The impact of the Covid-19 pandemic on postnatal anxiety and posttraumatic stress: Analysis of two population-based national maternity surveys in England

BACKGROUND

Few studies have evaluated postnatal anxiety and posttraumatic stress (PTS) before and during the Covid-19 pandemic using comparable data across time. We used data from two national maternity surveys in England to explore the impact of the pandemic on prevalence and risk factors for postnatal anxiety and PTS.

METHODS

Analysis was conducted using population-based surveys carried out in 2018 (n = 4509) and 2020 (n = 4611). Weighted prevalence estimates for postnatal anxiety and PTS were compared across surveys. Adjusted risk ratios (aRR) were estimated for the association between risk factors and postnatal anxiety and PTS.

FINDINGS

Prevalence of postnatal anxiety increased from 13.7 % in 2018 to 15.1 % in 2020 (+1.4 %(95%CI:-0.4-3.1)). Prevalence of postnatal PTS increased from 9.7 % in 2018 to 11.5 % in 2020 (+1.8 %(95%CI:0.3-3.4)), due to an increase in PTS related to birth trauma from 2.5 % to 4.3 % (+1.8 %(95%CI:0.9-2.6); there was no increase in PTS related to non-birth trauma. Younger age (aRR = 1.31-1.51), being born in the UK (aRR = 1.29-1.59), long-term physical or mental health problem(s) (aRR = 1.27-1.94), and antenatal anxiety (aRR = 1.97-2.22) were associated with increased risk of postnatal anxiety and PTS before and during the pandemic, whereas higher satisfaction with birth (aRR = 0.92-0.94) and social support (aRR = 0.81-0.82) were associated with decreased risk.

INTERPRETATION

Prevalence of postnatal PTS was significantly higher during the pandemic, compared to before the pandemic, due to an increase in PTS related to birth trauma. Prevalence of postnatal anxiety was not significantly higher during the pandemic. Risk factors for postnatal anxiety and PTS were similar before and during the pandemic.

Ethnicity and paediatric healthcare utilisation: Improving the quality of quantitative research

Background

The COVID-19 pandemic highlighted the stark health inequities affecting minority ethnic populations in Europe. However, research on ethnic inequities and healthcare utilisation in children has seldom entered the policy discourse. A scoping review was conducted in the UK, summarising and appraising the quantitative evidence on ethnic differences (unequal) and inequities (unequal and unfair or disproportionate to healthcare needs) in paediatric healthcare utilisation.

Methods

Embase, Medline and grey literature sources were searched for studies published 2001-2021. Studies that found differences and inequities were mapped by ethnic group and healthcare utilisation outcome. They were appraised using the National Institute for Health and Care Excellence appraisal checklists. The distribution of studies was described across various methodological parameters.

Results

Of the 61 included studies, most found evidence of ethnic variations in healthcare utilisation (n = 54, 89%). Less than half attempted to distinguish between ethnic differences and inequities (n = 27, 44%). Studies were concentrated on primary and preventive care and hospitalisation, with minimal evidence on emergency and outpatient care. The quality of studies was often limited by a lack of theory underpinning analytical decisions, resulting in conflation of difference and inequity, and heterogeneity in ethnic classification. The majority of studies examined children's ethnicity but overlooked parent/caregiver ethnicity, and also didn't investigate patterns across age, year or location.

Conclusions

To improve the validity, generalisability and comparability of research on ethnicity and paediatric healthcare utilisation, findings from this scoping review were used to develop recommendations for future research. These lessons could be applied more broadly across the European context to improve evidence generation and evidence-based policy-making to reduce inequities in healthcare.

Key messages

• Quantitative studies of ethnicity and paediatric healthcare utilisation in the UK lack the use of sound theoretical frameworks, and often do not distinguish between ethnic differences and inequities.

• The quality of future studies can be improved with greater attention to how ethnicity is classified and analysed, alongside specific considerations for examining healthcare utilisation in children.

Planned mode of birth after previous caesarean section and special educational needs in childhood: a population-based record linkage cohort study

Objective

To investigate the association between planned mode of birth after previous caesarean section and a child’s risk of having a record of special educational needs (SENs).

Design

Population‐based cohort study.

Setting

Scotland.

Population

A cohort of 44 892 singleton children born at term in Scotland between 2002 and 2011 to women with one or more previous caesarean sections.

Methods

Linkage of Scottish national health and education data sets.

Main outcome measures

Any SENs and specific types of SEN recorded when a child was aged 4–11 years and attending a Scottish primary or special school.

Results

Children born following planned vaginal birth after previous caesarean (VBAC) compared with elective repeat caesarean section (ERCS) had a similar risk of having a record of any SENs (19.24 versus 17.63%, adjusted risk ratio aRR 1.04, 95% CI 0.99–1.09) or specific types of SEN. There was also little evidence that planned VBAC with or without labour induction compared with ERCS was associated with a child’s risk of having a record of any SENs (21.42 versus 17.63%, aRR 1.09, 95% CI 1.01–1.17 and 18.78 versus 17.63%, aRR 1.03, 95% CI 0.98–1.08, respectively) or most types of SEN. However, an increased risk of sensory impairment was seen for planned VBAC with labour induction compared with ERCS (1.18 versus 0.78%, risk difference 0.4%, adjusted odds ratio aOR 1.60, 95% CI 1.09–2.34).

Conclusions

This study provides little evidence of an association between planned mode of birth after previous caesarean and SENs in childhood beyond a small absolute increased risk of sensory impairment seen for planned VBAC with labour induction. This finding may be the result of performing multiple comparisons or residual confounding. The findings provide valuable information to manage and counsel women with previous caesarean section concerning their future birth choices.

Tweetable abstract

There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

Prevalence and factors associated with postpartum posttraumatic stress in a population-based maternity survey in England

BACKGROUND

Studies on prevalence and factors associated with postpartum posttraumatic stress (PTS) typically do not distinguish between PTS related to childbirth (PTS-C) and PTS related to other stressors (PTS-O). This study aimed to describe the prevalence, clinical characteristics, and factors associated with PTS-C and PTS-O in postpartum women.

METHODS

The study was a cross-sectional population-based survey of 16,000 postpartum women, selected at random from birth registrations in England to receive a postal questionnaire, including the Primary Care Posttraumatic Stress Disorder Screen.

RESULTS

Questionnaires were returned by 4,509 women. The median age was 32 years (IQR=29-36), 64% were married, 77% were UK-born, and 76% were White-British. Prevalence of PTS-C was 2.5% (95%CI:2.0-3.0) and prevalence of PTS-O was 6.8% (95%CI:6.0-7.8). Women with PTS-C were significantly more likely to report re-experiencing symptoms (Chi-Square=7.69,p<0.01). Factors associated with PTS-C were: higher level of deprivation, not having a health professional to talk to about sensitive issues during pregnancy, and the baby being admitted for neonatal intensive care. Factors associated with PTS-O were: age ≤24 years, depression during pregnancy, and having a pregnancy affected by long-term health problems. Factors associated with both were: living without a partner, anxiety during pregnancy, pregnancy-specific health problems, and lower birth satisfaction.

