The risks of venous thromboembolic disease among German women using oral contraceptives: a database study

This study investigated the risk of venous thromboembolic disease (VTE) between second and third generation combined oral contraceptives, using the German MediPlus database of patient records. Women studied included 42 patients between the ages of 18 and 49 years, with a diagnosis of VTE treated with an anticoagulant, who were exposed to an oral contraceptive (OC). Four controls per patient (168), matched by year of birth and exposure to an OC on the even day, were identified. More women were users of second generation than third generation OC, and none were using progestogen-only pills. There was no significant difference between patients and control subjects with respect to the type of OC used on the event day (unadjusted odds ratio for third versus second generation users was 0.77; 95% confidence interval [CI] 0.38-1.57). There was no significant age difference between second and third generation users among patients or control subjects. Between January 1 and the event date, there was no significant difference between the patients and control subjects in terms of the number of oral contraceptive prescriptions, number of consultations for psychotherapeutic complaints, or mixed physical and psychotherapeutic consultations; however, patients did demonstrate significantly more consultations for purely physical complaints compared with control subjects (p < 0.0001). There were no significant consultation differences between patients with pulmonary emboli (n = 6) and other VTE patients (n = 36). No significant differences with respect to VTE risk between users of second and third generation oral contraceptives were found in this study. Consultations (physical) for patients were higher than for control subjects before the VTE event. If consultation rate relates to the general health status of a person, this might indicate that VTE risk is higher among women of poorer health, but that this is not related to the type of progestogen in the oral contraceptive that they use.

Thromboembolic stroke in young women. A European case-control study on oral contraceptives. Transnational Research Group on Oral Contraceptives and the Health of Young Women

A matched case-control study was performed between 1993 and 1996 in 16 centers in the United Kingdom, Germany, France, Switzerland, and Austria. The objective was to determine the influence of oral contraceptives (OC), particularly those containing modern progestins, on the risk for ischemic stroke in women aged 16-44 years. A total of 220 women who had had an incident ischemic stroke and were compared with 775 control subjects who were unaffected by stroke. At least one hospital and one community control subject per patient was matched and interviewed with the corresponding patient for 5-year age band and for area of residence. Crude odds ratios (95% confidence intervals [CI]) for ischemic stroke were as follows. For current use of any OC versus no use 2.3 (1.7-3.2), the adjusted odds ratio (OR) 3.6 (2.4-5.4). The OC associated risk was higher for first generation than for second or third generation OC. The risk estimates for patients versus community control subjects were always lower than for hospital control subjects. No major regional difference of the risk estimates was found. Compared with nonusers of OC without hypertension, women with hypertension who used OC had an almost 10-fold increased risk. However, OC users who had had a blood pressure check before OC prescription had a lower risk than did those without such a check. Smoking > 10 cigarettes/day is associated with higher risk of stroke, particularly for OC users. No significant effect was found for duration of OC use. We conclude that although there is a small relative risk of occlusive stroke for healthy women currently using OC, the attributable risk is very small because the incidence in this age group is very low. The small increase in risk of OC use may be further reduced by preventive efforts for cardiovascular risk factors, particularly hypertension and smoking.

Case-control study of oral contraceptives and risk of thromboembolic stroke: results from International Study on Oral Contraceptives and Health of Young Women

OBJECTIVE

To determine the influence of oral contraceptives (particularly those containing modern progestins) on the risk for ischaemic stroke in women aged 16-44 years.

DESIGN

Matched case-control study.

SETTING

16 Centres in the United Kingdom, Germany, France, Switzerland, and Austria.

SUBJECTS

Cases were 220 women aged 16-44 who had an incident ischaemic stroke. Controls were 775 women (at least one hospital and one community control per case) unaffected by stroke who were matched with the corresponding case for 5 year age band and for hospital or community setting. Information on exposure and confounding variables were collected in a face to face interview.

MAIN OUTCOME MEASURES

Odds ratios derived with stratified analysis and unconditional logistic regression to adjust for potential confounding.

