Rates of initial virological suppression and subsequent virological failure after initiating highly active antiretroviral therapy: the impact of aboriginal ethnicity and injection drug use

Objectives:

To compare rates of initial virological suppression and subsequent virological failure by Aboriginal ethnicity after starting highly active antiretroviral therapy (HAART).

Methods:

We conducted a retrospective cohort study of antiretroviral-naïve HIV-patients starting HAART in January 1999-June 2005 (baseline), followed until December 31, 2005 in Alberta, Canada. We compared the odds of achieving initial virological suppression (viral load <500 copies/mL) by Aboriginal ethnicity using logistic regression and, among those achieving suppression, rates of virological failure (the first of two consecutive viral loads > 1000 copies/mL) by Aboriginal ethnicity using cumulative incidence curves and Cox proportional hazards models. Sex, injection drug use as an HIV exposure category (IDU), baseline age, CD4 cell count, viral load, calendar year, and HAART regimen were considered as potential confounders.

Results:

Of 461 study patients, 37% were Aboriginal and 48% were IDUs; 71% achieved initial virological suppression and were followed for 730.4 person-years. After adjusting for confounding variables, compared to non-Aboriginals with other exposures, the odds of achieving initial virological suppression were lower for Aboriginal IDUs (odds ratio (OR)=0.33, 95% CI=0.19-0.60, p=0.0002), non-Aboriginal IDUs (OR=0.30, 95% CI=0.15-0.60, p=0.0006), and Aboriginals with other exposures (OR=0.38, 95% CI=0.21-0.67, p=0.0009). Among those achieving suppression, Aboriginals experienced higher virological failure rates ≥1 year after suppression (hazard ratio=3.35, 95% CI=1.68-6.65, p=0.0006).

Conclusions:

Future research should investigate adherence among Aboriginals and IDUs treated with HAART and explore their treatment experiences to assess ways to improve outcomes.

Emergency department coding of bicycle and pedestrian injuries during the transition from ICD-9 to ICD-10

Background

The international classification of diseases version 10 (ICD-10) uses alphanumeric expanded codes and external cause of injury codes (E-codes).

Objective

To examine the reliability and validity of emergency department (ED) coders in applying E-codes in ICD-9 and -10.

Methods

Bicycle and pedestrian injuries were identified from the ED information system from one period before and two periods after transition from ICD-9 to -10 coding. Overall, 180 randomly selected bicycle and pedestrian injury charts were reviewed as the reference standard (RS). Original E-codes assigned by ED coders (ICD-9 in 2001 and ICD-10 in 2004 and 2007) were compared with charts (validity) and also to ICD-9 and -10 codes assigned from RS chart review, to each case by an independent (IND) coder (reliability). Sensitivity, specificity, simple, and chance-corrected agreements (κ statistics) were calculated.

Results

Sensitivity of E-coding bicycle injuries by the IND coder in comparison with the RS ranged from 95.1% (95% CI 86.3 to 99.0) to 100% (95% CI 94.0 to 100.0) for both ICD-9 and -10. Sensitivity of ED coders in E-coding bicycle injuries ranged from 90.2% (95% CI 79.8 to 96.3) to 96.7% (95% CI 88.5 to 99.6). The sensitivity estimates for the IND coder ranged from 25.0% (95% CI 14.7 to 37.9) to 45.0% (95% CI 32.1 to 58.4) for pedestrian injuries for both ICD-9 and -10.

Conclusion

Bicycle injuries are coded in a reliable and valid manner; however, pedestrian injuries are often miscoded as falls. These results have important implications for injury surveillance research.

Bicycle helmet use four years after the introduction of helmet legislation in Alberta, Canada

BACKGROUND

Bicycle helmets reduce fatal and non-fatal head and face injuries. This study evaluated the effect of mandatory bicycle helmet legislation targeted at those less than 18 years old on helmet use for all ages in Alberta.

METHODS

Two comparable studies were conducted two years before and four years after the introduction of helmet legislation in Alberta in 2002. Bicyclists were observed in randomly selected sites in Calgary and Edmonton and eight smaller communities from June to October. Helmet wearing and rider characteristics were recorded by trained observers. Poisson regression adjusting for clustering by site was used to obtain helmet prevalence (HP) and prevalence ratio (PR) (2006 vs. 2000) estimates.

RESULTS

There were 4002 bicyclists observed in 2000 and 5365 in 2006. Overall, HP changed from 75% to 92% among children, 30% to 63% among adolescents and 52% to 55% among adults. Controlling for city, location, companionship, neighborhood age proportion <18, socioeconomic status, and weather conditions, helmet use increased 29% among children (PR = 1.29; 95% CI: 1.20-1.39), over 2-fold among adolescents (PR 2.12; 95% CI: 1.75-2.56), and 14% among adults: (PR = 1.14; CI: 1.02-1.27).

CONCLUSIONS

Bicycle helmet legislation was associated with a greater increase in helmet use among the target age group (<18). Though HP increased over 2-fold among adolescents to an estimated 63% in 2006, this percentage was approximately 30% lower than among children <13.

Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway

BACKGROUND

Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization.

METHODS

A pre-post study design using two population based inception cohorts of hip fracture patients aged > or =65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization.

RESULTS

Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (p<0.001). Postoperative cardiac arrythmias were significantly lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p<0.001). There was no difference in risk adjusted in-hospital mortality between the two groups. Overall length of stay (LOS) and costs were unchanged between the groups; however, hospital LOS increased while rehabilitation LOS decreased in the CP group.

CONCLUSION

Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.

Utilization of health services following spinal cord injury: a 6-year follow-up study

STUDY DESIGN

Cohort study with 6-years follow-up.

OBJECTIVE

To describe the utilization of health services by persons with spinal cord injury (SCI) and compare it with that of the general population.

SETTING

Alberta, Canada.

METHODS

All persons who sustained an SCI in Alberta between April 1992 and March 1994 were followed from date of injury to 6 years postinjury. Cases were matched (1:5) with controls randomly selected from the general population and matched for age, gender, and region of residence. Administrative data from centralized health care databases were compiled to provide a complete picture of health care use, including hospitalizations, physician contacts, long-term care admissions, home care services, and the occurrence of secondary complications.

RESULTS

In all, 233 individuals with SCI and 1165 matched controls were followed for 6 years. Compared with the control group, persons with SCI were rehospitalized 2.6 times more often, spent 3.3 more days in hospital, were 2.7 times more likely to have a physician contact, and required 30 times more hours of home care services. Of those with SCI, 47.6% were treated for a urinary tract infection, 33.8% for pneumonia, 27.5% for depression, and 19.7% for decubitus ulcer.

CONCLUSION

SCI places a heavy burden on the health care system. Persons with SCI have greater rates of contact with the health system compared with the general population. Secondary complications continue to affect persons with SCI long after the acute trauma.

Gastric cancer: establishing predictors of biologic behavior with use of population-based data

BACKGROUND

Tumor thickness and nodal status are important predictors of survival following curative resection for gastric cancer. Lymphovascular invasion (LVI) is a potential predictor of biological behavior. The relationship between LVI and tumor thickness (T status) has not been established in population-based studies.