CONCLUSIONS

PTS during the postpartum period is relatively common and, for many women, unrelated to childbirth. Increased awareness among health professionals of prevalence, clinical characteristics and factors associated with postpartum PTS-C and PTS-O will aid the development of appropriate management protocols to identify and support women during the perinatal period. Posttraumatic stress, posttraumatic stress disorder, postpartum PTSD/PTS, birth-related PTSD/PTS, birth trauma, perinatal mental health.

Exclusive breastfeeding duration and infant infection

BACKGROUND/OBJECTIVES

We estimated the risk of infection associated with the duration of exclusive breastfeeding (EBF).

SUBJECT/METHODS

We analysed the data on 15 809 term, singleton infants from the UK Millennium Cohort Study. Infants were grouped according to months of EBF: never, <2, 2-4, 4-6 and 6 (the latter being World Health Organisation (WHO) policy since 2001: 'post-2001 WHO policy'). Among those EBF for 4-6 months, we separated those who started solids, but not formula, before 6 months, and were still breastfeeding at 6 months (that is, WHO policy before 2001: 'pre-2001 WHO policy'), from other patterns. Outcomes were infection in infancy (chest, diarrhoeal and ear).

RESULTS

EBF was not associated with the ear infection, but was associated with chest infection and diarrhoea. EBF for <4 months was associated with a significantly increased risk of chest infection (adjusted risk ratios (RR) 1.24-1.28) and diarrhoea (adjusted RRs 1.42-1.66) compared with the pre-2001 WHO policy. There was an excess risk of the chest infection (adjusted RR 1.19, 95% confidence interval (CI): 0.97-1.46) and diarrhoea (adjusted RR 1.66, 95% CI: 1.11, 2.47) among infants EBF for 4-6 months, but who stopped breastfeeding by 6 months, compared with the pre-2001 WHO policy. There was no significant difference in the risk of chest infection or diarrhoea in those fed according to the pre-2001 versus post-2001 WHO policy.

CONCLUSIONS

There is an increased risk of infection in infants EBF for <4 months or EBF for 4-6 months who stop breastfeeding by 6 months. These results support current guidelines of EBF for either 4-6 or 6 months, with continued breastfeeding thereafter.

Long-term cognitive and school outcomes of late-preterm and early-term births: a systematic review

BACKGROUND

Children born before full term (39-41 weeks' gestation) are at increased risk of adverse cognitive outcomes. Risk quantification is important as late-preterm (LPT; 34-36 weeks) and early-term (ET; 37-38 weeks) births are common.

METHOD

This review analyses the effect of LPT and ET births on long-term cognitive and educational outcomes. The primary outcome was general cognitive ability. Secondary outcomes included verbal/non-verbal intelligence quotient, subject-specific school performance and special educational needs. The search strategy included Medline and Embase from January 1975 to June 2013. Eligible studies investigated specified outcomes and included suitable gestational age participants assessed at 2 years and older. Outcome measures and socio-demographic descriptors were extracted, and data meta-analysed where possible.

RESULTS

Eight studies compared ET birth with full-term birth. Fourteen studies compared LPT birth with either term birth (>37 weeks, n = 12 studies) or full-term birth (39-41 weeks, n = 2 studies). Substantial between-study heterogeneity existed. LPT and ET children underperformed in most outcomes compared with their term/full-term counterparts, respectively. For example, LPT children had an increased risk of lower general cognitive ability (adjusted risk ratio 1.38 [95% confidence interval 1.06-1.79]), and full-term children performed 5% of a standard deviation higher (z-score 0.05 [0.02, 0.08]) than ET children. Poorer outcomes persist into adulthood; term cohorts performed 5% of a standard deviation higher than LPT cohorts (z-score 0.05 [0.04, 0.07]), and full-term cohorts performed 3% of a standard deviation higher than ET cohorts (z-score 0.03 [0.02, 0.04]).

CONCLUSION

This review critically examines the knowledge around long-term cognitive outcomes of LPT and ET births, demonstrating multiple, small, adverse differences between LPT/ET and term/full-term births.

Potential economic impacts from improving breastfeeding rates in the UK

RATIONALE

Studies suggest that increased breastfeeding rates can provide substantial financial savings, but the scale of such savings in the UK is not known.

OBJECTIVE

To calculate potential cost savings attributable to increases in breastfeeding rates from the National Health Service perspective.

DESIGN AND SETTINGS

Cost savings focussed on where evidence of health benefit is strongest: reductions in gastrointestinal and lower respiratory tract infections, acute otitis media in infants, necrotising enterocolitis in preterm babies and breast cancer (BC) in women. Savings were estimated using a seven-step framework in which an incidence-based disease model determined the number of cases that could have been avoided if breastfeeding rates were increased. Point estimates of cost savings were subject to a deterministic sensitivity analysis.

RESULTS

Treating the four acute diseases in children costs the UK at least £89 million annually. The 2009-2010 value of lifetime costs of treating maternal BC is estimated at £959 million. Supporting mothers who are exclusively breast feeding at 1 week to continue breast feeding until 4 months can be expected to reduce the incidence of three childhood infectious diseases and save at least £11 million annually. Doubling the proportion of mothers currently breast feeding for 7-18 months in their lifetime is likely to reduce the incidence of maternal BC and save at least £31 million at 2009-2010 value.

CONCLUSIONS

The economic impact of low breastfeeding rates is substantial. Investing in services that support women who want to breast feed for longer is potentially cost saving.

Light drinking versus abstinence in pregnancy - behavioural and cognitive outcomes in 7-year-old children: a longitudinal cohort study

OBJECTIVE

To assess whether light drinking in pregnancy is linked to unfavourable developmental outcomes in children.

DESIGN

Prospective population-based cohort.

SETTING

UK.

POPULATION

Ten thousand five hundred and thirty-four 7-year-olds.

METHODS

Quasi-experimental using propensity score matching (PSM) to compare children born to light (up to 2 units per week) and non-drinkers.

MAIN OUTCOME MEASURES

Behavioural difficulties rated by parents and teachers; cognitive test scores for reading, maths and spatial skills.

RESULTS

Ordinary least squares (OLS) regression and PSM analyses are presented. For behavioural difficulties, unadjusted estimates for percentage standard deviation (SD) score differences ranged from 2 to 14%. On adjustment for potential confounders, differences were attenuated, with a loss of statistical significance, except for teacher-rated boys' difficulties. For boys, parent-rated behavioural difficulties: unadjusted, -11.5; OLS, -4.3; PSM, -6.8; teacher-rated behavioural difficulties: unadjusted, -13.9; OLS, -9.6; PSM, -10.8. For girls, parent-rated behavioural difficulties: unadjusted, -9.6; OLS, -2.9; PSM, -4.5; teacher-rated behavioural difficulties: unadjusted, -2.4; OLS, 4.9; PSM, 3.9. For cognitive test scores, unadjusted estimates for differences ranged between 12 and 21% of an SD score for reading, maths and spatial skills. After adjustment for potential confounders, estimates were reduced, but remained statistically significantly different for reading and for spatial skills in boys. For boys, reading: unadjusted, 20.9; OLS, 8.3; PSM, 7.3; maths: unadjusted, 14.7; OLS, 5.0; PSM, 6.5; spatial skills: unadjusted, 16.2; OLS, 7.6; PSM, 8.1. For girls, reading: unadjusted, 11.6; OLS, -0.3; PSM, -0.5; maths: unadjusted, 12.9; OLS, 4.3; PSM, 3.9; spatial skills: unadjusted, 16.2; OLS, 7.7; PSM, 6.4.