RESULTS

Adjusted odds ratios (95% confidence intervals) for ischaemic stroke (unmatched analysis) were 4.4 (2.0 to 9.9), 3.4 (2.1 to 5.5), and 3.9 (2.3 to 6.6) for current use of first, second, and third generation oral contraceptives, respectively. The risk ratio for third versus second generation was 1.1 (0.7 to 2.0) and was similar in the United Kingdom and other European countries. The risk estimates were lower if blood pressure was checked before prescription.

CONCLUSION

Although there is a small relative risk of occlusive stroke for women of reproductive age who currently use oral contraceptives, the attributable risk is very small because the incidence in this age range is very low. There is no difference between the risk of oral contraceptives of the third and second generation; only first generation oral contraceptives seem to be associated with a higher risk. This small increase in risk may be further reduced by efforts to control cardiovascular risk factors, particularly high blood pressure.

The spectrum of spinal cord dysraphism and bladder neuropathy in children

The frequency of bladder neuropathy and its relationship to abnormalities of the neural axis on MR scan was examined in a group of 49 children with known occult spinal dysraphism and 148 children with daytime urinary incontinence. Of the patients with known spinal dysraphism 55% had bladder neuropathy. There was no relationship between either the type of abnormality or the number of abnormalities seen on MR scan and the presence or absence of bladder neuropathy. 5 of the 9 patients with a normal cord had neuropathic bladders. Four of the 148 patients with daytime wetting turned out to have spinal dysraphism. Of the rest, 51 patients required urodynamic studies and of these 12 had clearcut bladder neuropathy. 15 patients had MR scans, all of which were normal. The range of urodynamic findings in those with bladder neuropathy was identical to the range found in patients with spinal dysraphism. On the basis of these findings it is suggested that children with isolated bladder problems could well have spinal cord dysraphism as a cause of these - the lesions being beyond the resolution of MR scanning. For those children with clearcut spinal dysraphism the absence of any relationship between the bladder findings and the lesion places a question mark over the potential benefits of neurosurgical intervention.

How adequate are hospital records?--The first report of the North West Spina Bifida Registry

The United Kingdom North West Regional Registry of patients with Neural Tube Defects was established in June 1996. The aims of the registry are to keep a record of all patients in a defined geographical location with neural tube defects and to ensure appropriate facilities and follow-up are available. During the first year of the registry 217 patients have been identified and the hospital records of 163 of these reviewed. This report deals with the shortcomings of hospital records identified during this exercise. We identified many inaccuracies and omissions when reviewing case notes. 3% of patients had unclear records as to the presence/absence of shunts. Bladder management was unclear in 17% of patients and bowel management in 26% of cases. There was no record as to the presence/absence of hydronephrosis or renal scarring in 24% and 34% of patients respectively, no blood pressure measurement in 50% of patients and no record of a serum creatinine in 56%. Mobility was not recorded in over 30% of patients. Developmental achievement and school placement were rarely if ever recorded. These results demonstrate the problems with the current medical record system. The potential consequences of this are discussed and means of improving record systems suggested.