METHODS

Clinicopathological and survival data of 577 patients at nine centers, from between 1991 and 1997, was collected from patient records and a Provincial Cancer Registry. The primary endpoint of the study was death. A secondary analysis of a node-negative subgroup examined the significance of LVI with respect to T status.

RESULTS

The population disease-specific survival was 28%. In a multivariate analysis, T, N, M, esophageal margin, tumor morphology, and residual tumor category were independent predictors of survival. LVI was documented in 58% of resected tumors. LVI correlated with advancing T and N status but was not significant in a multivariate population model. Subgroup analysis of node-negative gastric cancer found T status and LVI to be independent predictors of survival. LVI was associated with a 5-year survival of 8%, versus 43% among patients in whom it was absent (P <.001).

CONCLUSIONS

T status and N status were the most important independent predictors of survival in a population-based study of gastric cancer. LVI correlated with advancing N and T status. Multivariate analysis of node-negative patients showed LVI and T status are independent predictors of survival.

Appendectomies in rural hospitals. Safe whether performed by specialist or GP surgeons

OBJECTIVE

To compare outcomes of appendectomies performed in rural hospitals by specialist surgeons and GP surgeons.

DESIGN

Retrospective analysis of the Canadian Institute for Health Information's (CIHI) Discharge Abstract Database (DAD) 1996-1999.

SETTING

Rural hospitals in Ontario, Saskatchewan, Alberta, and British Columbia.

PARTICIPANTS

All surgeons who performed appendectomies in these hospitals during the study period.

MAIN OUTCOME MEASURES

Mortality; diagnostic accuracy, perforation, and repeat laparotomy rates; length of stay; and need for transfer to another acute-care institution.

RESULTS

Specialist surgeons performed 3624 appendectomies; GP surgeons performed 963. Rates of comorbidity, diagnostic accuracy, and transfer, and mean lengths of stay were similar for patients of GP and specialist surgeons. Patients operated on by specialists were older and more likely to have perforations and to require second intra-abdominal or pelvic procedures. Triage to a specialist, older age, and comorbidity all independently predicted perforation. Only perforation predicted a second intra-abdominal or pelvic procedure.

CONCLUSION

Appendectomy is a safe procedure in rural hospitals, whether performed by specialist or GP surgeons. Some difficult cases are routinely referred to specialists.

Preeclampsia and cerebral palsy in low-birth-weight and preterm infants: implications for the current "ischemic model" of preeclampsia

OBJECTIVE

One of the prevailing hypotheses for the pathogenesis of preeclampsia is the "ischemic model." It assumes that reduced uteroplacental perfusion is the primary step and the point of convergence of diverse pathogenic processes in the development of preeclampsia. One might expect a fetus under such "ischemic conditions" to be at an increased risk of later development of cerebral palsy (CP). The objective of this study was to test the hypothesis that maternal preeclampsia increases the risk of CP in preterm and low-birth-weight infants.

METHODS

A meta-analysis was performed based on published articles identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, Current Contents, Biological Abstracts, and Dissertation Abstracts) from 1966 through 1999. Ten observational studies on the association between preeclampsia and CP were identified based on prespecified inclusion criteria. Two independent reviewers extracted data and assessed the methodological quality of eligible articles. Odds ratios (OR) of CP for preeclampsia from individual studies were pooled.

MAIN OUTCOME MEASURE

Cerebral palsy.

RESULTS

In case-control studies, preeclampsia was associated with a statistically significant decreased risk of CP [pooled adjusted OR, 0.50; 95% confidence interval (CI), 0.33-0.81; p < 0.01). In cohort studies, preeclampsia was associated with a nonstatistically significant reduced risk of CP (pooled OR, 0.91; 95% CI, 0.35-2.41; p > 0.05).

CONCLUSIONS

Preeclampsia may be associated with a decreased risk of CP in preterm and low-birth-weight infants. This challenges the currently held belief that reduced uteroplacental perfusion is the unique pathophysiological process in preeclampsia.

Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes

OBJECTIVES

To study prevalence, risk factors, and maternal and infant outcomes of women with gestational diabetes mellitus (GDM).

METHODS

A retrospective cohort study was performed based on 111563 pregnancies delivered between 1991 through 1997 in 39 hospitals in northern and central Alberta, Canada. Multivariate logistic regression was used to estimate the odds ratios with 95% confidence intervals, and to control for confounding variables.

RESULTS

The prevalence of GDM was 2.5%. Risk factors for GDM included age >35 years, obesity, history of prior neonatal death, and prior cesarean section. Teenage mothers and women who drank alcohol were less likely to have GDM. Mothers with GDM were at increased risk of presenting with pre-eclampsia, premature rupture of membranes, cesarean section, and preterm delivery. Infants born to mothers with GDM were at higher risk of being macrosomic or large-for-gestational-age.

CONCLUSIONS

Specific conditions predispose to GDM which itself is associated with a significantly increased risk of maternal and fetal morbidity.

Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators

BACKGROUND

Studies of survival of patients with multivessel coronary artery disease (MVD) in the prestent era suggested that outcomes after coronary artery bypass surgery (CABG) are similar to those after percutaneous coronary intervention (PCI) in subsets of coronary severity. The purpose of this study of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) was to examine the association between treatment and survival up to 5 years in patients with MVD enrolled from 1995 through 1998.

METHODS AND RESULTS

Data on patient characteristics were obtained at the time of the initial coronary angiography. Survival was determined through data linkage to the provincial Bureau of Vital Statistics. Risk-adjusted hazard ratios were calculated to compare different treatments. In the 11,661 patients with MVD, CABG was the initial therapy in 3782, PCI in 3540, and medical therapy in 4339. Cumulative 5-year survival was 91.4% with CABG, 91.9% with PCI, and 82.9% with medical therapy (P <.001). Hazard ratios were CABG: medical 0.53 (95% confidence interval [CI] 0.46-0.71), PCI: medical 0.65 (95% CI 0.56-0.74), and CABG: PCI 0.81 (95% CI 0.68-0.96). Analysis across coronary severity groups revealed a benefit of CABG compared with PCI only in the group with severe left main CAD: 0.30 (95% CI 0.17-0.54).

CONCLUSIONS

In a multicenter clinical setting, MVD patients treated with revascularization have significantly higher 5-year survival rate than do those treated medically. Risk-adjusted comparison reveals PCI treatment to be associated with long-term survival similar to treatment with CABG in all coronary severity subgroups except the group with severe left main coronary artery disease. Patient selection factors are likely to be contributing to these findings.

Maternal smoking and preeclampsia

OBJECTIVE

To study the relationship between maternal smoking and preeclampsia and whether this association differs between primiparous and multiparous women.

STUDY DESIGN

We conducted a population-based, retrospective, cohort study of 58,216 singleton pregnancies from northern and central Alberta, Canada, between 1995 and 1997. Multivariate logistic regression was used to control for maternal alcohol consumption, drug dependence, maternal age, maternal weight, prior intrauterine growth restriction and other confounders.

