Significant Increase In Odds Research Articles

Lower respiratory tract disorder hospitalizations among children born via elective early-term delivery

Objective: We evaluated the hypothesis that elective early-term delivery increases the risk of childhood lower respiratory tract disorder hospitalization.Methods: Children born via early-term elective inductions were compared to full- or late-term elective inductions in a retrospective cohort study using Washington State birth certificate and hospital discharge data. Outcomes were the odds of lower respiratory disorder hospitalization before age five and cause specific odds ratios for asthma, bronchiolitis, bronchitis, and pneumonia. In addition, a subgroup analysis excluding infants with perinatal complications was conducted.Results: Electively induced early-term children were at significantly increased risk of hospitalization before age five for lower respiratory disorders compared to similar full- or late-term children (adjusted OR: 1.31, 95% CI: 1.11–1.55). Bronchiolitis was the only cause-specific outcome with a statistically significant increase in odds of hospitalization, though comparable increases were found for the less common diagnoses of asthma (adjusted OR: 1.39, 95% CI: 0.93–2.08) and pneumonia (adjusted OR: 1.27, 95% CI: 0.99–1.64). Excluding infants with perinatal complications did not alter the results.Conclusions: There was an association between electively induced early-term delivery and hospitalization for lower respiratory tract disorders before age five. This reinforces policies discouraging elective early-term delivery.

Clinical relevance of fixed ratio vs lower limit of normal of FEV1/FVC in COPD: patient-reported outcomes from the CanCOLD cohort.

The way in which spirometry is interpreted can lead to misdiagnosis of chronic obstructive pulmonary disease (COPD) resulting in inappropriate treatment. We compared the clinical relevance of 2 criteria for defining a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC): the fixed ratio and the lower limit of normal. We analyzed data from the cross-sectional phase of the population-based Canadian Cohort of Obstructive Lung Disease (CanCOLD) study. We determined associations of the spirometric criteria for airflow limitation with patient-reported adverse outcomes, including respiratory symptoms, disability, health status, exacerbations, and cardiovascular disease. Sensitivity analyses were used to explore the impact of age and severity of airflow limitation on these associations. We analyzed data from 4,882 patients aged 40 years and older. The prevalence of airflow limitation was 17% by fixed ratio and 11% by lower limit of normal. Patients classified as having airflow limitation by fixed ratio only had generally small, nonsignificant increases in the odds of adverse outcomes. Patients having airflow limitation based on both fixed ratio and lower limit of normal had larger, significant increases in odds. But strongest associations were seen for patients who had airflow limitation by both fixed ratio and lower limit of normal and also had a low FEV1, defined as one less than 80% of the predicted value. Our results suggest that use of the fixed ratio alone may lead to misdiagnosis of COPD. A diagnosis established by both a low FEV1/FVC (according to fixed ratio and/or lower limit of normal) and a low FEV1 is strongly associated with clinical outcomes. Guidelines should be reconsidered to require both spirometry abnormalities so as to reduce overdiagnosis of COPD.

Abstract 87: Lactate and Need for Vasopressors Predicts Mortality After Out-of-Hospital Cardiac Arrest

Background: Early prediction of outcome after out of hospital cardiac arrest (OHCA) is difficult. Previous work has indicated that the combination of lactate and the need for vasopressors may stratify patients and predict outcome. Hypothesis: The combination of initial lactate and requirement for vasopressor support will predict survival post-arrest. Methods: To validate previous retrospective findings, we conducted a prospective observational study of all OHCA (age &gt18, non-traumatic) patients presenting to the emergency department of a tertiary care center between June 2006 and July 2013 with ROSC. We conducted a logistic regression model with hypotensive status (yes or no) and lactate level (lactate &lt5, between 5-10 mmol/L and &gt10) as predictors of mortality. Results: A total of 140 patients were enrolled. Median age of the cohort was 67 (IQR: 53-79.) 72% underwent mild therapeutic hypothermia. Overall mortality rate for the cohort was 60.71%. Patients who received vasopressors had a significantly higher mortality rate than those who did not receive vasopressors (69.4% v. 47.3% ; p=0.009). There was a step-wise increase in mortality associated with increasing lactate levels (37.0% lactate &lt5, 68.8% lactate 5-10, 95.5% lactate &gt10; p=0.0001). The AUC for our model was 0.76. Adjusting for hypotensive status, higher lactate levels were associated with increased odds of death compared to lactate 5-10 as the reference group (lactate 5-10 OR = 3.4, 95%CI: 1.6, 7.4; lactate &gt10 OR = 30.9, 95%CI: 3.8, 249.4). When adjusting for lactate level there was no significant increase in odds of death for patients who were hypotensive compared to patients who were not hypotensive (OR=0.541, 95%CI: 0.3, 1.2). Conclusion: In this prospective validation of a previously retrospective finding, the combination of lactate and need for vasopressors in the immediate post-arrest period is predictive of mortality. Future multicenter validation of this tool is warranted.