The incidence of chronic headache in children with shunted hydrocephalus

Report of chronic headache amongst children with shunted hydrocephalus is frequent, and often leads to investigation for raised intra-cranial pressure and shunt malfunction, and much debate has appeared in the literature concerning possible cause. However headache is a common neurological symptom amongst children, and studies of prevalence indicate incidence of frequent non-migrainous headache to be 6.8%, and migrainous headache 4% in the general child population. A relationship between stress and anxiety and headache is recognised, and the hydrocephalic child has many reasons above those of his/her peers to be subject to stress. It is also hypothesised that this group may be more vulnerable than peers to developing a migraine-like condition in the face of adequate shunt function. The clinician dealing with complaint of chronic headache in a hydrocephalic child must therefore be wary of over-investigation in a child with a working shunt, or missing possible shunt malfunction when the only symptom is chronic headache. It was speculated therefore that incidence of non-shunt related chronic headache in this group would be high, and an attempt was made to document incidence of migrainous and non-migrainous headache in the medical notes, and in replies to postal questionnaire sent to a sample of 130 children with shunted hydrocephalus of varying aetiology. Incidence of migrainous headache was documented in the medical notes in 8.5% of cases, with incidence rising to 21.5% using self-report. Incidence of non-migrainous headache was also very high (15.4%) and the overlap between migraine and tension headache, combined with difficulty of diagnosis in children may indicate migraine to be more frequent still. The concept of "Shunt Migraine" is therefore worthy of consideration. Report of chronic headache led to investigation in a large proportion of cases, but symptomatology often continued. Even when shunt malfunction was indicated, shunt revision did not "cure" complaint of headache. Headache was not found to be related to diagnosis associated with hydrocephalus, to presence of seizure disorder, or to the sex of the child, although in common with other studies, there was a strong trend towards girls being statistically more likely to experience headache than boys. There was a relationship however between report of chronic headache, and the sort of school a child was likely to attend; children who attended mainstream school without the support of a Statement of Special Educational Need were more likely to report headache than their peers, and it is hypothesised that these children may be suffering sufficient stress to contribute to maintenance of headache. The importance of the multi-disciplinary team in assessment of children's physical, intellectual and emotional status is stressed, in order that medical interventions have the greatest chance of success.

A comparison of double-cuffed with single-cuffed Tenckhoff catheters in the prevention of infection in pediatric patients

Double-cuffed peritoneal catheters (DCCs) may be more effective at preventing penetrating infection than single-cuffed catheters (SCCs). The aim of this study was to see whether DCCs conferred any benefit in the pediatric population. Twenty consecutive SCCs inserted for chronic dialysis were compared with 20 subsequent DCCs. All catheters were inserted by a single operator (MAL). Outcome was assessed by the number of exit-site infections (ESIs) and episodes of peritonitis. There was no difference in the age or sex distribution of the groups, both having 50% of patients under 5 years. The SCCs were followed for 106 patient-months (1 still in situ) and the DCCs for 145 patient-months (11 still in situ). Peritonitis-related catheter loss was significantly more common with SCCs (9 vs 1, p < 0.01). S. aureus was a significantly more common cause of peritonitis in SCCs (10 vs 3, p < 0.03), although almost all ESIs were with this organism. The relative risk of S. aureus peritonitis with a SCC compared to a DCC was 2.077 (95% confidence interval, CI, 1.17-3.69), and the relative risk of catheter loss with peritonitis was 7.5 for SCCs (95% CI 1.14-49.6). In conclusion, double-cuffed peritoneal catheters are more effective than single-cuffed catheters in preventing penetrating infection in infants and children.

Educating APNs for implementing the guidelines for adolescents in Bright futures: guidelines of health supervision of infants, children, and adolescents

As the scope of what constitutes health and the range of determinants of health-promoting and compromising behaviors among adolescents are expanded, APNs must be well prepared to be powerful influences in the lives of all adolescents. The guidelines offered by Bright Futures challenge nurse educators to prepare APNs who possess the core competencies to knowledgeably address the health issues and concerns of all adolescents in multiple settings. The American Academy of Nursing Expert Panel's recommendations contained herein, if implemented, will further enhance the capabilities of graduate programs to prepare APNs to provide developmentally and culturally relevant disease prevention and health promotion care to adolescents and their families.