RESULTS

Maternal smoking was associated with a significantly reduced overall risk of preeclampsia (adjusted odds ratio [aOR]: .61; 95% confidence interval [CI]: .50-.75; P < .01). Stratified analyses showed that in primiparous pregnancies, maternal smoking was associated with a significantly decreased risk (aOR: .63; 95% CI: .50-.80; P < .01); in multiparous women, maternal smoking was not associated with a statistically significant decreased risk of preeclampsia (aOR: 0.72; 95% CI: .51-1.02; P > .05).

CONCLUSION

Maternal smoking is protective against preeclampsia. Understanding the underlying biologic mechanisms of this protective effect may advance our knowledge of the pathogenesis of preeclampsia.

Association of preeclampsia with high birth weight for age

OBJECTIVE

The purpose of this study was to examine the effect of gestational hypertension and preeclampsia on fetal growth.

STUDY DESIGN

A retrospective cohort study was conducted on the basis of 97,270 pregnancies delivered between 1991 and 1996 in 35 hospitals in northern and central Alberta, Canada. Univariate and multivariate logistic analyses were performed to examine the impact of preeclampsia and gestational hypertension on high-birth-weight (> or =4200 g), large-for-gestational-age, low-birth-weight (<2500 g), and small-for-gestational-age babies.

RESULTS

The rate of high-birth-weight fetuses in women with gestational hypertension (7. 3%) was higher than in those with normal blood pressure (5.6%). After we controlled for confounders, the adjusted odds ratio of high birth weight was 1.44 (95% confidence interval, 1.21-1.70) in women with gestational hypertension. Preeclampsia was also associated with a statistically nonsignificant (P =.054) increased risk of high birth weight (adjusted odds ratio, 1.40; 95% confidence interval 0. 99-1.98). The rate of large-for-gestational-age babies was significantly higher in women with gestational hypertension (4.5%) and preeclampsia (4.7%) than in those with normal blood pressure (2. 2%), with adjusted odds ratios of 1.50 (95% confidence interval, 1. 22-1.85) for gestational hypertension and 1.87 (95% confidence interval, 1.31-2.67) for preeclampsia. Concurrently, women who had gestational hypertension were also at higher risk of having low-birth-weight (adjusted odds ratio, 2.4; 95% confidence interval, 2.13-2.93) and small-for-gestational-age (adjusted odds ratio, 2.04; 95% confidence interval, 1.68-2.48) babies. Women with preeclampsia were also at markedly higher risk of having low-birth-weight (adjusted odds ratio, 4.14; 95% confidence interval, 3.32-5.15) and small-for-gestational-age (adjusted odds ratio, 2.56; 95% confidence interval, 1.92-3.41) babies.

CONCLUSIONS

There is a significant association of preeclampsia and gestational hypertension with large-for-gestational-age infants, in addition to a significant association with low-birth-weight and small-for-gestational-age infants. This study challenges the currently held belief that reduced uteroplacental perfusion is the unique pathophysiologic process in preeclampsia.

Nedocromil sodium in the treatment of exercise-induced asthma: a meta-analysis

Exercise-induced asthma (or bronchoconstriction) afflicts millions of people worldwide. While generally self-limiting, it can hinder performance and reduce activity levels, thus it is an important condition to diagnose and treat. The objective of this review was to assess the prophylactic effect of a single dose of nedocromil sodium on exercise-induced asthma. The Cochrane Airways Group trials register, the Cochrane Controlled Trials Register, Current Contents, reference lists of relevant articles, review articles and textbooks were searched for randomized trials comparing a single dose of nedocromil to placebo to prevent exercise-induced asthma in people >6 yrs of age. Authors and the drug manufacturer were contacted for additional trials. Trial quality assessments and data extraction were conducted independently by two reviewers. Authors were contacted when possible. Twenty trials were included. All were rated as having good methodological quality. Nedocromil inhibited bronchoconstriction in all age groups. The pooled weighted mean difference for the maximum percentage fall in forced expiratory volume in one second was 15.6%, (95% confidence interval (95% CI): 13.2-18.1) and for the peak expiratory flow was 15.0% (95% CI: 8.3-21.6). These differences are both statistically and clinically significant. After nedocromil the time to recover normal lung function was <10 min compared to >30 min with placebo. Nedocromil had a greater effect on people with a fall in lung function of >30% from baseline. There were no significant adverse effects reported with this short-term use. In conclusion, Nedocromil taken before exercise appears to reduce the severity and duration of exercise-induced bronchoconstriction. This effect appears to be more pronounced as severity increases.

Dealing with missing data in observational health care outcome analyses

Observational outcome analyses appear frequently in the health research literature. For such analyses, clinical registries are preferred to administrative databases. Missing data are a common problem in any clinical registry, and pose a threat to the validity of observational outcomes analyses. Faced with missing data in a new clinical registry, we compared three possible responses: exclude cases with missing data; assume that the missing data indicated absence of risk; or merge the clinical database with an existing administrative database. The predictive model derived using the merged data showed a higher C statistic (C = 0.770), better model goodness-of-fit as measured in a decile-of-risk analysis, the largest gradient of risk across deciles (46.3), and the largest decrease in deviance (-2 log likelihood = 406.2). The superior performance of the enhanced data model supports the use of this "enhancement" methodology and bears consideration when researchers are faced with nonrandom missing data.

A cost-effectiveness analysis of the application of nitric oxide versus oxygen gas for near-term newborns with respiratory failure: results from a Canadian randomized clinical trial

OBJECTIVE

To conduct a cost-effectiveness analysis of the use of inhaled nitric oxide (NO) vs. oxygen administered to near-term (gestational age > or =34 wks) newborns with severe respiratory illness that were referred for consideration of extracorporeal membrane oxygenation (ECMO).

DESIGN

The cost-effectiveness analysis is based on outcome and utilization data from two multicentered randomized clinical trials conducted by the Canadian Inhaled Nitric Oxide Study group, one for patients with congenital diaphragmatic hernia (CDH) and one for patients without CDH. Data from the western Canadian ECMO center were used to establish costs.

SETTING

Patients were cared for in Canadian regional neonatal intensive care units, including two ECMO centers. Air transport was used for transporting patients between centers.

PATIENTS

Term and near-term newborns with severe respiratory illness who were receiving maximum conventional therapy and whose oxygenation index was >40.

INTERVENTIONS

Patients randomly received NO or oxygen. If their conditions deteriorated, they qualified for ECMO. Not all that qualified for ECMO received it because of individual parent/ physician preferences.

MEASUREMENTS AND MAIN RESULTS

The cost-effectiveness ratio was the ratio of net cost (including neonatal intensive care, ECMO, and transport) to net outcome (survival) for the two interventions. For non-CDH cases, the cost-effectiveness ratio was $36,613 (Canadian) per life saved; the confidence intervals were wide and the results were not statistically significant. For CDH patients, the death rate was lower for oxygen and the oxygen patients cost less; the results were not statistically significant.

CONCLUSIONS

The small numbers of patients in the trials precluded significant results. Further, our results have a short-term time horizon (discharge to home or death). Thus, for non-CDH patients, the favorable ratio provides very qualified evidence in favor of NO.