Oropharyngeal Dysphagia and Gross Motor Skills in Children With Cerebral Palsy

To determine the prevalence of oropharyngeal dysphagia (OPD) and its subtypes (oral phase, pharyngeal phase, saliva control), and their relationship to gross motor functional skills in preschool children with cerebral palsy (CP). It was hypothesized that OPD would be present across all gross motor severity levels, and children with more severe gross motor function would have increased prevalence and severity of OPD. Children with a confirmed diagnosis of CP, 18 to 36 months corrected age, born in Queensland between 2006 and 2009, participated. Children with neurodegenerative conditions were excluded. This was a cross-sectional population-based study. Children were assessed by using 2 direct OPD measures (Schedule for Oral Motor Assessment; Dysphagia Disorders Survey), and observations of signs suggestive of pharyngeal phase impairment and impaired saliva control. Gross motor skills were described by using the Gross Motor Function Measure, Gross Motor Function Classification System (GMFCS), Manual Ability Classification System, and motor type/ distribution. OPD was prevalent in 85% of children with CP, and there was a stepwise relationship between OPD and GMFCS level. There was a significant increase in odds of having OPD, or a subtype, for children who were nonambulant (GMFCS V) compared with those who were ambulant (GMFCS I) (odds ratio = 17.9, P = .036). OPD was present across all levels of gross motor severity using direct assessments. This highlights the need for proactive screening of all young children with CP, even those with mild impairments, to improve growth and nutritional outcomes and respiratory health.

Validation of skin surface microtopography as a measure of skin photoaging in a subtropical population aged 40 and over

Evidence suggests that skin surface microtopography is a valid measure of photoaging among young adults, but whether this applies to older adults is unknown. We investigated the association between degree of photoaging as measured by histological dermal elastosis and skin microtopography grades by decade of age from 40 to 89 years in a community sample in Australia. Skin surface replicas and punch biopsies were taken from 664 participants of the Nambour Skin Cancer Study. The association was assessed using ordinal logistic regression with proportional odds assumption, using histological dermal elastosis grades as outcome. There was significant increase in odds of higher skin surface microtopography grades with higher dermal elastosis grades for age groups below 70 years [40 to 49 years: odds ratio (OR) 2.96, 95% confidence interval (CI) 1.68-5.22; 50 to 59 years: OR 3.78, 95% CI 2.28-6.26; 60 to 69 years: OR 2.47, 95% CI 1.41-4.35). The association was not significant for those 70 years or older. Skin surface microtopography grading system is a valid measure of degree of dermal elastosis for middle-aged and older adults up to 69 years but appears not to be valid for adults 70 years or more living in a high sun exposure setting.