CONCLUSION

The findings suggest that light drinking during pregnancy is not linked to developmental problems in mid-childhood. These findings support current UK Department of Health guidelines on drinking during pregnancy.

Asthma in children born after infertility treatment: findings from the UK Millennium Cohort Study

STUDY QUESTION

Is asthma more common in children born after subfertility and assisted reproduction technologies (ART)?

SUMMARY ANSWER

Yes. Asthma, wheezing in the last year and anti-asthmatic medication were all more common in children born after a prolonged time to conception (TTC). This was driven specifically by an increase in children born after ART.

WHAT IS KNOWN ALREADY

Few studies have investigated any association between ART and asthma in subsequent children, and findings to date have been mixed. A large registry-based study found an increase in asthma medication in ART children but suggests underlying infertility is the putative risk factor. Little is known about asthma in children after unplanned or mistimed conceptions.

STUDY DESIGN, SIZE, DURATION

The Millennium Cohort Study is a UK-wide, prospective study of 18 818 children recruited at 9 months of age. Follow-up is ongoing. This study analyses data from follow-up surveys at 5 and 7 years of age (response rates of 79 and 70%, respectively).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Singleton children whose natural mothers provided follow-up data were included. Mothers reported whether their pregnancy was planned; planners provided TTC and details of any ART. The population was divided into 'unplanned' (unplanned and unhappy), 'mistimed' (unplanned but happy), 'planned' (planned, TTC < 12 months), 'untreated subfertile' (planned, TTC >12 months), 'ovulation induced' (received clomiphene citrate) and 'ART' (IVF or ICSI). The primary analysis used the planned children as the comparison group; secondary analysis compared the treatment groups to the children born to untreated subfertile parents. Outcomes were parent report of asthma and wheezing at 5 and 7 years, derived from validated questions in the International Study of Asthma and Allergies in Childhood, plus use of anti-asthmatic medications. A total of 13 041 (72%) children with full data on asthma and confounders were included at 5 years of age, and 11 585 (64%) at 7 years.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared with planned children, those born to subfertile parents were significantly more likely to experience asthma, wheezing and to be taking anti-asthmatics at 5 years of age [adjusted odds ratio (OR): 1.39 (95% confidence interval (CI): 1.07, 1.80), OR: 1.27 (1.00, 1.63) and OR: 1.90 (1.32,2.74), respectively]. This association was mainly related to an increase among children born after ART (adjusted OR: 2.65 (1.48, 4.76), OR: 1.97, (1.10, 3.53) and OR: 4.67 (2.20, 9.94) for asthma, wheezing and taking anti-asthmatics, respectively). The association was also present, though reduced, at the age of 7 years.

LIMITATIONS, REASONS FOR CAUTION

The number of singletons born after ART was relatively small (n = 104), and as such the findings should be interpreted with caution. However, data on a wide range of possible confounding and mediating factors were available and analysed. The data were weighted for non-response to minimize selection bias.

WIDER IMPLICATIONS OF THE FINDINGS

The findings add to the growing body of evidence suggesting an association between subfertility, ART and asthma in children. Further work is needed to establish causality and elucidate the underlying mechanism. These findings are generalizable to singletons only, and further work on multiples is needed.

Persistent effects of women's parity and breastfeeding patterns on their body mass index: results from the Million Women Study

Objective:

To explore the long-term effects of women's childbearing patterns on their body mass index.

Design:

Cross-sectional analysis.

Setting:

Population-based study of UK women.

Participants:

740 628 postmenopausal participants in the Million Women Study who reported their height, weight, reproductive histories and other relevant factors.

Main Outcome Measures:

Standardized mean BMI (kg m⁻²) in groups defined by their parity and breastfeeding history.

Results:

Women were aged 57.5 (s.d. 4) years on average, and had a mean BMI of 26.2 kg m⁻² (s.d. 5); 88% were parous, with 2.1 (s.d. 1.2) children on average. The standardised mean BMI increased progressively with the number of births from 25.6 kg m⁻² (95% confidence interval (CI): 25.5–25.6) in nulliparous women up to 27.2 kg m⁻² (CI: 27.2–27.3) for women with four or more births, a difference of 1.7 kg m⁻² (CI: 1.6–1.7). Among the parous women 70% had ever breastfed and their average total duration of breastfeeding was 7.7 (s.d. 8.8) months. At every parity level the standardised mean BMI was significantly lower among women who had breastfed than those who had not, decreasing by 0.22 kg m⁻² (CI: 0.21–0.22) for every 6 months of breastfeeding, that is, women's mean BMI was 1% lower for every 6 months that they had breastfed. These associations were highly statistically significant (P<0.0001) and independent of the effects of socioeconomic group, region of residence, smoking and physical activity.

Conclusions:

Childbearing patterns have a persistent effect on adiposity in this population. The reduction in BMI associated with just 6 months breastfeeding in UK women could importantly reduce their risk of obesity-related disease as they age.

Effect of pregnancy planning and fertility treatment on cognitive outcomes in children at ages 3 and 5: longitudinal cohort study

OBJECTIVE

To investigate how pregnancy planning, time to conception, and infertility treatment influence cognitive development at ages 3 and 5.

DESIGN

Prospective population based cohort study.

SETTING

Millennium Cohort Study in the United Kingdom.

PARTICIPANTS

18,818 children recruited at 9 months and followed up at 3 and 5 years. 11,790 singletons with available data on pregnancy, cognitive outcomes, and confounders were included in analyses at age 3 and 12,136 at age 5. Exposure measures Mothers reported whether the pregnancy was planned, and their feelings when first pregnant; those in whom the pregnancy was planned provided time to conception, and details of any assisted reproductive technologies. The population was divided into "unplanned" (unplanned and unhappy), "mistimed" (unplanned but happy), "planned" (planned, time to conception <12 months), "subfertile" (planned, time to conception ≥ 12 months), "induced ovulation" (received clomiphene citrate), and "assisted reproduction" (in vitro fertilisation or intracytoplasmic sperm injection). The "planned" group was the comparison group in all analyses.

OUTCOME MEASURES

Three components of the British Ability Scales (BAS II). Naming vocabulary assessed verbal ability at age 3; this test was repeated at age 5 with the picture similarities and pattern construction subscales, which measure non-verbal and spatial abilities.

RESULTS

In unadjusted analyses, the scores on all scales in children from unplanned pregnancies were significantly lower than in those from planned pregnancies-for example, the difference in mean verbal ability score at age 3 was -4.8 (95% confidence interval -6.0 to -3.7; P<0.05), equivalent to an average delay of four months. After adjustment for sociodemographic factors these differences were attenuated: -0.3 (-1.3 to 0.7), equivalent to no delay. Children born after assisted reproduction performed consistently better in verbal ability tests (3.8 (-0.2 to 7.9) at age 3 and 3.5 (0.2 to 6.8) at age 5), which suggests that on average these children are three to four months ahead; this difference did not completely disappear with adjustment for confounders. Children born after infertility treatment had lower mean scores in non-verbal tests (-1.2 (-4.1 to 1.6) after assisted reproduction and -1.5 (-3.5 to 0.4) after induced ovulation) and in spatial ability tests (-2.7 (-6.9 to 1.6) after assisted reproduction), though the differences were not significant.