Nedocromil sodium for preventing exercise-induced bronchoconstriction

BACKGROUND

Exercise-induced asthma causes cough, dyspnea, wheeze and chest tightness. Management of focuses on prevention through pharmaco-therapy and alternate strategies. Single use, pre-exercise beta2-agonists and non-steroidal anti-inflammatory agents such as the cromones are the most common treatments.

OBJECTIVES

The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise-induced bronchoconstriction.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register, the Cochrane Controlled Trials Register, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations.

SELECTION CRITERIA

Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise-induced bronchoconstriction in people over six years of age.

DATA COLLECTION AND ANALYSIS

Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data.

MAIN RESULTS

Twenty randomised controlled trials involving 280 participants were identified. 15-60 min following inhalation of 4 mg nedocromil, the maximum fall in forced expiratory volume in one second due to exercise was improved by 15.6%, (95% CI:13.2 to 18.1) compared to the placebo response. The maximum percentage fall in peak expiratory flow rate was of the same magnitude (weighted mean difference 15.0%; 95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. The relative magnitude of its effect was greatest in patients with more severe exercise-induced bronchoconstriction (defined as an exercise-induced fall in lung function > 30% from baseline). There were no significant adverse effects reported.

REVIEWER'S CONCLUSIONS

Nedocromil sodium used before exercise appears to reduce the severity and duration of exercise-induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise-induced bronchoconstriction.

Inhaled steroids in acute asthma following emergency department discharge

BACKGROUND

Patients with acute asthma treated in the emergency department are frequently treated with inhaled beta-agonists and corticosteroids (CS) after discharge. The use of inhaled CS (ICS) following discharge may also be beneficial in acute asthma.

OBJECTIVES

To determine the effect of inhaled corticosteroids (ICS) on outcomes in the treatment of acute asthma following discharge from the emergency department (ED).

SEARCH STRATEGY

Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by hand searching of 20 respiratory journals. In addition, abstracts from conferences were searched; primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews, and texts also were searched.

SELECTION CRITERIA

Only RCTs or quasi RCTs were eligible for inclusion. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids (CS). Two reviewers independently assessed articles for potential relevance, final inclusion, and methodological quality - to "expand" the search. We didn't include any in the end)

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers if the authors were unable to verify the validity of information. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager 4.0.4.

MAIN RESULTS

Ten trials were selected for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus CS Vs CS therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to CS therapy in the trials. Relapses were reduced, but not significantly, with the addition of ICS therapy (OR: 0.68; 95% CI: 0.46 to 1.02). As well, no differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores, or adverse effects. Seven trials, involving a total of 1204 patients, compared high-dose ICS therapy alone Vs CS therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone and CS therapy alone for relapse rates (OR: 1.00; 95% CI: 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to confidently exclude the possibility of either treatment being significantly inferior, and severe asthmatics were excluded from these trials.

REVIEWER'S CONCLUSIONS

There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard CS therapy upon ED discharge for acute asthma. There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics upon ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment in the ED or following ED discharge.

Regionalization and hospital utilization: Alberta 1991/2-1996/7

BACKGROUND

In February 1994 Alberta Health announced a three-year business plan for the radical restructuring of the health care system in Alberta. The business plan outlined large reductions in funding for acute hospital care spending and the establishment of 17 Regional Health Authorities (RHAs).

OBJECTIVES

The objectives of this study are to describe for the period 1991/2 to 1996/7: 1) Trends in overall acute hospital utilization by Alberta residents and residents of each of the 17 RHAs. 2) Trends in the provision of acute hospital services by each of the 17 RHAs and the Alberta Cancer Board. 3) Trends in the transfer of patients between RHAs.

RESULTS

Between 1991/2 and 1996/7, the age-sex standardized separation rate, the age-sex standardized average length of stay, and age-sex standardized hospital days rate for Alberta residents fell by 25.6%, 18.7%, and 39.5% respectively. The age-standardized hospital days rate fell in all 17 RHAs. The total number of separations (Alberta residents and non-residents) from Alberta acute care facilities fell by 19.6% while the average care intensity for all separations from Alberta acute care facilities rose by 8.7%. The ratio of the highest to lowest average RHA care intensity remained between 1.7 and 1.9 during the study period. RHA self-sufficiency indices increased dramatically in one RHA and remained largely unchanged in the remaining RHAs. RHA import indices decreased for most RHAs.

CONCLUSIONS

Large reductions in the use of acute hospital services have occurred in Alberta during the period of major health care restructuring. Further research is needed to examine shifts in services to other sectors and to assess the impact of these reductions on patient outcomes.

The cost-effectiveness of magnetic resonance imaging for patients with internal derangement of the knee

Magnetic resonance imaging (MRI) has excellent specificity and sensitivity for the diagnosis of internal derangement of the knee (IDK). The use of MRI to screen patients with suspected IDK could avoid unnecessary arthroscopies with a reduction in costs. The purpose of this study was to evaluate the use of arthroscopy among patients with IDK, and to estimate the potential cost-effectiveness of MRI in these patients to avoid unnecessary arthroscopies. The study was based on a retrospective cohort of all patients attending three orthopedic clinics between April and September 1993 with a new diagnosis of IDK. Charts were reviewed in 1994 to allow for a follow-up of more than 6 months. An economic evaluation was performed based on cost-effectiveness ratios (per averted arthroscopy), including direct and indirect costs. There were 241 patients with a new diagnosis of IDK (67% males, mean age 35 +/- 12 years), and 110 (46%) underwent arthroscopy. The remaining patients received conservative therapy and were not scheduled for arthroscopy within the period of observation. Using a priori established criteria, 10% of the arthroscopies could be considered diagnostic only (e.g., normal knee) and 27% were of doubtful efficacy from a therapeutic perspective (e.g., debridement alone). Many of these arthroscopies could have been avoided by performing a prior MRI. Using these findings, we conducted decision tree analyses of the use of MRI among patients requiring arthroscopy of the knee. A sensitivity analysis was performed to evaluate the various model assumptions. In general, MRI appeared to be a cost-effective diagnostic procedure for patients with IDK requiring arthroscopy of the knee, and there were cost savings associated with it in some of the models tested.

Cost effectiveness of Streetworks' needle exchange program of Edmonton

OBJECTIVE

To conduct a cost-effectiveness analysis of the Edmonton Streetworks needle exchange program, in terms of the additional cost per HIV infection averted. The main outcome measures were needle use with and without Streetworks, HIV cases averted, and program costs.

METHODS

We conducted interviews and HIV saliva tests on a sample of street-involved intravenous drug users (IDU) who are regular Streetworks' clients. Outcomes were used in a cost-effectiveness model.

RESULTS

It is projected that the program has a cost-effectiveness of $9,500 (Canadian) per HIV infection delayed for one year.

CONCLUSIONS

The discounted cost per case averted is less than the cost of a case of AIDS. Continuing the program is a dominant strategy.