The use of oral contraceptives and the occurrence of acute myocardial infarction in young women. Results from the Transnational Study on Oral Contraceptives and the Health of Young Women

The objective of this study was to assess the risk of myocardial infarction (MI) associated with the use of new and old combination oral contraceptives (OC). A matched case-control study in 16 centers in Germany, the United Kingdom, France, Austria, and Switzerland explored the association of current use of combination OC with the occurrence of MI. Our subjects were 182 women aged 16-44 years with MI; the controls were 635 women without MI (at least one hospital control and one community control per case) matched for 5-year age group and region. The main outcome measures were odds ratios comparing current use of a specific group of OC against current use of other groups or against no current use. The adjusted overall odds ratio (OR; 95% confidence intervals) for MI for second generation OC versus no current use was 2.35 (1.42 to 3.89) and 0.82 (0.29 to 2.31) for third generation OC (low dose ethinyl estradiol, gestodene, and desogestrel). A direct comparison of third generation users with second generation users yielded an OR of 0.28 (0.09 to 0.86). In subgroup analyses, the odds ratio for the UK alone was 1.25 (0.36 to 4.29), while for continental Europe it was 0.10 (0.02 to 0.48). For hospital controls, the risk estimated was 0.98 (0.22 to 4.44), and 0.18 (0.04 to 0.65) for community controls. The independent risk of MI among current smokers adjusted for OC use was 7.21 (4.58 to 11.36). Among users of third generation OC, the OR for current smokers was 3.75 (0.65 to 21.74) and among users of second generation it was 9.50 (2.93 to 30.96). A comparison of OC use in the UK for the time before and after regulatory action was taken in October 1995 shows that the likelihood of a control (last control accrued June 1996) being treated with second generation OC is seven times higher after 1 November 1995 than it was before. Third generation OC are the first to be associated with no excess risk of MI. A significantly lower risk of MI is found when comparing use of third generation OC with use of second generation OC. There seems to be an impressive amelioration of risk among smokers using newer OC. An impact of regulatory action in the UK was found in the OC use spectrum of controls.

Communication disturbances in the natural speech of schizophrenic patients and non-schizophrenic parents of patients

Subclinical communication disturbances in the relatives of schizophrenic patients appear to be heterogeneous in both form and origin. The Communication Disturbances Index (CDI) was applied to the natural speech of stable schizophrenic out patients, non-schizophrenic parents of patients, and control subjects. The parents of schizophrenic patients displayed more frequent overall instances of communication failure in their speech than the controls. The specific types of disturbance that were more frequent were structural lack of clarity, vague references and ambiguous word meanings. The parents did not differ significantly from the patients with regard to total CDI ratings. However, patients made more frequent missing-information references than parents, and parents made more frequent vague references than patients. High CDI scores in parents were associated with more severe lifetime core positive symptoms in their patient offspring.

Prolidase deficiency and systemic lupus erythematosus

Two children with prolidase deficiency, an inborn error of proline metabolism, developed clinical and immunological abnormalities consistent with a diagnosis of systemic lupus erythematosus (SLE). The first child died from septicaemia, and SLE was only diagnosed during his terminal illness. As a result of this diagnosis his cousin, who was already known to have prolidase deficiency, was investigated further and a diagnosis of SLE confirmed. Following treatment with oral prednisolone her clinical condition has improved, although she has a persistently raised erythrocyte sedimentation rate (ESR) and florid facial rash. Both prolidase deficiency and SLE are associated with disturbances in immune function and have clinical features in common. It is likely that prolidase deficiency is a risk factor for the development of SLE. Additionally, patients with SLE should-where there is a family history or presentation in childhood-be specifically investigated for prolidase deficiency, since standard immunological or haematological investigations will not identify the characteristic biochemical abnormalities.

Adherence of Candida albicans to experimental denture soft lining materials

STATEMENT OF PROBLEM

Colonization of denture soft lining materials by Candida albicans can result in clinical problems. Two experimental silicone soft lining materials have been developed and demonstrate good physical properties.

PURPOSE OF STUDY

The aim of this study was to determine the extent of candidal adherence to these materials compared with a commercially available soft lining material and an acrylic resin denture base.

MATERIAL AND METHODS

The experimental materials were constructed in a stainless-steel mold, and their surface energies were determined with a dynamic contact angle analyzer. The adherence of three strains of C. albicans was determined with an in vitro assay. In addition, one test strain was used to determine the effect on adherence of precoating the materials with whole saliva.