CONCLUSIONS

Pregnancy planning, subfertility, or assisted reproduction do not adversely affect children's cognitive development at age 3 or 5. The differences observed in the unadjusted analyses are almost entirely explained by marked inequalities in socioeconomic circumstances between the groups.

Cognitive development following ART: effect of choice of comparison group, confounding and mediating factors

BACKGROUND

Epidemiological studies have examined the health of children born after assisted reproductive technology (ART), with contradictory results. In this article, we address the question ‘Do singletons born after ART have a poorer cognitive developmental outcome at 3 years of age?’ We assess the implications of using different comparison groups, and discuss appropriate analytical approaches for the control of confounding and mediating variables.

METHODS

Data were drawn from the Millennium Cohort Study. Interviews captured sociodemographic, behavioural and pregnancy information. Developmental assessments conducted at age three included the British Ability Scales II Naming Vocabulary (BAS-NV) instrument. We compared ART infants (born after IVF or ICSI) to four comparison groups: a ‘matched’ group; a ‘subfertile’ group (time to conception >12 months); a ‘fertile’ group (time to conception <12 months); and an ‘any spontaneous conceptions’ group. Linear regression provided estimates of the difference in mean BAS-NV scores in the ART and comparison groups; both unadjusted estimates and those adjusted for confounding and mediating factors are presented.

RESULTS

In the unadjusted analyses, ART children gained significantly better BAS-NV test results than did the comparison group children. When converted to an estimate of developmental age gap, ART children were 2.5, 2.7, 3.6 and 4.5 months ahead of the ‘matched’, ‘subfertile’, ‘fertile’ and ‘spontaneous conception’ children, respectively. After adjusting for confounding and mediating factors, the differences were reduced, and were not statistically significant.

CONCLUSIONS

ART is not associated with poorer cognitive development at 3 years. We have highlighted methodological considerations for researchers planning to study the effect of infertility and ART on childhood outcomes.

Interpretation and application of world-wide safety data on diltiazem

The safety of medicinal agents being introduced into the marketplace is of growing concern to consumers, health care providers, and regulatory agencies. Although there are ever increasing efforts to improve techniques for testing drugs, and for anticipating and confirming possible adverse effects, arrangements for monitoring and detecting adverse drug reactions are far from satisfactory. Some factors which need to be understood in order to appropriately interpret data include: maturation processes; pretesting affects, measuring instruments affects; selection bias; and the affects of differential experimental mortality. A safety profile has been presented for the calcium entry blocker diltiazem hydrochloride. Efforts were made to focus attention upon the source of safety information as it relates to the quality of the report. The data presented suggests that diltiazem hydrochloride has a low incidence of adverse experiences.

Infant feeding, solid foods and hospitalisation in the first 8 months after birth

Most infants in the UK start solids before the recommended age of 6 months. We assessed the independent effects of solids and breast feeding on the risk of hospitalisation for infection in term, singleton infants in the Millennium Cohort Study (n = 15,980). For both diarrhoea and lower respiratory tract infection (LRTI), the monthly risk of hospitalisation was significantly lower in those receiving breast milk compared with those receiving formula. The monthly risk of hospitalisation was not significantly higher in those who had received solids compared with those not on solids (for diarrhoea, adjusted odds ratio 1.39, 95% CI 0.75 to 2.59; for LRTI, adjusted odds ratio 1.14, 95% CI 0.76 to 1.70), and the risk did not vary significantly according to the age of starting solids.

Formula milk versus donor breast milk for feeding preterm or low birth weight infants

BACKGROUND

When sufficient maternal breast milk is not available, the alternative sources of enteral nutrition for preterm or low birth weight infants are donor breast milk or artificial formula milk. Feeding preterm or low birth weight infants with formula milk might increase nutrient input and growth rates. However, since feeding with formula milk may be associated with a higher incidence of feeding intolerance and necrotising enterocolitis, this may adversely affect growth and development.

OBJECTIVES

To determine the effect of formula milk compared with donor human breast milk on growth and development in preterm or low birth weight infants.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised controlled trials comparing feeding with formula milk versus donor breast milk in preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two reviewer authors, and synthesis of data using relative risk, risk difference and weighted mean difference.

MAIN RESULTS

Eight trials fulfilled the inclusion criteria. Only one trial used nutrient-fortified donor breast milk. Enteral feeding with formula milk compared with donor breast milk resulted in higher rates of growth in the short term. There was no evidence of an effect on long-term growth rates or neurodevelopmental outcomes. Meta-analysis of data from five trials demonstrated a statistically significantly higher incidence of necrotising enterocolitis in the formula fed group: typical relative risk 2.5 (95% confidence interval 1.2, 5.1); typical risk difference: 0.03 (95% confidence interval 0.01, 0.06; number needed to harm: 33 (95% confidence interval 17, 100).

AUTHORS' CONCLUSIONS

In preterm and low birth weight infants, feeding with formula milk compared with donor breast milk results in a higher rate of short-term growth but also a higher risk of developing necrotising enterocolitis. There are only limited data on the comparison of feeding with formula milk versus nutrient-fortified donor breast milk. This limits the applicability of the findings as nutrient fortification of breast milk is now a common practice in neonatal care. Future trials may compare growth, development and adverse outcomes in infants who receive formula milk versus nutrient-fortified donor breast milk given as a supplement to maternal expressed breast milk or as a sole diet.

Agreement between hospital records and maternal recall of mode of delivery: Evidence from 12 391 deliveries in the UK Millennium Cohort Study

OBJECTIVE

The objective of this study was to measure the agreement between hospital records and maternal reporting of mode of delivery in a representative UK sample.

DESIGN

Population-based survey (Millennium Cohort Study).

SETTING

UK.

POPULATION

A total of 12,391 singleton infants born in 2000-2002.

METHODS

Mothers were interviewed when infants were approximately 9 months old. Information was collected by interview on many obstetric and perinatal factors including mode of delivery. Record linkage to the mother's delivery hospital records was undertaken in those who gave consent (90%). A matching record was found for 83%. Maternal report and hospital records were compared using mode of delivery classified into three (normal, assisted and caesarean) and six groups. Factors associated with disagreement between the two data sources were identified.

MAIN OUTCOME MEASURE

Proportion of records in which there was agreement between the two data sources.

RESULTS

Agreement between maternal report and hospital records was at least 94% using six mode of delivery groups and 98% using three groups. Much of the disagreement (57-63%, depending on country) was between forceps and ventouse, and between planned and emergency caesarean. Disagreement was more common in women whose babies were first born and in women not born in the UK.

CONCLUSION

Our study confirms that maternal reporting of mode of delivery is highly reliable. This is important for clinical staff caring for women and those conducting epidemiological studies. Additional data sources may be necessary to gather reliable data from ethnic minority women, particularly those born outside the UK, or to distinguish forceps from ventouse, or planned from emergency caesarean section.

Caesarean delivery and risk of stillbirth in subsequent pregnancy: a retrospective cohort study in an English population

OBJECTIVE

Two recent studies indicate an increased risk of stillbirth in the pregnancy that follows a pregnancy delivered by caesarean section. In this study, we report an analysis designed to test the hypothesis that delivery by caesarean section is a risk factor for explained or unexplained stillbirth in any subsequent pregnancy. We also report on the proportion of stillbirths in our study population, which may have been attributable to previous delivery by caesarean section.