Socioeconomic risk factors and population-based regional allocation of healthcare funds

Using the notion of professional uncertainty a population-based proxy need measure for hospital services was developed. Its relationship with socioeconomic variables and Standardized Mortality Ratios (SMR) was investigated in an attempt to develop an adjustment factor for socioeconomic risk factors beyond age-sex adjustment to be used for a population-based healthcare funding formula for Alberta. The data used are 1990, 1991, 1992 vital statistics and hospital separation abstracts, 1991 census data and Refined Diagnosis Related Group (RDRG) case weights. Geographic units studied were the 26 federal electoral districts in Alberta using postal codes as a linkage geo-code between census and hospital utilization and death data. SMRs, age-sex standardized per capita hospital utilization and proxy need rates were derived and correlated with socioeconomic variables derived from the census files. It appears that the poor, the less educated and aboriginals need more hospital services than the affluent, employed and educated, confirming previous findings. The unemployed tend to need more but use fewer services while immigrants and non-white ethnics tend to need and use fewer services. The unemployed, less educated and non-white ethnics are associated with positive correlation with premature mortality (SMR based on deaths under age 75 years), while the employed, highly educated tend to live longer. In general SMRs have positive but very low correlations with utilization and need rates suggesting that SMRs should not be used for resource allocation. Stepwise multiple regression analyses showed that the percentages of unemployed, immigrants, non-whites, aboriginals and those with education less than grade 9 explain about 90% of the variation in age-sex standardized hospital utilization rates. Percentages of unemployed, non-white ethnics, residents with education less than grade 9 and aboriginals explained 71% of variations in age-sex standardized per capita proxy hospital service need measures. Based on the results of regression analyses, a SEAM (Socio-Economic Adjustment Multiplier) scale was developed for utilization (SEAM-U) and proxy needs (SEAM-N). In essence a SEAM is a set of relative value (RV) multipliers applicable to a provincial common per age-sex adjusted capita allocation value to account for the impact of socioeconomic risk factors on hospital service needs or utilization. Finally, the resulting regression equations derived from the 26 Federal electoral district data were applied to Alberta's health regions, regional SEAMs were derived, and the impact of such adjustment was assessed.

Impact of pregnancy-induced hypertension on fetal growth

OBJECTIVE

The purpose of this study was to evaluate the effect of different types of pregnancy-induced hypertension on fetal growth.

STUDY DESIGN

A retrospective cohort study was conducted on the basis of 16,936 births from January 1, 1989, through December 31, 1990, by means of data from a population-based perinatal database in Suzhou, China. Pregnancy-induced hypertension was classified as gestational hypertension, preeclampsia, or severe preeclampsia-eclampsia. Univariate and multivariate regression analyses were performed to examine the effect of the various types of pregnancy-induced hypertension on gestational age, preterm birth, birth weight, low birth weight, and intrauterine growth restriction.

RESULTS

Gestation was 0.6 week shorter in women with severe preeclampsia than in normotensive women (P <.01). However, the risk of preterm birth was not increased with any classification of pregnancy-induced hypertension (for severe preeclampsia: adjusted odds ratio 1.75; 95% confidence interval, 0.88-3.47). After adjustment for duration of gestation and other confounders, preeclampsia and severe preeclampsia increased the risk of intrauterine growth restriction and low birth weight. The adjusted odds ratios of low birth weight were 2.65 (1.73-4.39) for preeclampsia and 2.53 (1.19-4.93) for severe preeclampsia. However, the risk of low birth weight was not increased significantly for gestational hypertension (adjusted odds ratio 1.56 [1.00-2.41]).

CONCLUSION

Preeclampsia increases the risk of intrauterine growth restriction and low birth weight.

Who gets missed: coverage in a provincial newborn screening program for metabolic disease

OBJECTIVE

To determine coverage of the newborn screening program (NSP) for metabolic disease in Alberta, Canada, and to determine reasons for not being screened.

STUDY DESIGN

Coverage was estimated by deterministic matching of live birth registration data with newborn screening data for the year 1992. Demographic characteristics of not-matched infants were compared with good-match infants using logistic regression.

RESULTS

For 42 392 live births, there were 41 553 screening records, of which 40 593 infants were very good matches to NSP records. Another 960 were possible matches. A total of 839 infants were not matched at all, and coverage was estimated at 98.0%. Determinants of infant not-matched status were death in week 1 (adjusted odds ratio [OR]: 383); birth weight of <1500 g (adjusted OR: 18.9) or between 1500 and 2500 g (adjusted OR: 3.2); having a mother who was single (adjusted OR: 2.7) or formerly married (adjusted OR: 12.9); or being born out of hospital (OR: 19. 2). The calculated 98% coverage is close to an estimate of 98.3% made by the NSP comparing total births with initial screenings.

CONCLUSION

The matched data give insight as to who was missed and point to the need for closer attention for infants at greater risk of not being screened for metabolic disease.

Considerations for regional health authorities in the provision of environmental health services

As population health programs, environmental health services differ fundamentally from other forms of health service delivery. At a time when the health sector is striving for integration, the incorporation of these unique services into the delivery system presents a unique challenge to policy makers and administrators across the country. The University of Alberta recently completed a comprehensive review and redesign of locally governed and delivered environmental health protection services in Alberta. This paper outlines the key issues and unique features surrounding the delivery of environmental health services and presents the study team's suggested approach to addressing these issues.

Toward a framework for health service research

Fiscal concerns have provided the impetus for wide-ranging attempts to reform the delivery of health care in Canada. Health reform has in turn stimulated great interest and activity in health service research. For health service research to be of maximum use in addressing current and future challenges to the health care system, closer liaison is needed between researchers and decision makers--the users of research. The purpose of this paper is to promote greater interaction between decision makers and researchers by proposing a framework for health predicated on types of information needed for decision-making rather than on study methodologies. We distinguish between decision makers at the societal, health system, program and service levels. Types of studies are classified by their purpose and by the phase of the management cycle for which they provide information for decision-making.

Survey of local environmental health programs in Alberta

As part of a larger initiative to develop a contemporary model for local environmental health services, a survey of Alberta health unit-based programs was undertaken. The objectives were to (a) obtain a comprehensive profile of environmental health services, and (b) identify current and emerging issues in these programs. Three survey instruments were designed for three respondent groups: chief executive officers, program managers and environmental health officers/public health inspectors. Results suggest an expanding scope of activities and issues faced by these programs. The most prevalent emerging issues noted were in the areas of chemical/ toxic exposures, injury prevention, indoor air quality and public risk perception. Issues receiving the greatest attention were food safety and waste management. Review of program management capacities suggested difficulties in coping with the increased pressures faced by these programs. Improvements recommended by respondents included increased resources, more educational and professional development opportunities, improved information systems and improved legislation.

Epidemiology of recreational and old-timer ice hockey injuries

OBJECTIVE

To examine the nature and incidence of injuries suffered by a sample of recreational and old-timer ice hockey players.

DESIGN

Random sample of teams followed prospectively.

SETTING

Various hockey rinks in the Greater Edmonton Region.