RESULTS

Adhesion to all materials was strain variable, with the lowest adherence recorded for the two experimental materials. Decreased adherence was also apparent after precoating the materials with saliva. Correlation between surface energy of the material and the degree of candidal adhesion was seen for one strain, but no correlation was seen for the other two strains.

CONCLUSION

Adherence of C. albicans to the two experimental silicone soft lining materials was significantly less than that for an acrylic resin denture base and a commercially available soft lining material.

Characterisation of the inflammatory cell infiltrate in chronic hyperplastic candidosis of the oral mucosa

The inflammatory cell infiltrate in biopsy material of chronic hyperplastic candidosis (CHC) from the oral mucosa was characterised using immunocytochemical techniques. Nine specimens were stained for human kappa and lambda immunoglobulin light chains, CD68 antigen (macrophages), lysozyme (macrophages, granulocytes), CD3 antigen (T-lymphocytes), CD20 antigen (B-lymphocytes) and leucocyte common antigen (LCA). In addition, these and a further 13 specimens were also examined for immunoglobulin (Ig)-containing cells (IgA, IgG and IgM). The density of the infiltrate varied considerably between cases; T-lymphocytes were the dominant cell type (53.9%), with fewer B-lymphocytes (8.2%) and macrophages (14.2%). Many Ig-containing cells were seen, and although IgG-containing cells predominated, (60.8%, SD +/- 9.0) there was a high proportion of IgA-containing cells (36.7%, SD +/- 9.1) with few IgM-containing cells (2.5%, SD +/- 3.0). Many neutrophils, together with smaller numbers of T-lymphocytes and macrophages, were seen in the epithelium. It is suggested that mucosal defence to Candida infection involves a cell-mediated reaction in which there is recruitment of macrophages and local production of immunoglobulin with a prominent IgA component.

Unilateral multicystic dysplastic kidney: the case for nephrectomy

Management of unilateral multicystic dysplastic kidneys (MCDK) presents physicians and surgeons with a significant dilemma. Recent studies have indicated that the incidence of short term complications of MCDK is low and many authors have recommended conservative non-operative treatment. Surgery has been proposed by some because of the potential complications of hypertension, infection, and malignant change. Three children with hypertension secondary to MCDK seen at this institution in the past four years, one of whom had been discharged from follow up as a result of 'disappearance' of the cystic kidney on ultrasound examination, are reported. We believe that the risks of hypertension secondary to MCDK have been understated, and that based on the conclusions of these studies, many children may be receiving suboptimal follow up. We currently favour elective nephrectomy as the treatment of choice for this lesion.

Antibiotic prescription for acute dental conditions in the primary care setting

To determine the pattern of antibiotic prescribing (source and type) for acute dental conditions in the emergency setting, a prospective cross-sectional study was undertaken of 500 consecutive new patients attending the examination and emergency clinic of the Cardiff Dental Hospital in May 1994. The source and type of antibiotics prescribed, the nature of complaint and type of antibiotic prescribed in the primary care and dental hospital setting were recorded. Antibiotic prescription was a feature of the treatment of 30% (149/500) of patients. The 60 patients who had received emergency treatment prior to attending the hospital emergency clinic had been prescribed a total of 14 different types of antibiotics; 41% of these patients had sought treatment from general medical practitioners. Antibiotics were frequently prescribed without generally accepted criteria and there was wide variation in prescribing. Overall, only seven different types of antibiotics were prescribed in the dental hospital setting. The use of second generation antibiotics was more common in general practice than in the dental hospital. The results suggest that many patients with dental pain may seek treatment from medical practitioners, prior to, or in place of, definitive dental treatment. In summary, rationalisation of antibiotic prescription and the provision of emergency dental treatment is needed.

Hydrolytic and depolymerising enzyme activity of Prevotella intermedia and Prevotella nigrescens

OBJECTIVE

Prevotella intermedia has been reported to be associated with periodontal disease whilst P. nigrescens has predominantly been isolated from more specific conditions and healthy sites. The aim of the present study was to compare the enzyme activity of these species.