DESIGN

Retrospective cohort study.

POPULATION

Linked statistical data set of 81 784 singleton deliveries registered in Oxfordshire and West Berkshire between 1968 and 1989.

METHODS

The crude and adjusted hazard ratios for stillbirth in deliveries following a previous delivery by caesarean section, compared with no previous caesarean, were estimated using Cox regression.

MAIN OUTCOME MEASURE

Stillbirth.

RESULTS

The unadjusted hazard ratios for all, explained, and unexplained stillbirths were 1.54 (95% CI 1.04-2.29); 2.13 (1.22-3.72); and 1.19 (0.68-2.09), respectively. After adjustment for maternal age, parity, social class, previous adverse outcome of pregnancy, body mass indexand smoking the hazard ratios were 1.58 (0.95-2.63), 2.08 (1.00-4.31) and 1.24 (0.60-2.56).

CONCLUSIONS

Pregnancies in women following a pregnancy delivered by caesarean section are at an increased risk of stillbirth. In our study, the risk appears to be mainly concentrated in the subgroup of explained stillbirths. However, there are sufficient inconsistencies in the developing literature about stillbirth risk that further research is needed.

How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study

AIMS

To assess the effect of several measures of infant feeding on diarrhoeal disease, and whether these effects vary according to markers of social deprivation.

METHODS

Case-control study of diarrhoeal disease cases presenting to 34 general practices in England. Controls were stratified on age group, area deprivation index for the practice, and whether or not the practice was in London. Data were available on 304 infants (167 cases and 137 controls).

RESULTS

After adjustment for confounders, breast feeding was associated with significantly less diarrhoeal disease. Associations were striking even in infants aged > or = 6 months. They did not vary by social class, but were greater in those living in rented council accommodation and in more crowded households. The effect of receiving no breast milk was stronger in more deprived areas than in less deprived areas. The effect of not receiving exclusive breast milk was stronger in more deprived areas than in less deprived areas. In formula fed infants, there was significantly more diarrhoeal disease in those not sterilising bottles/teats with steam or chemicals. The protective effect of breast feeding did not persist beyond two months after breast feeding had stopped.

CONCLUSIONS

Breast feeding protects against diarrhoeal disease in infants in England although the degree of protection may vary across infants and wear off after breast feeding cessation. Education about the benefits of breast feeding and the risks of inadequate sterilisation should be targeted at carers in deprived areas or households.

Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace

BACKGROUND

Lateral ligament ankle sprains are the single most common sports injury.

OBJECTIVE

To determine the functional outcome of the ankle joint after a moderate or severe inversion injury, comparing standard treatment with an elastic support bandage against an Aircast ankle brace.

DESIGN

Prospective, randomised controlled trial.

SETTING

Two accident and emergency departments.

METHOD

Fifty patients presenting consecutively were randomised into two equal groups: one group was treated with an elastic support bandage and the other with an Aircast ankle brace. All patients were given a standardised advice sheet referring to rest, ice, compression, and elevation. Patients were reviewed after 48-72 hours, 10 days, and one month.

PRIMARY OUTCOME MEASURE

Ankle joint function assessed at 10 days and one month using the modified Karlsson scoring method (maximum score 90).

SECONDARY OUTCOME MEASURE

The difference in ankle girth (swelling) and pain score at 10 days.

RESULTS

Seventeen patients in the elastic support bandage group (six defaulted, two excluded) and 18 patients in the Aircast ankle brace group (six defaulted, one excluded) completed the study. There were no significant differences between the two groups at presentation in terms of age (mean 35.3 and 32.6 years respectively), sex, dominant leg, left or right ankle injured, previous injury, time to presentation (median three and four hours respectively), difference in ankle girth (mean 14.5 and 14.3 mm respectively), and pain scores (mean 6.2 and 5.8 respectively). The Karlsson score was significantly higher in the Aircast ankle cast group than in the elastic bandage group at 10 days (mean 50 v 35, p = 0.028, 95% confidence interval (CI) 1.7 to 27.7) and one month (mean 68 v 55, p = 0.029, 95% CI 1.4 to 24.8) (Student's t test). There was no difference between the groups in the secondary outcome measures (swelling, p = 0.09; pain, p = 0.07). When hierarchical multiple regression analysis was used to correct for possible baseline confounding factors, the Aircast ankle brace group was significantly associated with higher Karlsson scores at 10 days (p = 0.009) and one month (p = 0.024).

CONCLUSION

The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with standard management with an elastic support bandage.

An audit of sports injuries in children attending an Accident & Emergency department

OBJECTIVE

To assess the incidence of attendance, type of injury, sport involved and management of sports injuries in children attending an Accident & Emergency (A&E) department.

METHOD

Children, aged between 5-16 years, presenting with an injury related to sport, were studied over a period of three months.

RESULTS

1858 children attended the A&E department during the three month period. 238 (12.8%) were classified as sports injuries. Boys (71%) were injured more frequently than girls (29%). Injury rates in boys peaked at 14 years whereas in girls a peak occurred earlier at 12 years. Football was the most common sport implicated in injuries (39%). Rollerblading (14%), Rugby (8%), Basketball (7%) and Physical Education at school (7%) were the next most frequently involved sports. Soft tissue injuries dominated (61%). The upper limb was the most common anatomical area injured (46%). Other injuries involved the lower limb (36%), head and neck (15%) and the trunk (3%). Injuries to the wrist were the most frequent presentation accounting for 30 fractures and 30 soft tissue injuries (25%). The majority of children were discharged from the A&E department after treatment (71%). 26% were reviewed at out-patient clinics and 3% required hospital admission. No children were referred for physiotherapy.

CONCLUSION

Children participate in sport and can be injured. The majority of sports injuries presenting to an A&E department appear to be of a minor nature and could be managed with simple first aid techniques by parents, teachers and coaches at the scene or by attending primary care in the first instance. Supervision of children, participation in organised sport and the use of protection devices may help to prevent serious injury.

Test-retest precision of functional magnetic resonance imaging processed with independent component analysis

This study was designed to compare the test-retest precision of functional magnetic resonance imaging (fMRI) data processed with independent component analysis (ICA) and the same data analyzed with a conventional model-dependent method (Student's- t mapping). Volunteers underwent two or three iterations of visual and auditory stimuli, while data were collected for fMRI scans. The scan data were separately processed with ICA and with Student's- t mapping (STM). As a measure of test-retest precision, concurrence ratios were calculated for each subject and each task as the number of voxels that were activated by two iterations of a task divided by the average number of voxels activated in each repetition. In 28 test-retest comparisons, the average concurrence ratio was 0.69+/-0.10 for ICA and 0.65+/-0.13 for the conventional method, a statistically insignificant difference. In fMR image data of block stimulus paradigms, ICA had similar test-retest precision to a conventional model-dependent method.

Unintentional rapid opioid detoxification

Naltrexone is a long acting opioid antagonist that is used in rehabilitation programmes to maintain heroin abstinence. It is a relatively new drug prescribed by specialists in substance misuse. Its actions and effects may not be familiar to many accident and emergency doctors or even to the people who take it. A case report is described where accidental ingestion of naltrexone results in a medical emergency by precipitating acute withdrawal in a heroin addict.