Oral Antidiabetic Drugs and Regression from Prediabetes to Normoglycemia: A Meta-Analysis

Impaired glucose tolerance, impaired fasting glucose, and elevated hemoglobin A(1c) are intermediate stages, considered prediabetes, a precursor to overt type 2 diabetes mellitus. Prediabetes is associated with increased risk for cardiovascular disease, independent of diabetes development. Data have shown that various oral antidiabetic drugs can help people regress from prediabetes to normoglycemia. To evaluate the efficacy of oral antidiabetic drugs in promoting regression from prediabetes to normoglycemia. MEDLINE (1950-November 2011), EMBASE (1990-November 2011), and Cochrane Central Register of Controlled Trials (indexed September 2011) were systematically searched. A manual search of references from reports of clinical trials and review articles was performed to identify additional relevant studies. Randomized controlled trials 12 weeks or more in duration evaluating any of the oral antidiabetic drugs and studying regression from prediabetes to normoglycemia were included. A random-effects model was used to calculate pooled odds ratios with 95% confidence intervals. Thirteen studies (N = 11,600 participants) were included in the meta-analysis. Use of oral antidiabetic drugs in prediabetic patients was shown to double the odds of achieving normoglycemia compared to controls (OR 2.03, 95% CI 1.54 to 2.67). When individual classes of oral antidiabetic drugs were evaluated, use of thiazolidinediones (OR 2.33, 95% CI 1.93 to 2.81) and α-glucosidase inhibitors (OR 2.02, 95% CI 1.26 to 3.24) was associated with significantly increased odds. However, biguanides (OR 2.04) and sulfonylureas (OR 1.84) failed to reach statistical significance (p = 0.06 and p = 0.39, respectively). In patients with prediabetes, oral antidiabetic drugs were associated with increased odds of regression to normoglycemia versus placebo/control. Only thiazolidinediones and α-glucosidase inhibitors provided a statistically significant increase in odds of regressing to normoglycemia.

Associations of Sexual Identity or Same-Sex Behaviors With History of Childhood Sexual Abuse and HIV/STI Risk in the United States

To measure associations of childhood sexual abuse (CSA) with sexual orientation, behaviors, and attractions and HIV/sexually transmitted infection (STI) incidence in a nationally representative sample of men and women. Data from the 2004-2005 Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed, including frequencies of CSA and HIV/STI incidence for 5 subgroups defined by sexual orientation based on identity and behaviors and attraction to the same sex or opposite sex. Overall, 14.9% of women and 5.2% of men reported CSA. Among women, bisexuals, lesbians, and heterosexuals with same-sex partners had 5.3 times, 3.4 times, and 2.9 times the odds, respectively, for CSA occurring sometimes/more frequently (vs. never) compared with heterosexuals not having same-sex partners or attractions. Among men, bisexuals, gay men, and heterosexuals with same-sex partners had 12.8 times, 9.5 times, and 7.9 times the odds, respectively, for CSA. Men and women sometimes or frequently abused had significant increases in odds for HIV/STI incidence compared with those not abused. Among women, sexual minorities had 3.8 times the odds and heterosexuals had 2.8 times the odds, whereas among men, sexual minorities had 4.2 times odds and heterosexuals had 1.5 times odds. Extraordinarily high rates of CSA were observed for sexual minorities, and sexual minorities were more likely to have incident HIV or STIs, in this U.S. population survey. Identifying the impact of CSA among heterosexuals and sexual minorities in the US is a crucial first step in examining the sequelae of CSA, including the potential mediators of mental health and substance abuse disorders in the relationship between CSA and sexual risk taking.

Recurrent miscarriage: Are three miscarriages one too many? Analysis of a Scottish population-based database of 151,021 pregnancies

Objective To assess the risk of further miscarriage or preterm delivery in women with a history of miscarriages in previous pregnancies, adjusting for maternal age and smoking. Study design Retrospective cohort study using all women with first pregnancies recorded between 1950 and 2000 in the Aberdeen Maternity and Neonatal Databank.Exposure was one or more spontaneous miscarriages, while outcomes assessed were further miscarriage or preterm delivery. Results There were 143,595 pregnancies with none, 6,577 with one, 700 with two, 115 with three and 24 with four consecutive previous miscarriages. The odds of miscarriage were greater in pregnancies following one previous miscarriage than none {adj.O.R. 1.94 (95% C.I. 1.80, 2.09)}. The risk of miscarriage following two miscarriages was greater than in pregnancies following one {adj.O.R. 1.56 (95% C.I. 1.28, 1.90)}. However, there was no further significant increase in odds of miscarriage for pregnancies following three {adj.O.R. 1.37 (95% C.I. 0.86, 2.17)} previous consecutive miscarriages. Odds of spontaneous preterm delivery were greater following one miscarriage than none {adj.O.R. 1.52 (95% C.I. 1.36, 1.69)} but no further increases in risk were seen. Conclusion After adjusting for age and smoking, the risk of a further miscarriage increased sequentially in women who had one and two miscarriages. Three miscarriages did not increase the odds any further. One miscarriage was associated with an increased chance of spontaneous preterm delivery, but two or three miscarriages did not increase the odds any further.