MATERIALS AND METHODS

Nine strains of P. intermedia and 12 strains of P. nigrescens were studied. Lipolytic, saccharolytic, nucleolytic and proteolytic activity was determined by traditional microbiological and chromogenic substrate methods.

RESULTS

All strains hydrolysed gelatine, casein, DNA and RNA. Lipase activity was produced by all strains except P. nigrescens ATCC 33563T. Lipolytic activity of P. nigrescens strains decreased as the environmental glucose concentration was increased. Only two strains, both P. intermedia, hydrolysed benzyl-arg-rho-nitroanilide. All strains hydrolysed alkaline rho-nitrophenolphosphate (except P. intermedia DAL100), produced glycylprolyl dipeptidase activity and demonstrated elastase-like activity. All but three strains (2 P. intermedia and I P. nigrescens) hydrolysed suc-ala-ala-pro-phe-rho-nitroanilide. Overall, no qualitatively analysed enzyme activity was exclusive to all strains of either species. Quantitatively analysed activity exhibited a high degree of variability both within and between species.

CONCLUSIONS

P. intermedia and P. nigrescens degrade natural and synthetic substrates, but intra- and interspecies activity is variable.

Alkylation of 2'-deoxynucleosides and DNA by quinone methides derived from 2,6-di-tert-butyl-4-methylphenol

4-Alkylphenols, such as the antioxidant 2, 6-di-tert-butyl-4-methylphenol (BHT), exhibit toxicities that appear to be mediated by their oxidative metabolism to electrophilic quinone methides. Reactions of these Michael acceptors with simple nucleophiles and proteins have been reported, but little information is available on quinone methide binding to the competing nucleophilic sites in DNA. In the present investigation, 2'-deoxynucleoside adducts generated in vitro with two BHT-derived quinone methides, 2,6-di-tert-butyl-4-methylenecyclohexa-2,5-dienone and 6-tert-butyl-2- (2'-hydroxy-1',1'-dimethylethyl)-4-methylenecyclohexa-2,5-dieno ne (BHTOH-QM) were isolated and identified. Both quinone methides produced adducts at the 1- and N2-positions of deoxyguanosine (dG) and the N6-position of deoxyadenosine (dA). In addition, a labile adduct formed at the 7-position of dG, which degraded to the corresponding 7-alkylguanine derivative. Additional work was conducted with BHTOH-QM, the more reactive of the two quinone methides. This species also formed stable adducts at the N4-position of deoxycytosine (dC) and the 3-position of thymidine and formed a labile adduct at the 3-position of dC that underwent hydrolytic cleavage to regenerate dC. In mixtures of deoxynucleosides treated with [14C]BHTOH-QM, alkylation occurred primarily at the N2- and 7-positions of dG and the N6-position of dA and occurred secondarily at the 1-position of dG. Treatment of calf thymus DNA with this quinone methide yielded N6-dA and N2-dG adducts with the former predominating. The unstable 7-dG adduct was detected by analysis of the 7-alkylguanine product from depurination. These results demonstrate that quinone methides are most likely to damage DNA through alkylation of the exocyclic amino groups of purine residues and possibly also by attack at the 7-position of dG followed by depurination.

Peritonitis, functional catheter loss and the sitting of the Dacron cuff in chronic peritoneal dialysis catheters in children

Functional peritoneal dialysis catheter loss due to persistent or recurrent peritonitis is a common clinical problem in paediatric patients. To examine the effect of positioning of the cuff on infection and loss rate we compared catheters where the cuff was buried in the rectus sheath (deep cuffs) with those where the cuff was sutured to the external oblique muscle, just below the subcutaneous fascia (superficial cuffs). Of 62 catheters inserted into 35 patients (median age 7.76 yrs, range 0-17 yrs) 28 were lost through peritonitis of which 19 (68%) were due to Staph. aureus infection, usually associated with exit site colonisation or infection. 12 out of 20 catheters with superficial cuffs were lost through infection compared with 16 out of 42 with deep cuffs (relative risk reduction 37%, p = ns). Controlling for patient age and infecting organism made no difference to this statistic. 15 out of 21 catheters inserted into patients < 2yrs of age were lost through peritonitis compared to 13 out of 41 catheters inserted into patients over 2 yrs of age (p = 0.037). We conclude that although siting of the Dacron cuff in the rectus sheath is somewhat protective against penetrating infection this is still a major problem in the infant and young child where alternative strategies for the prevention of Staph. aureus infection need to be sought.