Rollerblading injuries in children attending an accident & emergency department: should the use of wrist splints be compulsory?

Our aim was to determine the incidence and nature of injuries in children from rollerblading attending a district general hospital Accident & Emergency (A&E) department in Scotland. Children, aged between 5-16 years, presenting with an injury from rollerblading, were studied prospectively over a three month period. A total of 34 children attended the department with a rollerblading injury. Boys (53%) and girls (47%) were injured almost equally. The wrist was the most frequently injured area of the body (62%) with 12 fractures and 9 soft tissue injuries. No children were wearing any form of protective equipment. Rollerblading is an increasingly popular, but expensive, activity amongst children in Scotland. Wrist injuries from falling were the most common presentation which may result in prolonged school absenteeism. Emphasis is normally placed on protective headgear, however, with wrist injuries more common, consideration must be given to the active promotion of injury prevention and the wearing of wrist splints.

Frequencies contributing to functional connectivity in the cerebral cortex in "resting-state" data

BACKGROUND AND PURPOSE

In subjects performing no specific cognitive task ("resting state"), time courses of voxels within functionally connected regions of the brain have high cross-correlation coefficients ("functional connectivity"). The purpose of this study was to measure the contributions of low frequencies and physiological noise to cross-correlation maps.

METHODS

In four healthy volunteers, task-activation functional MR imaging and resting-state data were acquired. We obtained four contiguous slice locations in the "resting state" with a high sampling rate. Regions of interest consisting of four contiguous voxels were selected. The correlation coefficient for the averaged time course and every other voxel in the four slices was calculated and separated into its component frequency contributions. We calculated the relative amounts of the spectrum that were in the low-frequency (0 to 0.1 Hz), the respiratory-frequency (0.1 to 0.5 Hz), and cardiac-frequency range (0.6 to 1.2 Hz).

RESULTS

For each volunteer, resting-state maps that resembled task-activation maps were obtained. For the auditory and visual cortices, the correlation coefficient depended almost exclusively on low frequencies (<0.1 Hz). For all cortical regions studied, low-frequency fluctuations contributed more than 90% of the correlation coefficient. Physiological (respiratory and cardiac) noise sources contributed less than 10% to any functional connectivity MR imaging map. In blood vessels and cerebrospinal fluid, physiological noise contributed more to the correlation coefficient.

CONCLUSION

Functional connectivity in the auditory, visual, and sensorimotor cortices is characterized predominantly by frequencies slower than those in the cardiac and respiratory cycles. In functionally connected regions, these low frequencies are characterized by a high degree of temporal coherence.

Assessment of Leishmaniasis notification system in Santiago del Estero, Argentina, 1990-1993

Using a capture-recapture method, this study evaluates the completeness of the cutaneous leishmaniasis (CL) surveillance system in four districts of Santiago del Estero province, Argentina, for the period 1990-1993. Four reporting sources were evaluated: medical records kept by health facilities, interviews conducted during a case-control study, and the national and provincial levels of the leishmaniasis surveillance system (LSS). Using the capture-recapture method it was estimated that 210 cases (95% confidence interval [CI]: 202-218) of CL occurred in the four districts during the study period. Completeness of reporting to the leishmaniasis surveillance system at the national level was estimated to be 44.8% (95% CI: 43.2-46.4). The study results indicate that there is substantial underreporting within the LSS, although it did show the appropriate secular trends. The reasons for under-reporting and methods for addressing this problem are discussed.

HIV-1-related pleural tuberculosis: elevated production of IFN-gamma, but failure of immunity to Mycobacterium tuberculosis

BACKGROUND

Pleural tuberculosis can resolve spontaneously, suggesting that the inflammatory process may represent a protective immune response. However, pleural tuberculosis is strongly associated with HIV infection. It has been suggested that cell-mediated immune responses may be reduced, and direct bacterial invasion may have a role in pathogenesis, in HIV-positive cases. To test this hypothesis, we compared production of the pro-inflammatory cytokines, interferon (IFN)-gamma and tumour necrosis factor(TNF)-alpha, production of the immunosuppressive cytokine, interleukin (IL)-10, and mycobacterial culture positivity, in HIV-negative and HIV-positive patients with pleural tuberculosis.

METHODS

Cytokine levels were measured in serum and pleural fluid, and in supernatants of blood and pleural fluid stimulated in vitro using mycobacterial antigens. Intracellular IFN-gamma and TNF-alpha production was measured after stimulation with phorbol myristate acetate and ionomycin in vitro.

RESULTS

IFN-gamma was strikingly elevated in serum and pleural fluid in HIV-positive, compared to HIV-negative subjects (P < or = 0.02). TNF-alpha was elevated, but this was not statistically significant. IL-10 levels were higher in serum (P < 0.001), but similar in pleural fluid. IFN-gamma responses to soluble mycobacterial antigen in vitro were reduced in peripheral blood (P = 0.006), but not pleural fluid, of HIV-positive subjects. Intracellular cytokine staining suggested that CD8+ T cells were a major source of IFN-gamma in HIV-positive subjects. The proportion of subjects with a positive culture for Mycobacterium tuberculosis from pleural fluid was higher in the HIV-positive group.

CONCLUSIONS

HIV-positive patients with pleural tuberculosis show elevated production of IFN-gamma, for which CD8+ T cells may be a major source. Mycobacterium tuberculosis can proliferate despite high levels of pro-inflammatory cytokines.

Male circumcision as a measure to control HIV infection and other sexually transmitted diseases

There is growing epidemiological evidence from sub-Saharan Africa that male circumcision reduces the risk of HIV acquisition. We review the recent evidence of the protective effect on HIV and other sexually transmitted diseases, including discussion of possible biological mechanisms and highlighting the limitations of the observational studies on which these findings are based. We conclude by discussing the public health implications of these findings, including issues such as safety, acceptability, feasibility and cost-effectiveness of promoting male circumcision in African populations.

Long-term effect of preventive therapy for tuberculosis in a cohort of HIV-infected Zambian adults

OBJECTIVE

To determine the long-term effect of preventive therapy (PT) for tuberculosis on the rates of tuberculosis, mortality and HIV progression.

METHODS

In a randomized controlled trial, 1053 HIV-positive Zambian adults received isoniazid (H) for 6 months, rifampicin plus pyrazinamide (RZ) for 3 months, or a placebo. CD4 percentage, neopterin, absolute lymphocyte count and haemoglobin were measured from enrolment (absolute CD4 cell counts from 12 months after enrolment). Because PT reduced the incidence of tuberculosis, eligible placebo subjects were offered H. Here, tuberculosis and mortality rates are compared in the three original arms (intention to treat) using data beyond the end of the trial (average follow-up 3 years; maximum 7 years).

RESULTS

There were 102 cases of tuberculosis and 281 deaths (rates 3.6 and 9.0/100 person-years, respectively). There was no significant difference between the tuberculosis rates in the H and RZ groups at any time. The effect of H/RZ on tuberculosis diminished over time (P = 0.011) but the cumulative risk of tuberculosis in the first 2.5 years was significantly lower in the H/RZ group than the placebo group (rate ratio 0.55; 95% confidence interval 0.32-0.93; P = 0.028). There was no significant effect of PT on mortality or progression markers. Tuberculosis was associated with an increased mortality (adjusted rate ratio 1.96; 95% confidence interval 1.21-3.18; P = 0.006).