The association between thiazolidinediones and hospitalisation for fracture in type 2 diabetic patients: a Taiwanese population-based nested case–control study

Evidence from the USA has emerged that thiazolidinediones may have a negative effect on the skeleton and increase the risk of fracture, but the association between thiazolidinediones use and fractures has not been evaluated in an Asian population. Using the 2000-2005 Taiwan National Health Insurance claims database, this Taiwanese population-based nested case-control study explored the association between thiazolidinediones use and hospitalisation for bone fracture in type 2 diabetic patients. In the study cohort of type 2 diabetic patients, we identified 18,003 patients with fracture and 90,015 matched controls. Multivariable conditional logistic regressions were used to estimate the association between exposure to thiazolidinediones and fractures. Duration of thiazolidinediones use was defined on the basis of cumulative days of exposure to thiazolidinediones during the year prior to the index date, i.e. <30 days, 30 to 180 days and >180 days. More type 2 diabetic patients with fractures than controls used thiazolidinediones (fractures 5.99% vs control 4.06%). Thiazolidinediones use was associated with hospitalisation for fracture and the association was stronger with longer term exposure to thiazolidinediones (<30 days OR 1.32 [95% CI 1.09-1.54], p = 0.005; 30-180 days 1.42 [1.24-1.62], p < 0.0001; and >180 days 1.54 [1.37-1.74], p < 0.0001). This dose-response relationship was significantly evident in women (<30 days, 1.20 [0.93-1.55], p = 0.17; 30-180 days, 1.57 [1.32-1.86], p < 0.0001; and >180 days, 1.76 [1.52-2.04], p < 0.0001), but not in men. Long-term exposure of type 2 diabetic patients to thiazolidinediones was associated with higher odds of fractures among women without a significant increase in odds of fractures among men.

The First National Level Estimate of Emergency Department Charges for Sickle Cell Disease.