The increased risk of venous thromboembolism and the use of third generation progestagens: role of bias in observational research. The Transnational Research Group on Oral Contraceptives and the Health of Young Women

A matched case-control study was undertaken in 10 centers in Germany and the United Kingdom to explore the association of current use of major combination oral contraceptives with the occurrence of venous thromboembolism. The cases recruited were 505 women aged 16-44 years with venous thromboembolism, controls were 1877 women (at least 3 controls per case) matched for 5-year age group and region without VTE. The main outcome measures were odds ratios derived by comparing current use of a specific oral contraceptive or group of OC against current use of other groups or against no current use of OC. The odds ratios (95% confidence intervals) for venous thromboembolism were: for third generation products (low dose ethinyloestradiol, gestodene and desogestrel) versus second generation products (low dose ethinyloestradiol, no gestodene and desogestrel, 1.5 (1.1 to 2.0), for third versus second generation products with norgestimate included in third generation, 1.6 (1.2 to 2.2). The odds ratios for current use for women aged 16-44 of specific progestagens versus levonorgestrel-containing compounds were 1.7 (1.1 to 2.6) for gestodene, 1.8 (1.2 to 2.6) for desogestrel, 1.9 (1.0 to 3.6) for norgestimate and 1.3 (0.7 to 2.5) for progestagen-only pills. For women aged 25 to 44 likely to be exposed to any of these progestagens, odds ratios for the comparison of progestagens versus levonorgestrel showed a successive increase by market introduction ranging from 1.5 (0.9 to 2.5) for desogestrel with 30 micrograms oestrogen content (introduced 1981) to 2.8 (1.3 to 6.5) for desogestrel with 20 micrograms oestrogen content (introduced 1992) significant in linear trend analysis (p = 0.00012). The influence of norgestimate classification as third or second generation product does not significantly alter the results regarding the association of third generation products and venous thromboembolism. A direct comparison of current use of norgestimate (which is primarily metabolized to levonorgestrel) versus levonorgestrel shows an increased odds ratio. The trend of increasing risk of progestagens by recency of market introduction when compared with levonorgestrel is strongly indicative of the existence of external bias due to attrition of susceptibles.

Measuring public hospital costs: empirical evidence from the Dominican Republic

Effective analysis of hospital performance requires the existence of accurate cost and output data. However, these are missing ingredients in most developing countries due to lack of information systems or other sources of data. Typically, expenditures are substituted for actual costs in analyzing hospital finance. This paper presents a methodology and analysis of the actual costs of inpatient, emergency, and outpatient services in a Dominican hospital. Through applying a set of survey instruments to a large sample of patients, the study measures and costs all hospital staff time, in-kind goods (drugs, medical supplies, reagents, etc.), overhead, and the depreciated value of plant and equipment related to the treatment of each patient. The results are striking. The budget is over 50% higher than the actual costs of services, reflecting the high cost of waste, down time, and low productivity. For example, high fixed costs translate into immunizations that on the average cost over 20% more than outpatient surgical interventions. The most disturbing finding is that although physicians represent the bulk of personnel spending, the surveys could account for only 12% of the contracted time of staff physicians, including time dedicated to treatment, supervision, administration, and teaching. As a proportion of the hospital total budget, personnel spending represents a high 84%. Yet staff costs for patient treatment never exceed 12%. These results suggest gross inefficiency, chaotic medical care organization, and poor hospital management.