CONCLUSIONS

Both PT regimens protect against tuberculosis for at least 2.5 years but appear to have no effect on HIV progression or mortality. These results may be used in cost-effectiveness models of PT.

Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVE

To systematically review studies of male circumcision and the risk of HIV-1 infection in men in sub-Saharan Africa, and to summarize the findings in a meta-analysis.

DESIGN

A meta-analysis of observational studies.

METHODS

A systematic literature review was carried out of studies published up to April 1999 that included circumcision as a risk factor for HIV-1 infection among men in sub-Saharan Africa. A random effects meta-analysis was used to calculate a pooled relative risk (RR) and 95% confidence interval (CI) for all studies combined, and stratified by type of study population. Further analyses were conducted among those studies that adjusted for potential confounding factors.

RESULTS

Twenty-seven studies were included. Of these, 21 showed a reduced risk of HIV among circumcised men, being approximately half that in uncircumcised men (crude RR = 0.52, CI 0.40-0.68). In 15 studies that adjusted for potential confounding factors, the association was even stronger (adjusted RR = 0.42, CI 0.34-0.54). The association was stronger among men at high risk of HIV (crude RR = 0.27; adjusted RR = 0.29, CI 0.20-0.41) than among men in general populations (crude RR = 0.93; adjusted RR = 0.56, CI 0.44-0.70).

CONCLUSION

Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised.

Mapping functionally related regions of brain with functional connectivity MR imaging

BACKGROUND AND PURPOSE

In subjects who are performing no prescribed cognitive task, functional connectivity mapped with MR imaging (fcMRI) shows regions with synchronous fluctuations of cerebral blood flow. When specific tasks are performed, functional MR imaging (fMRI) can map locations in which regional cerebral blood flow increases synchronously with the performance of the task. We tested the hypothesis that fcMRI maps, based on the synchrony of low-frequency blood flow fluctuations, identify brain regions that show activation on fMRI maps of sensorimotor, visual, language, and auditory tasks.

METHODS

In four volunteers, task-activation fMRI and functional connectivity (resting-state) fcMRI data were acquired. A small region of interest (in an area that showed maximal task activation) was chosen, and the correlation coefficient of the corresponding resting-state signal with the signal of all other voxels in the resting data set was calculated. The correlation coefficient was decomposed into frequency components and its distribution determined for each fcMRI map. The fcMRI maps were compared with the fMRI maps.

RESULTS

For each task, fcMRI maps based on one to four seed voxel(s) produced clusters of voxels in regions of eloquent cortex. For each fMRI map a closely corresponding fcMRI map was obtained. The frequencies that predominated in the cross-correlation coefficients for the functionally related regions were below 0.1 Hz.

CONCLUSION

Functionally related brain regions can be identified by means of their synchronous slow fluctuations in signal intensity. Such blood flow synchrony can be detected in sensorimotor areas, expressive and receptive language regions, and the visual cortex by fcMRI. Regions identified by the slow synchronous fluctuations are similar to those activated by motor, language, or visual tasks.

Combining independent component analysis and correlation analysis to probe interregional connectivity in fMRI task activation datasets

A new approach in studying interregional functional connectivity using functional magnetic resonance imaging (fMRI) is presented. Functional connectivity may be detected by means of cross correlating time course data from functionally related brain regions. These data exhibit high temporal coherence of low frequency fluctuations due to synchronized blood flow changes. In the past, this fMRI technique for studying functional connectivity has been applied to subjects that performed no prescribed task ("resting" state). This paper presents the results of applying the same method to task-related activation datasets. Functional connectivity analysis is first performed in areas not involved with the task. Then a method is devised to remove the effects of activation from the data using independent component analysis (ICA) and functional connectivity analysis is repeated. Functional connectivity, which is demonstrated in the "resting brain," is not affected by tasks which activate unrelated brain regions. In addition, ICA effectively removes activation from the data and may allow us to study functional connectivity even in the activated regions.

Case-control study of risk factors for incident HIV infection in rural Uganda

OBJECTIVE

To identify risk factors associated with HIV incidence in a rural Ugandan population.

DESIGN

Case-control study.

METHODS

Men and women who seroconverted between 1990 and 1997 (cases) and seronegative subjects (controls) were drawn from a general population cohort of approximately 5000 adults in rural, southwestern Uganda. Information on risk factors was ascertained through a detailed interview and physical examination by clinicians who were blind to the study subjects' HIV status. All patients were interviewed within 2 years of their estimated date of seroconversion.

RESULTS

Data were available on 130 men (37 cases, 93 controls) and 133 women (46 cases, 87 controls). There was a significantly higher risk of infection in men (odds ratio [OR], 6.51; 95% confidence interval [CI], 1.06-39.84) and women (OR, 4.75; 95% CI, 1.26-17.9) who were unmarried and in a steady relationship, and in men who were divorced, separated, or widowed (OR, 4.33; 95% CI, 1.32-14.25) compared with those who were married. There was a significantly higher risk of HIV infection in men (OR, 3.78; 95% CI, 1.20-11.93) and women (OR, 20.78; 95% CI, 2.94-141.2) who reported > or =5 lifetime sexual partners compared with those who reported at most 1 partner. For men, there was an increased risk of infection associated with receiving increasing numbers of injections in the 6 months prior to interview (p < .001 for trend). Women reporting sex against their will in the year prior to interview were at higher risk of infection (OR, 7.84; 95% CI, 1.29-47.86; p = .020).

CONCLUSIONS

The strongest risk factor for HIV incidence in this rural Ugandan population is lifetime sexual partners. The increased risks found for women reporting coercive sex and men reporting injections require further investigation.

Validity of data-derived algorithms for ascertaining causes of adult death in two African sites using verbal autopsy

background Verbal autopsy (VA) is used to ascertain causes of death using information obtained from bereaved relatives. Causes of death can be ascertained from VA questionnaires by a panel of physicians or from predefined algorithms. In a previous study, we developed data-derived algorithms using VA data from 796 adult deaths in hospitals in Tanzania, Ethiopia, and Ghana (primary sites). These computerized algorithms accurately estimated the cause-specific mortality fractions (CSMFs) for deaths due to injuries, meningitis, TB/AIDS and diarrhoeal diseases in the primary sites. Since the same data were used to generate and to validate the algorithms, the accuracy of our algorithms may have been overestimated. We report here on the validity of the algorithms when they were applied to VA data from two secondary sites in Ghana and Tanzania. Here, 'validity' is taken to mean the degree to which the algorithms replicated the physician-generated CSMF for major causes of death, when applied to the same VA data. methods VA interviews were conducted in two secondary sites: in Navrongo, Ghana, on 406 adult deaths, where three local physicians independently reviewed the questionnaires and assigned a cause of death. In Morogoro, Tanzania, VA interviews were conducted on 209 adult deaths, and a panel of physicians independently reviewed the VA questionnaires together with the hospital death certificates or hospital records to determine the cause of death. The CSMF obtained using each algorithm was compared with the CSMF obtained using physician review. results For injuries and meningitis, the algorithms and physician review estimated a similar CSMF in the Morogoro and Navrongo data. For TB/AIDS, the algorithm estimated a similar CSMF as the physicians in Morogoro. The algorithm for diarrhoeal diseases did not agree closely with the physicians in Morogoro or Navrongo. conclusions In general, our data-derived algorithms for assigning causes of death due to injuries, meningitis, and TB/AIDS estimated a similar CSMF as the physicians in the secondary sites. Recommendations for further validation and refinement are discussed. Computerized algorithms offer a potentially quick, affordable, and feasible method for assigning causes of death in mortality surveillance or studies using VA.