Abstract 553First National Level Estimate of Emergency Department Charges for Sickle Cell DiseaseIt is estimated that there are 100,000 people with sickle cell disease (SCD) living in the US. Little data is currently availabel on the number of emergency room visits made per year by this patient population. Given prior data demonstrating the cost savings associated with comprehensive care delivery and specialized day hospital units that have decreased ED visits and hospitalizations, our goal was to estimate the national burden of SCD care in the ED setting. The purpose of this study was to estimate the number of ED visits made by SCD patients in 2006, the total and average charges for those visits and the subsequent hospital admissions, and to identify factors that predicted if patients were admitted to the hospital. In addition, we used the online Healthcare Cost and Utilization Project program (HCUP) to compare the number of SCD visits with the number of ED visits and subsequent admissions for other chronic illnesses. Methods:The Nationwide Emergency Department Sample (NEDS) contains information from 950 hospitals and approximates a 20% stratified sample of US hospital based EDs. Data is currently only availabel for 2006. Using this dataset we identified all ED visits with the following SCD ICD9 codes 28260,28261,28262,28263,28264,28268,28269,28241,28242 listed anywhere in the diagnosis list. Bivariate and multivariate analyses were conducted using t-tests, oneway ANOVAs, and multiple linear or logisitic regressions as appropriate. Sampling weights are included in the NEDS to allow for the generation of national estimates. In addition to the full NEDS dataset the Agency for Healthcare Research and Quality makes availabel on-line a query system based on HCUP data free on its website. We used this system to collect data on total ED visits for asthma, HIV and congestive heart failure (CHF) that ended in a hospital admission using the clinical classification software codes 128, 5, and 108 as defined in the HCUP system. Results:There were a total of 58993 ED visits for patients with SCD sampled in the NEDS in 2006, representing a national estimate of 232,381 ED visits. Using the weighted data there were an estimated 190,000 adult ED visits and 44,000 pediatric visits. The total charges for all of the ED visits were estimated to be $266 million of which 191 million were for patients not subsequently admitted to the hospital. Being female and adult resulted in significantly higher ED charges. 50% of the visits were covered by Medicaid, 22% by Medicare, 18% were private pay, 7.5% self-pay and the remainder were no charge or other. 60% of the visits occurred in the South, 18% in the Northeast, 15% in the Midwest and 7% in the West. 5% of the visits had a code for pneumonia, 0.25% had a code for stroke and 7.3% had a code for asthma. These ED visits resulted in an estimated 91,000 hospitalizations. Pediatric patients were more likely to be admitted than adult patients (44% v 38% p=0.03). The combined ED and inpatient charges for those admitted were estimated to be $2.7 billion with a mean charge of $23,669 (range $591-871,111). 64 individuals are estimated to have died in the ED and another 522 died during their hospital stay. The average age of those that died in the ED was 33 and in the hospital was 42. In adjusted analyses being female, in the pediatric age group, or having a code for sickle crisis, asthma, stroke or pneumonia all were associated with a significant increase in odds of being admitted to the hospital. Table 1 shows the comparison number of admissions from the ED for SCD, asthma, HIV and CHF.Table 1:Comparison of Admissions from the ED for SCD and other Chronic ConditionsDiagnosisTotal admissions from EDEstimated size of population in USAdmissions/ per 100 patientsSCD91,000100,00091Asthma1,357,38826 million5.2HIV188,8411.2 million15.7CHF958,7314.8 million20 Conclusions:Given the size of the US sickle population this data suggests that the ED is a major source of care for this patient population. Given that there are over 2 billion dollars in charges for those admitted from the ED, a focus of improving quality of care and decreasing costs of care should be eliminating ED use by the SCD population by providing alternative venues for treatment of painful crises that is more likely to result in a discharge home. Disclosures:No relevant conflicts of interest to declare.

Outcomes of Perioperative β-Blockade in Patients Undergoing Noncardiac Surgery: A Meta-Analysis

Several studies have evaluated the impact on myocardial infarction (MI), stroke, and overall mortality of perioperative beta-blocker use in patients undergoing noncardiac surgery (NCS). However, most studies did not have adequate sample size and statistical power and were therefore underpowered to adequately evaluate these endpoints. To conduct a meta-analysis to determine the balance of benefits and harms associated with perioperative beta-blocker use in NCS. A systematic literature search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted from January 1960 through February 2009. Manual reference search was performed to identify additional relevant trials. Randomized, double-blinded, placebo-controlled trials comparing the use of beta-blockers with placebo; using beta-blockers perioperatively in beta-blocker-naïve patients undergoing NCS; and evaluating endpoints of MI, stroke, or all-cause mortality were included. Six trials (N = 10,183) met our inclusion criteria. Perioperative beta-blocker use was associated with a significant reduction in patients' odds of developing MI (OR 0.74, 95% CI 0.61 to 0.89) but a significant increase in odds of developing stroke (OR 1.98, 95% CI 1.23 to 3.20) and also a nonsignificant increase in mortality (OR 1.21, 95% CI 0.98 to 1.49) versus placebo. Control-rate meta-regression determined that patients with highest baseline odds of stroke had decreased relative odds of having a stroke with a beta-blocker versus placebo (beta coefficient -0.97; 95% credible interval -1.04 to -0.90). When perioperative beta-blockers are used in NCS patients, there is a trade-off between reduction in MI and increase in stroke, with a troubling trend toward an increase in mortality. Patients with lower baseline odds of developing stroke appear to be at greater risk of beta-blocker-induced stroke.