PARTICIPANTS

Four hundred and thirty-one subjects--287 adult male recreational (AMRL) and 144 male old-timer (OTL) from five leagues were followed over the 1992-93 hockey season.

MAIN OUTCOME MEASURES

Injuries sustained during the duration of a hockey season.

RESULTS

A total of 151 injuries (100 AMRL and 51 OTL) were reported. The aggregate injury rate was 12.2/1000 player-exposures (12.3 AMRL and 12.0 OTL). The anatomic region most often injured by AMRL players was the head/neck/facial area (32%) while OTL players reported a greater proportion of lower extremity injuries (40%). Both groups reported sprains/strains as the most common diagnosis (35% AMRL and 47% OTL). The predominant injury mechanism for AMRL players was stick contact (24%) and for OTL players was puck contact (23%). No significant differences were detected between the anatomic, diagnostic, and mechanistic distributions of injury between AMRL and OTL players. Seventy-five percent of injuries occurred during league games, 10% during playoff games, 5% during tournament games, and 10% during practices. Penalties were assessed in 31% of injury instances. Forty-two percent of head/neck/facial injuries, 32% of upper extremity injuries, 13% of torso injuries, and 15% of lower extremity occurred as a result of penalizable behavior (p = 0.01). Three percent of players wearing full or half face protectors suffered facial injuries while 9% of players not wearing facial protection reported facial injuries (p = 0.03; Relative Risk = 2.56).

CONCLUSIONS

The injury rates observed were lower than reported rates for major/elite hockey. The proportion of players injured through body contact was lower than that observed in adult major/elite hockey while the diagnostic and anatomic distribution of injury was similar. Studies such as this are useful in the development of injury prevention strategies.

Use of second line drugs for the treatment of rheumatoid arthritis in Edmonton, Alberta. Patterns of prescription and longterm effectiveness

OBJECTIVE

Our purpose was to compare the patterns of prescription of 2nd line drugs for the treatment of rheumatoid arthritis (RA) among rheumatologists in Edmonton, Alberta, and to examine the longterm effectiveness of these drugs.

METHODS

A 1985 inception cohort of 128 patients with RA was assessed between 1991 and 1992, using measures of disease activity, radiological scores and physical functional status. Use of different therapies was retrieved from the medical charts.

RESULTS

All patients had seen a rheumatologist at any time between January, 1985 and December, 1991, 88% within the first 3 years of disease. Most (85%) had received at least one 2nd line drug, the majority within the first 2 years. Overall, gold salts were the most frequently prescribed drugs. Patterns of prescription varied among different rheumatologists; some drugs were never prescribed by some and very often by others (e.g., auranofin). Terminations because of toxicity and lack of efficacy were high. Methotrexate (MTX) had the lowest termination rate and sulfasalazine the highest, mostly due to lack of efficacy.

CONCLUSION

In this cohort, patients were treated early in the course of RA. Patterns of prescription of 2nd line drugs varied among rheumatologists. Termination rates were highest for sulfasalazine and lowest for MTX.

Acute care hospital morbidity in the Blood Indian Band, 1984-87

Acute care hospital morbidity of the Blood Indian Band was compared with that of all Albertans between April 1, 1984 and March 31, 1987. The Blood Indians had over 2.5 times as many hospital separations and 2.2 times as many patient days as the Albertans. The highest separation rare ratios by ICD-9-CM chapter for both Blood males and females were for endocrine, metabolic and nutritional disorders. Blood females had higher rate ratios for hospitalizations for all chapters except neoplasms and Blood males had higher rate ratios for all except congenital anomalies and neoplasms. For individual conditions, Blood males had the highest separation rate ratios for alcohol dependence syndrome, gastritis/duodenitis and diabetes mellitus. Bronchitis/emphysema and diabetes mellitus had the highest rate ratios for Blood females. The results are consistent with those reported in other studies of North American Indians. Their health status is more consistent with a developing country than that expected in Canada and does not appear to be improving.

Outcome in rheumatoid arthritis. A 1985 inception cohort study

OBJECTIVE

Our purpose was to describe the clinical status and outcome of a 1985 inception cohort of patients with rheumatoid arthritis (RA), retrospectively established.

METHODS

All patients with RA in Edmonton, with a possible onset of disease in 1985, and who consulted a rheumatologist at any time from January, 1985 through June, 1991 were considered for inclusion in the cohort. Patients were contacted and assessed between August, 1991 and June, 1992. The following indices were used as outcome measures: joint counts, radiological scores of hand radiographs and the modified Health Assessment Questionnaire for activities of daily living (MHAQ).

RESULTS

One hundred and twenty eight patients were included in the cohort (70% were women; age at onset was 52 +/- 13 years). At the time of the assessment, 41 patients (32%) had no articular swelling. Twenty-nine patients (23%) had a radiological score of 0, and 39 (31%) had no erosions. The mean MHAQ score was 0.49 +/- 0.47; 39 patients (31%) had a score of 0 (normal function). Rheumatoid factors and nodules were related to more severe outcomes. Sex, age at onset and mode of onset were not related to prognosis. Most patients had received 2nd line therapy within the first 3 years of RA.

CONCLUSION

Our results suggest that the prognosis of RA after 6-7 years of disease is not as ominous as has been suggested by others. Since most of the previous studies have been conducted in prevalent cases attending tertiary centers, a selection bias may be responsible for some of these results. Since these patients were treated early in the course of the disease, the beneficial effects of prompt 2nd line therapy cannot be excluded.

Unintentional house fire deaths in Alberta 1985-1990: a population study

We extracted data from the Medical Examiner's files for all fire deaths in Alberta reported to the Medical Examiner's for the period 1985-1990. Of the 320 fire deaths, 183 (57%) were unintentional deaths from house fires. The highest house fire death rates occurred in children 0-4 years and in adults > or = 80 years of age (2.9 and 3.2 per 100,000 per year). The majority (53%) of fatal house fires occurred in single detached dwellings but the rate of fatal house fires was 9.0 times higher in moveable dwellings than in single detached dwellings. At least 61 (33%) of unintentional fatal house fires were caused by smokers' material. Blood alcohol levels above 0.8 g/L were found in 84 (59%) of victims tested and in 39 (76%) of victims of fires caused by smoking materials. 143 (78%) house fire deaths were due, at least in part, to inhalation of toxic fumes. The cause of fatal house fires in Alberta is multifactorial. However, particular attention should be paid towards the lethal combination of cigarettes and alcohol in preventing these fires.

The fluoridation of drinking water and hip fracture hospitalization rates in two Canadian communities

OBJECTIVES

The purpose of this study was to compare hip fracture hospitalization rates between a fluoridated and a non-fluoridated community in Alberta, Canada: Edmonton, which has had fluoridated drinking water since 1967, and Calgary, which considered fluoridation in 1991 but is currently revising this decision.

METHODS

Case subjects were all individuals aged 45 years or older residing in Edmonton or Calgary who were admitted to hospitals in Alberta between January 1, 1981, and December 31, 1987, and who had a discharge diagnosis of hip fracture. Edmonton rates were compared with Calgary rates, with adjustment for age and sex using the Edmonton population as a standard.