Diagnostic accuracy of physician review, expert algorithms and data-derived algorithms in adult verbal autopsies

BACKGROUND

The verbal autopsy (VA) is used to collect information on cause-specific mortality from bereaved relatives. A cause of death may be assigned by physician review of the questionnaires, or by an algorithm. We compared the diagnostic accuracy of physician review, an expert algorithm, and data-derived algorithms.

METHODS

Data were drawn from a multicentre validation study of 796 adult deaths that occurred in hospitals in Tanzania, Ethiopia, and Ghana. A 'gold standard' cause of death was assigned using hospital records and death certificates. The VA interviews were carried out by trained fieldworkers 1-21 months after the subject's death. A cause of death was assigned by physician review and an expert algorithm. Data-derived algorithms that most accurately estimated the cause-specific mortality fraction (CSMF) for each cause of death were identified using logistic regression.

RESULTS

The most common causes of death were tuberculosis/AIDS (CSMF = 18.6%), malaria (CSMF = 10.7%), meningitis (CSMF = 8.3%), and cardiovascular disorders (CSMF = 8.2%). The CSMF obtained using physician review was within +/-20% of the gold standard value for 12 causes of death including the four common causes. The CSMF obtained using the expert algorithm was within +/-20% of the gold standard for eight causes of death, including tuberculosis/AIDS, malaria, and meningitis. The CSMF obtained using the data-derived algorithms was within +/-20% of the gold standard for seven causes of death, including tuberculosis/ AIDS, meningitis, and cardiovascular disorders. All three methods yielded a specificity of at least 80% for all causes of death, and a sensitivity of at least 80% for deaths due to injuries and rabies.

CONCLUSIONS

For those settings where physician review is not feasible, expert and data-derived algorithms provide an alternative approach for assigning many causes of death. We recommend that the algorithms proposed herein are validated further.

Inverse association between BCG immunisation and intestinal nematode infestation among HIV-1-positive individuals in Uganda

Exposure to infections in infancy may induce a sustained bias in the immune response. In our study, previous BCG immunisation was associated with a reduced prevalence of intestinal nematode infection.

The immune response to Mycobacterium tuberculosis in HIV-infected and uninfected adults in Uganda: application of a whole blood cytokine assay in an epidemiological study

SETTING

Out-patient clinic, Entebbe, Uganda.

BACKGROUND

It has been proposed that 'type 1' cytokines are essential in protective immunity to Mycobacterium tuberculosis and that suppression of 'type 1' or a switch to a 'type 2' profile is deleterious. We employed a simple assay to examine whether the dependence of the immunological responses to mycobacterial antigens on a range of explanatory factors could be determined in a population where tuberculosis is endemic.

OBJECTIVE

To determine the relationship between the tuberculin skin test response and cytokine profile, and the effect of human immunodeficiency virus (HIV) infection.

DESIGN

A cross-sectional study of 97 Ugandan adults (22 HIV-positive, 75 HIV-negative). Whole blood was stimulated in vitro using mycobacterial antigens (purified protein derivative [PPD] and culture filtrate proteins [CFP]). 'Type 1' cytokines (gamma interferon [IFN-gamma] and interleukin-2 [IL-2]), 'type 2' cytokines (IL-5 and IL-10) and tumour necrosis factor alpha (TNF-alpha) were measured in culture supernatants.

RESULTS

Among HIV-negative subjects, a positive tuberculin skin test was associated with type 1 or mixed (type 1 + type 2) cytokine production, but a positive IFN-gamma response also occurred in a proportion of tuberculin skin test negative subjects (36% for PPD, 17% for CFP). In association with HIV infection, IFN-gamma responses to mycobacterial antigens were profoundly impaired (odds ratio [OR] 0.10 for PPD, 0.06 for CFP, P< or =0.001), but production of IL-2, IL-5 and TNF-alpha was relatively sustained, and IL-10 increased or sustained (OR 3.97 for PPD, P = 0.01, 1.14 for CFP, P = 0.99).

CONCLUSION

The type 1/type 2 cytokine balance was not defined by the tuberculin skin test response, and may have a closer relation to protective immunity. IFN-gamma production was strikingly impaired in association with HIV infection, while production of type 2 cytokines was sustained or increased. Use of a simple assay allowed a large sample of subjects to be examined, producing epidemiologically meaningful results.

Algorithms for verbal autopsies: a validation study in Kenyan children

The verbal autopsy (VA) questionnaire is a widely used method for collecting information on cause-specific mortality where the medical certification of deaths in childhood is incomplete. This paper discusses review by physicians and expert algorithms as approaches to ascribing cause of deaths from the VA questionnaire and proposes an alternative, data-derived approach. In this validation study, the relatives of 295 children who had died in hospital were interviewed using a VA questionnaire. The children were assigned causes of death using data-derived algorithms obtained under logistic regression and using expert algorithms. For most causes of death, the data-derived algorithms and expert algorithms yielded similar levels of diagnostic accuracy. However, a data-derived algorithm for malaria gave a sensitivity of 71% (95% Cl: 58-84%), which was significantly higher than the sensitivity of 47% obtained under an expert algorithm. The need for exploring this and other ways in which the VA technique can be improved are discussed. The implications of less-than-perfect sensitivity and specificity are explored using numerical examples. Misclassification bias should be taken into consideration when planning and evaluating epidemiological studies.

Building a managed care approach

Managed care enhances nursing autonomy and accountability and increases awareness of patients' interactions within a complex multidisciplinary healthcare delivery system. By using this approach, both physicians and nurses are able to assist patients to achieve outcomes quickly, decrease length of hospital stay, and facilitate continuity of care in a cost-effective manner.

Decreased parietal cell acid secretion after vagotomy is not associated with altered gastric prostaglandin levels

In a previous investigation we demonstrated that after vagotomy there is a decreased ability of parietal cells to use intracellular cyclic adenosine monophosphate (cAMP). Prostaglandins are present in gastric mucosa and have been demonstrated to be inhibitors of in vivo and in vitro acid secretion through a cAMP-mediated mechanism. In the present study we have examined in vitro acid secretion and prostaglandin E2 levels in rabbits 8 weeks after vagotomy and pyloroplasty compared with control animals to investigate the possible role of prostaglandins in postvagotomy-impaired cAMP use. In vitro acid secretion was assessed in isolated gastric glands by 14C-labeled aminopyrine uptake and prostaglandin E2-generating capacity measured by high-pressure liquid chromatography. After vagotomy, there was a decrease in basal aminopyrine uptake (p less than 0.05), as well as that simulated by histamine and 8-bromo-cAMP (p less than 0.007). No differences were observed in prostaglandin E2 levels in either gastric glands or intact fundic mucosa (p greater than 0.5). These data suggest that impaired cAMP use observed in parietal cells after vagotomy is not the result of alterations in gastric prostaglandin levels.