Smoking tobacco along with marijuana increases symptoms of cannabis dependence

Aim User practices/rituals that involve concurrent use of tobacco and marijuana – smoking blunts and “chasing” marijuana with tobacco – are hypothesized to increase cannabis dependence symptoms. Design Ethnographers administered group surveys to a diverse, purposive sample of marijuana users who appeared to be 17–35 years old. Setting New York City, including non-impoverished areas of Manhattan, the transitional area of East Village/Lower East Side, low-income areas of northern Manhattan and South Bronx, and diverse areas of Brooklyn and Queens. Participants 481 marijuana users ages 14–35, 57% male, 43% female; 27% White, 30% Black, 19% Latino, 5% Asian, 20% of other/multiple race. Measurements Among many other topics, group surveys measured cannabis dependence symptoms; frequencies of chasing, blunt smoking, joint/pipe smoking, using marijuana while alone, and general tobacco use; and demographic factors. Findings Blunt smoking and chasing marijuana with tobacco were each uniquely associated with five of the seven cannabis dependence symptoms. Across symptoms, predicted odds were 2.4–4.1 times greater for participants who smoked blunts on all 30 of the past 30 days than for participants who did not smoke blunts in the past 30 days. Significant increases in odds over the whole range of the five-point chasing frequency measure (from never to always) ranged from 3.4 times to 5.1 times. Conclusions Using tobacco with marijuana – smoking blunts and “chasing” marijuana with tobacco – contributes to cannabis dependence symptoms. Treatment for cannabis dependence may be more effective it addresses the issue of concurrent tobacco use.

Oral corticosteroids for stable chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common chronic lung disorder, usually related to cigarette smoking, representing a major and increasing cause of morbidity and mortality. It is defined "as a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases". The use of corticosteroids for their anti-inflammatory effects has been suggested. To assess the effects of oral corticosteroids on the health status of patients with stable COPD. Searches of the Cochrane Airways Group Specialised Register and MEDLINE were carried out in December 2003 and 2004. Review articles and bibliographies were searched. Randomised controlled prospective studies in adults with stable COPD ( post-bronchodilator FEV1 <80% of predicted, FEV1/FVC <70%) and a history of smoking, excluding known asthmatics, in which oral steroid use was compared with placebo and use of co-interventions was matched in both groups. Data was extracted independently by two reviewers. All trials were combined using Review Manager (version 4.2.7). From 459 titles 24 studies met the inclusion criteria. Treatment lasted three weeks or less in 19 studies, high dose oral steroid was used in 21 studies and subjects had moderate or severe COPD in 15 studies. There was a significant difference in FEV1 after two weeks treatment, WMD 53.30 ml; 95% confidence interval 22.21 to 84.39 favouring oral steroid use compared to placebo when 14 studies with available data (n=396) were combined, with no significant heterogeneity. There was a significant increase in odds for individual patient FEV1 response greater than 20% from baseline with high dose oral steroid treatment compared to placebo, OR 2.71; 95% CI 1.84 to 4.01 (9 studies) . It would be necessary to treat 7 patients (95% CI 5 to 12) with oral corticosteroids to achieve one extra case of increasing FEV1 by more than 20%, with a placebo group risk of 0.13. All differences in health-related quality of life were less than the minimum clinically important difference. There were small statistically significant advantages for functional capacity and respiratory symptom of wheeze with oral steroid treatment but no significant difference in risk of withdrawal from study due to an exacerbation or rate of serious exacerbations over 2 years with low dose oral steroid treatment. There was an increased risk of adverse effects, including increased blood glucose, adrenal suppression and reduced serum osteocalcin. There is no evidence to support the long-term use of oral steroids at doses less than 10-15 mg prednisolone though some evidence that higher doses (>/= 30 mg prednisolone) improve lung function over a short period. Potentially harmful adverse effects e.g.. diabetes, hypertension, osteoporosis would prevent recommending long-term use at these high doses in most patients.