RESULTS

The hip fracture hospitalization rate for Edmonton from 1981 through 1987 was 2.77 per 1000 person-years. The age-sex standardized rate for Calgary was 2.78 per 1000 person-years. No statistically significant difference was observed in the overall rate, and only minor differences were observed within age and sex subgroups, with the Edmonton rates being higher in males.

CONCLUSIONS

These findings suggest that fluoridation of drinking water has no impact, neither beneficial nor deleterious, on the risk of hip fracture.

The spectrum of acquired immunodeficiency syndrome (AIDS)-associated malignancies in San Francisco, 1980-1987

Population-based disease registries for acquired immunodeficiency syndrome (AIDS) and cancer were linked for San Francisco residents to study the pattern of AIDS-associated malignancies diagnosed during the time period 1980-1987. A total of 1,756 newly diagnosed malignancies were identified during these years among members of the AIDS cohort. Of these, 1,752 (99.7%) occurred in males, 1,454 (83%) were Kaposi's sarcoma, 235 (13%) were non-Hodgkin's lymphoma, and 16 (1%) were Hodgkin's disease. The distributions of AIDS patients with cancer differed significantly from those without cancer by race and by risk group. Malignancies known to be human immunodeficiency virus (HIV)-associated, and now diagnostic of AIDS (Kaposi's sarcoma, non-Hodgkin's lymphoma), were, as would be expected, dramatically in excess among AIDS patients. Some malignancies not traditionally thought to be HIV-associated appear to have occurred more often than expected in the study cohort. These include Hodgkin's disease, rare non-melanoma skin cancers, and cancers of the rectum, anus, and nasal cavity. Malignancies known to be HIV-associated were more likely to be diagnosed concurrent with or subsequent to first AIDS diagnosis. Conversely, malignancies not known to be HIV-associated were more likely to be diagnosed before AIDS diagnosis. Compared with the concurrent reference population of the San Francisco Bay Area, there was little or no increase in Kaposi's sarcoma over the time interval of this study. For non-Hodgkin's lymphoma, and suggestively for Hodgkin's disease, however, the temporal increase has been quite dramatic.

Reducing the cesarean section rate in a rural community hospital

OBJECTIVE

To determine the success of a program designed to reduce the cesarean section rate in a rural community hospital, to identify reasons for any reduction in the rate and to identify any accompanying increases in the maternal and neonatal morbidity and mortality rates.

DESIGN

Longitudinal study of modes of delivery.

SETTING

A 44-bed community hospital with a medical staff of nine family physicians serving a population of 9000.

PATIENTS

All 1161 women who gave birth at the hospital from Jan. 1, 1985, to Dec. 31, 1989. Routinely recorded data were manually extracted from medical charts and entered into a computer database.

INTERVENTION

The guidelines of the National Consensus Conference on Aspects of Cesarean Birth (NCCACB) for vaginal birth after cesarean section (VBAC), management of breech presentation and the diagnosis of dystocia requiring cesarean section were introduced at the hospital in 1985.

OUTCOME MEASURES

The annual overall cesarean section rates and the rates among nulliparous women, multiparous women eligible for VBAC and multiparous women ineligible for VBAC.

RESULTS

The overall cesarean section rate decreased from 23% in 1985 to 13% in 1989 (p = 0.001). Among the nulliparous women the rate decreased from 23% to 12%, but the difference was insignificant (p = 0.069); this decrease was due to a drop in the number of dystocia-related cesarean sections. The rate among VBAC-eligible multiparous women decreased from 93% to 36% (p less than 0.001) because of an increased acceptance of VBAC by the patients and the physicians. The rate among multiparous women ineligible for VBAC was virtually unchanged. There were 20 neonatal transfers to an intensive care unit, with no tendency toward an increase over the study period. None of the mothers died; one newborn, of a nulliparous woman, died from a prolapsed umbilical cord.

CONCLUSIONS

The program was accompanied by a significant decrease in the cesarean section rate. Rural hospitals with facilities and personnel for emergency cesarean sections should consider the introduction of a similar program.

Cesarean sections in Alberta from April 1979 to March 1988

OBJECTIVES

To determine (a) trends in the cesarean section rate in Alberta from April 1979 to March 1988, (b) the contribution of different primary indications to the overall increase in the cesarean section rate and (c) trends in the cesarean section rate by residence of the mother.

DESIGN

Retrospective study.

PARTICIPANTS

Women who gave birth in acute care hospitals in Alberta during the study period. Indications for cesarean section were defined by a hierarchic classification system. Geographic regions were identified according to the mother's residence.

MAIN RESULTS

The crude cesarean section rate increased from 13.2 to 17.3 per 100 deliveries between 1979-80 and 1987-88. Previous cesarean section accounted for 54% of the increase, breech presentation for 17%, fetal distress for 17% and dystocia for 10%. The contribution of previous cesarean section was due to the substantial increase in the number of women presenting with a previous cesarean section. The cesarean section rate among women who had previously had the procedure decreased from 96.7% in 1979-80 to 84.6% in 1987-88. The crude cesarean section rates by region varied from 10.3 to 22.3 per 100 deliveries.

CONCLUSIONS

Further efforts to reduce the rate of cesarean section among women who have previously undergone the procedure are needed to control the rate of cesarean section in Alberta. Decreasing the rate of primary cesarean section is also an important goal.

Why are there so many injuries? Why aren't we stopping them?

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Pesticide food poisoning from contaminated watermelons in California, 1985

Aldicarb, a carbamate pesticide, is the most potent pesticide in the market and has a LD50 of 1 mg/kg. In the United States it is illegal to use aldicarb on certain crops, e.g., watermelons, because it is incorporated into the flesh of the fruit. Once an accidental or illegal use of such a potent pesticide occurs, there is no easy way for the agricultural or public health system to protect the populace. This paper describes the impact of one such event upon the health of individuals and the institutions of California. On July 4, 1985, California and other western states experienced the largest known outbreak of food-borne pesticide illness ever to occur in North America. This was attributed to watermelons contaminated through the illegal or accidental use of aldicarb by a few farmers in one part of the state. Within California, a total of 1,376 illnesses resulting from consumption of watermelons was reported to the California Department of Health Services (CDHS). Of the 1,376 illnesses, 77% were classified as being probable or possible carbamate illnesses. Many of the case reports involved multiple illnesses associated with the same melon among unrelated individuals. Seventeen individuals required hospitalization. There were 47 reports of illness involving pregnant women, two of whom reported having subsequent stillbirths. Thirty-five of the remaining pregnant women were followed-up 9 mo after the epidemic; no additional stillbirths were found.(ABSTRACT TRUNCATED AT 250 WORDS)

Mortality from unintentional injuries in California, 1985

In 1985 unintentional injuries were the fourth leading cause of death among California residents, causing 10,380 deaths. They were the leading cause of potential life lost, accounting for 278,109 years lost. This was more than twice the number of years lost due to heart disease and 1 1/2 times the number lost due to cancer. Motor vehicle traffic accidents were the leading cause of unintentional injury deaths, accounting for half (5,158) the deaths. The next two leading causes were poisoning (especially for men aged 25 to 44 years) and falls (especially among persons aged 75 and older). Drowning was second to motor vehicle accidents as a cause of death in children aged 1 to 14 years. California's age-adjusted injury mortality rates in 1985 were lower in coastal and urban counties than in inland and rural counties, and these rates were generally lower in counties having organized systems of trauma care.

