic amyloidosis identified, the name was subsequently changed to ATTR.2 Despite the name change, the disease itself continues to be regarded predominantly as a form of hereditary peripheral neuropathy. The phenotype of cardiac involvement, either as a solitary manifestation of the disease or in association with neuropathy, is probably underdiagnosed due to a lack of awareness of ATTR. As a result, patients who present with cardiac symptoms of ATTR may not gain access to current diagnostic tests or emerging therapies. Factors that probably contribute to low disease recognition include the overall rarity of ATTR and the regional variation in incidence. For example, most of the data on the typical pattern of disease in ATTR patients who have the …

Severe Traumatic Injury

The public health implications of regional variation in incidence and outcome of severe traumatic injury remain to be analyzed. The objective of this study was to determine whether the incidence and outcome associated with severe traumatic injury differs across geographic regions of North America. A prospective, observational study was conducted of the Resuscitation Outcomes Consortium of all patients in 9 North American sites (6 US and 3 Canadian) sustaining severe traumatic injury from April 1, 2006 to March 31, 2007 followed to hospital discharge. Eligible patients were assessed by organized emergency medical services, and had field-based physiologic criteria including systolic blood pressure <or=90 mm Hg, Glasgow Coma Scale score <or=12, respiratory rate <10 or >29 per minute, advanced airway procedure, or traumatic death in the field. Census data were used to determine rates adjusted for age and sex. The main outcome measures were incidence rate, mortality rate, case fatality rate, and survival to discharge for patients sustaining severe traumatic injury assessed by EMS. The total catchment population of 20.5 million yielded 7080 cases of severe traumatic injury. Median age was 36 years and 67% were male. The median incidence of EMS-assessed severe traumatic injury per 100,000 population across sites was 37.4 (interquartile range [IQR] = 24.6-69.6); survival ranged from 39.8% to 80.8%, with a median of 64.5% (IQR = 55.5-78.4). About 942 cases were pronounced dead at the scene and 5857 patients were transported to hospital; 4477 (63.2%) were discharged alive. The median incidence of severe trauma due to a blunt mechanism, transported to hospital, was 25.8 (IQR = 13.1-44.3); survival ranged from 52.6% to 87.3%, with a median of 78.0% (IQR = 68.4-83.5). The median incidence of severe penetrating trauma, transported to hospital, was 2.6 (IQR = 1.5-10.4); survival ranged from 37.5% to 84.7%, with a median of 67.5% (IQR = 54.1-75.9). All P values for differences across sites for incidence and survival were <0.001. In this study involving 9 geographic regions in North America, there were significant and important regional differences in severe traumatic injury, incidence, and outcome. These differences were sustained for patients with either isolated blunt or penetrating injury mechanisms.

Allergic fungal sinusitis: pathophysiology, diagnosis and management

Allergic fungal sinusitis (AFS) is a noninvasive form of fungal rhinosinusitis with an incidence of between 6 and 9% of all rhinosinusitis requiring surgery. Regional variation in incidence has been reported, with the southern and southwestern US particularly endemic. Patients with AFS commonly present with chronic rhinosinusitis with nasal polyps, inhalant atopy, elevated total serum immunoglobulin E (IgE), and sinus-obstructing inspissates of a characteristic extramucosal 'peanut buttery' visco-elastic eosinophil-rich material called 'allergic mucin' that contains sparse numbers of fungal hyphae. Sinus CT is always abnormal, showing findings of chronic rhinosinusitis that often include central areas of increased contrast ('hyperattenuation') within abnormal paranasal sinuses that represent the presence of fungal-containing allergic mucin. AFS has been found to be analogous in several ways to allergic bronchopulmonary aspergillosis (ABPA). Both are chronic inflammatory respiratory tract disorders that are driven by hypersensitivity responses to the presence of small numbers of extramucosal fungi found growing within airway-impacting allergic mucin. AFS allergic mucin typically cultures positive for either dematiaceous fungi such as Bipolaris spicifera or Curvularia lunata, or Aspergillus species such as A. fumigatus, A. flavus or A. niger. As with ABPA, patients have type I immediate hypersensitivity to the etiologic mold in AFS. Further, both AFS and ABPA have been found to have association with specific class II major histocompatibility alleles. Proper diagnosis of AFS and differentiation from the other forms of both noninvasive and invasive fungal rhinosinusitis requires strict adherence to published diagnostic criteria. Medical treatment of AFS has been modeled to an extent after treatment approaches for ABPA that includes the use of postoperative oral corticosteroids and aggressive antiallergic inflammation therapy. The use of follow-up measurements of total serum IgE during treatment of both AFS and ABPA patients can help to monitor disease activity. Future AFS research will lead to further insights into pathogenesis, improved treatments, and ultimately decreases in surgical recurrence rates for this highly recurrent hypertrophic rhinosinusitis disorder.

HIRSCHSPRUNG’S DISEASE: A REGIONAL EXPERIENCE

Hirschsprung's disease (HD) is widely quoted to have an incidence of approximately 1 in 5000 live births. However, it is also known that regional variation in incidence can occur. The aim of this paper was to study the incidence of Hirschsprung's disease in Tasmania and to document a regional experience of HD. A retrospective review of all patients with newly diagnosed HD between January 1998 and December 2005 was carried out. Data were extracted from medical records and reported. Tasmanian birth statistics from 1998 to 2005 were obtained from the Australian Bureau of Statistics website and the incidence was calculated. Over the 8-year study period, 14 new cases of HD were identified in Tasmania. The estimated incidence of HD in Tasmania based on this study is 1 in 3429. This incidence is higher than the widely quoted incidence of 1 in 5000, but the difference did not reach statistical significance. Between 2003 and 2005, there was a surge in the number of cases with 11 of 14 cases being derived from these 3 years. No obvious reasons were found to explain this surge in the number of cases. Abdominal distension and vomiting were most common modes of presentation (100 and 71%, respectively). There was delayed passage of meconium in 43%. The incidence of Hirschsprung's disease seems higher in Tasmania. The surge in the number of cases is also of interest, although the reasons behind this remain unknown. Delayed passage of meconium was also less common than previously cited.

Regional variation in out-of-hospital cardiac arrest incidence and outcome.

The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined. To evaluate whether cardiac arrest incidence and outcome differ across geographic regions. Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex. Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation. Among the 10 sites, the total catchment population was 21.4 million, and there were 20,520 cardiac arrests. A total of 11,898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954 (4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100,000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100,000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P<.001). In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.