The role of lipid profile in determining the risk of ischemic stroke in the elderly: a case–control study

In this study, we investigated the association of lipids with ischemic stroke and its different subtypes in elderly patients. In particular, lipid parameters not extensively investigated so far in previous case–control studies specifically focused in the old population, such as lipoprotein Lp (a) and Apoproteins AI (ApoAI) and B (ApoB), have been taken into account. Seventy nine patients (mean age 83±7.4, range 67–99), consecutively admitted to a Geriatric Ward between January 1998 and June 2000 with acute stroke (first event) were studied. A complete clinical and laboratory assessment, including neurological evaluation, head CT scan, carotid ultrasonography and ECG, was employed to define the clinical and etiologic stroke subtype, according to standardized criteria. Fasting blood samples were collected within 48 h from admission, for determination of total cholesterol (TC), triglycerides (TG), High Density Lipoprotein-cholesterol (HDL-C), Lp(a), ApoAI and ApoB; Low Density Lipoprotein-Cholesterol (LDL-C) was estimated by Friedwald formula. Eighty eight age and sex-matched outpatients, referred to the hospital for non-inflammatory disorders of joints and musculoskeletal system, served as controls. Patients showed HDL-C and HDL-C/ApoAI ratio significantly lower than controls, with higher LDL-C/HDL-C ratio. Analysis on quartiles of lipoprotein concentrations showed also a significant increase in odds of stroke for LDL-C concentrations over 100 mg/dl, in absence of a linear relationship between LDL-C levels and risk. Multiple logistic regression, adjusting for non-lipid risk factors for stroke, confirmed the independent association of low HDL-C and HDL-C/ApoAI with all strokes, as well as with each subtype. In conclusion, these data suggest that lipids give some contribution to stroke risk even in the elderly, with a more prevalent role for HDL than LDL, and that lipid profile assessment must be taken into account in estimating the individual risk of stroke.

Therapeutic hypothermia for head injury.

Induced hypothermia has been used in the treatment of head injury for many years. Encouraging results from small trials and laboratory studies led to renewed interest in the area and some larger trials. To estimate the effects of mild induced hypothermia in moderate and severe head injury on mortality, long-term functional outcome, complications, and short-term control of intracranial pressure (ICP). We searched the Injuries Group Specialised register (last searched in 2001), Medline, EMBASE and the Cochrane Controlled Trials Register. We handsearched conference proceedings and checked reference lists of relevant articles. Randomised controlled trials of mild hypothermia to 34-35 Celsius for a t least 12 hours versus control (open or normothermia) in patients with any closed head injury requiring hospitalisation. Two reviewers independently assessed all trials. Data on death, Glasgow Outcome Scale, complications and ICP were sought and extracted, either from published material or by contacting the investigators. Odds ratios and 95% confidence intervals were calculated for each trial on an intention-to-treat basis. Quantitative synthesis of data on complications other than pneumonia or ICP was not attempted. Trials of immediate and deferred hypothermia were analysed separately. We found 12 trials with 812 participants. Active immediate hypothermia was associated with an odds ratio for death of 0.88, (771 patients, OR 0.88, 95% CI 0.63 to 1.21), and 0.75 for odds of being dead or severely disabled, (746 patients, OR 0.75, 95% CI 0.56 to 1.00). Hypothermia treatment was associated with a statistically significant increase in odds of pneumonia (281 patients, OR 1.95, 95% CI 1.18 to 3.23). The trial of deferred hypothermia (33 patients) reported a huge but not statistically significant reduction in the odds of death at 6 months, (OR 0.21, 95% CI 0.04 to 1.05). For death or severe disability deferred hypothermia was associated with an odds ratio of 0.10 (95% CI 0.01 to 1.00). There is no evidence that hypothermia is beneficial in the treatment of head injury. The earlier, encouraging, trial results have not been repeated in larger trials. The reasons for this are unclear. Hypothermia increases the risk of pneumonia and has other potentially harmful side effects. Therefore, it would seem inappropriate to use this intervention outside of controlled trials in subgroups of patients for whom there is good reason to think the treatment would be beneficial.

Anaemia in pregnancy--a cross-sectional study in Singapore.