Differences in the timeliness of diagnosis, breast and cervical cancer, San Francisco 1974-85

Cancer registry data for San Francisco (1974-85) were used to identify women at greater risk of late diagnoses for breast and cervical cancers by age and ethnicity. For breast cancer, Black women were at greater risk for late diagnoses. For cervical cancer, women of all ethnic groups ages 50-69 years and Japanese and Filipino women were at greater risk for late diagnoses.

Outbreak of Omite-CR-induced dermatitis among orange pickers in Tulare County, California

An outbreak of dermatitis cases among 198 orange pickers employed by a Tulare County, California, packinghouse was investigated. Dermatitis was contracted by 114 (58%) of the 198 workers exposed when Omite-CR-treated fields were harvested. The dermatitis occurred predominantly in the exposed areas of the neck and chest. A dose-response association with dermatitis was suggested for Omite-CR exposure, but not for Carzol, Omite-CR + Carzol, or other pesticides. Because no violations of pesticide preharvest intervals or application rates were found, it appears that residue degradation was not given adequate consideration in the registration of Omite-CR, thus compromising the safety of the worker.

Clinical competence of paediatric primary health care nurses in Soweto

Primary health care (PHC) nurses provide care at polyclinics in Soweto. Our study assessed nurse competence in the clinical detection of important respiratory signs in 337 consecutive paediatric patients with respiratory complaints. The patients were then independently re-examined by two paediatricians, one of whom was arbitrarily chosen as a 'standard doctor'. The standard doctor found 95 patients with important respiratory signs; nurses detected the same signs in 45 and the other doctor in 44 patients. Therefore nurses detected important signs as well as could be expected, considering the inter-observer variation between doctors. The nurses did, however, significantly overdiagnose one condition, follicular tonsillitis. Our results suggest that the Soweto paediatric PHC nurses detect clinical signs with as much accuracy as doctors. This study adds to the available evidence that adequately trained and supervised nurse practitioners can provide high-quality health care.

Tuberculosis management in Soweto

Despite the availability of highly effective therapy, tuberculosis (TB) remains a major problem in South Africa, even in urban centres such as Soweto which is relatively well provided with health services. We therefore assessed two aspects of TB management in Soweto: (i) the proportion of known tuberculous patients adequately treated; (ii) whether case finding through investigation of home contacts of notified patients was effective. In 1978 patients with TB were required to take chemotherapy for at least a year. Only 28% of newly notified patients attended the clinics frequently enough and/or were hospitalized long enough to obtain 80% or more of the treatment they required during that first year. A major part of this problem of non-compliance was infrequent attendance; these patients received therapy of an adequate duration, but at an inadequate dosage. At least 17% of patients over 10 years of age had tubercle bacilli in their sputa on microscopy more than 4 months after therapy was started. About two-thirds of known home contacts were investigated by the health services in accordance with their stated policy, and 5% of contacts were subsequently notified. Home-contact tracing therefore seems worthwhile.

Why don't patients return for antihypertensive treatment in Soweto?

Out of an inception cohort of 91 newly treated hypertensive patients at a Soweto polyclinic only 16 (18%) attended regularly during the year after their first visit. Visits were made to the homes of the 75 non-compliant patients between 18 and 21 months after the patient's first visit to establish the reasons for non-attendance. Five of the 75 (7%) had died, 16 (21%) were not available for an interview and 54 (72%) were interviewed. These 54 patients gave many different reasons for not returning regularly. The most common reasons were: (i) they did not remember being told that they had hypertension and that they needed to return for more treatment--14 patients; (ii) they had been away from Soweto--7 patients; (iii) they had been unable to take time off work--6 patients; (iv) they considered themselves to be regular attenders--5 patients; (v) they had not felt ill--5 patients; and (vi) they experienced unwanted side-effects--4 patients. Only 2 patients said that they had received regular treatment elsewhere. In the light of these results different approaches designed to improve both attendance and medication compliance are being developed and evaluated.

Queueing and patient flow at a Soweto polyclinic

We studied all 265 adult patients who came to a Soweto polyclinic on 18 March 1980. The objectives were: (i) to determine the flow of patients and the time spent in the polyclinic; (ii) to use computer models to predict the effects of altering numbers of staff and/or the introduction of an appointment system; and (iii) to elicit information relating to the feasibility of introducing an appointment system. The results show that of the 265 patients, 80% arrived before 10h00 and 1% arrived after 13h00. Forty-one per cent of these patients waited in 5 or more queues. Of the 245 patients for whom the amount of time spent in the clinic was available the mean time spent in the clinic was 171 minutes, with a range of 16 - 375 minutes. The mean time spent receiving attention was 24 minutes. IBM's GPSS/360 programme was not found to be useful for running computer-simulated flow models. Of 241 patients who returned questionnaires, 65% said they would like the introduction of an appointment system and 70% would be able to make appointments relatively easily. An appointment system might considerably reduce time being wasted. The practicalities of such a system in terms of the functioning of the clinic must still be carefully investigated. We suggest that a feasible appointment system be introduced and its effect on patient satisfaction and flow carefully monitored.

Hypertension management and patient compliance at a Soweto polyclinic

The aim of our study was to assess the quality of hypertension detection and management at the Senaoane polyclinic for Black patients in Soweto and to determine the degree of patient compliance with antihypertensive drug treatment. We reviewed the records of 2,200 consecutive new patients who were 15 years of age or older. The blood pressures of 84% of the patients were measured at their first visit to the polyclinic. Of the patients seen initially by primary health care nurses, 98% were managed correctly according to the blood pressure management protocol that these nurses had been trained to use. Of 55 patients started on antihypertensive drug treatment at their first visit to the polyclinic, 31% did not visit the polyclinic again during the next year. Only 15 patients (27%) were compliant, i.e. they attended often enough during the following year to allow them to receive 80% or more of the necessary drugs. These 15 patients had substantial reductions in their diastolic blood pressures (mean reduction 21 mmHg). We regard poor compliance as the major factor preventing the polyclinic from reducing morbidity and mortality in hypertensives. Strategies for improving compliance need to be developed and evaluated for different poor compliance groups. These groups can be defined according to the severity of the hypertension and the pattern of poor compliance ("early drop-outs' v. "irregular attenders').

A demographic and socio-economic profile of a rural black South African community

Demographic data regarding households in a Black rural community in the Eastern Transvaal were collected. Detailed socio-economic and health data were collected from a 10% random sample of households (response rate 92,5%). These data will be used for planning and evaluating a community health project. An extremely high infant mortality rate (198,1/1 000 live births), very low household incomes (median monetary household income R20 - R50 per month), low rates of immunization (39,4% of children under 12 years old had not been immunized), and gaps between the knowledge and practice of and the expressed desire for family planning were striking features.