To determine the prevalence and predictors of anaemia in pregnancy in Singapore. Hospital based case controlled study. National University Hospital, between January-December 1993. All women delivered at the National University Hospital, Singapore in 1993 had their haemoglobin estimated. If it was less than 11 gm/dl, blood was taken to establish the cause of anaemia. Data was also collected with regard to their antenatal progress, and factors predisposing to anaemia in pregnancy. Logistic regression, Chi-square test, Fischer's exact test, Mantel-Haenszel test were used to assess the relationships between categorical variables. The prevalence of anaemia at delivery was 15.3%. The most common cause of anaemia in pregnancy was due to iron deficiency (81.3%). The occurrence of anaemia in pregnancy is related to the socio-economic status of the women. Multiparous women of the lower socio-economic class who tend to book late in pregnancy were found to have the highest risk of anaemia. Multivariate logistic regression analysis revealed iron prophylaxis, haemoglobin level at booking, race and previous history of anaemia in earlier pregnancy as important predictors of anaemia at delivery. The odds of anaemia for a woman not on therapy was about 11 times that of her counterpart on prophylactic iron therapy (95% CI 8.76-14.13). A 55% reduction in odds of anaemia was estimated per 1 gm% increase in haemoglobin level at booking. As compared to Chinese, Malays and Indians who experienced significant increase in odds of anaemia of 95% and 58% respectively. Further, a pregnant woman with a previous history of anaemia is 2.6 times as likely to be anaemic, as compared with one without history of anaemia. Except for a higher incidence of preterm delivery, there was no other statistically increased risk of complications in the antepartum, intrapartum or postpartum periods. There was no difference in the incidence of antepartum haemorrhage/operative deliveries, postpartum haemorrhage, low birthweight, intrauterine growth retardation and neonatal outcome. The study confirms that iron deficiency anaemia is the most common cause of anaemia in pregnancy and is a major health problem in developing and developed countries.

Determinants of on-scene time in injured patients treated by physicians at the site.

The controversy surrounding the use of advanced life support (ALS) for the pre-hospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in-hospital care. In Montreal, Québec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene. The use of on-site ALS by physicians is associated with a significant increase in scene time. A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were used to analyze the data. Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean = 5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (> 20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009). This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with severe injuries.

Rising mortality from cryptogenic fibrosing alveolitis.

To determine the pattern of mortality ascribed to cryptogenic fibrosing alveolitis and to identify factors that might be important in the aetiology of the disease; and to assess the validity of death certification of the disease. A retrospective examination of mortality ascribed to cryptogenic fibrosing alveolitis in England and Wales between 1979 and 1988 with analysis, by multiple logistic regression, of independent effects of age, sex, region of residence, and social class as indicated by occupation on data for 1979-87; also a retrospective review of hospital records of patients certified as having died of cryptogenic fibrosing alveolitis in Nottingham and of the certified cause of death of patients known to have had the disease. Time trends in mortality nationally; effects on mortality of age, sex, and region of residence; validity of death certification in Nottingham. The annual number of deaths ascribed to cryptogenic fibrosing alveolitis doubled from 336 in 1979 to 702 in 1988, the increase occurring mainly at ages over 65. Mortality standardised for age for both sexes likewise increased steadily over the period. Deaths due to cryptogenic fibrosing alveolitis were commoner in men (odds ratio 2.24, 95% confidence interval 2.11 to 2.33) and increased substantially with age, being 7.84 (7.24 to 8.49) times higher in subjects aged much greater than 75 than those aged 45-64. Odds ratios of death due to cryptogenic fibrosing alveolitis adjusted for age and sex were increased in the traditionally industrialised central areas of England and Wales (p less than 0.02, maximum odds ratio between regions 1.25), but no significant increase in odds of death was found for manual occupations. Of 23 people whose deaths were registered in Nottingham as having been due to cryptogenic fibrosing alveolitis, 19 were ascertained from clinical records to have had the disease. Only 17 of 45 patients known to have had cryptogenic fibrosing alveolitis in life were recorded as having died from the disease. The diagnostic accuracy of death certification of cryptogenic fibrosing alveolitis is high, but the number of deaths recorded as being due to the disease may underestimate the number of patients dying with the disease by up to half. Mortality due to the disease is increasing, and the male predominance and regional differences in mortality suggest that environmental factors are important in its aetiology.