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Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998. Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates. Setting Southern England. Subjects 5312 people admitted to hospital with acute pancreatitis. Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission. Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women. Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.

Could eating in a smoky restaurant precipitate an acute myocardial infarction in a non—smoker? As unlikely as this sounds, a growing body of scientific data suggests that this is possible. In this context, the results of the observational study in Helena, MT are provocative: hospital admissions for acute myocardial infarction declined by about 40% during the six months in which a comprehensive local ordinance on clean air was in effect, and rebounded after the ordinance was suspended.1 Given the small size and observational design of the study, these findings might be discounted or even disregarded altogether. However, the study focuses attention on an interesting subset of literature on secondhand smoke and its consequences. We now have a considerable amount of epidemiological literature and laboratory data on the mechanisms by which relatively small exposures to toxins in tobacco smoke seem to cause unexpectedly large increases in the risk of acute cardiovascular disease.2–7 Exposure to secondhand smoke increases the risk of fatal and non-fatal coronary heart disease in non-smokers by about 30%.2 5 8 9 Because coronary heart disease is a leading cause of death in many countries, even relatively small increases in risk from this one factor can result in a large population burden of disease attributable to exposure to tobacco smoke.10 11 While the substantial cardiovascular risks posed by active smoking are now almost universally accepted, the tobacco industry and some other observers continue to question the idea that secondhand smoke can cause cardiovascular disease and death.12–15 Notwithstanding the substantial clinical and experimental evidence regarding the adverse cardiovascular effects of exposure to secondhand smoke, some have argued that an association between low level environmental exposures and health outcomes should be more critically evaluated, particularly when the relative risk for the exposure …

Objectives: To relate alcohol consumption to mortality. Design: Prospective cohort study. Setting: 27 workplaces in the west of Scotland. Participants: 5766 men aged 35-64 when screened in 1970-3 who answered questions on their usual weekly alcohol consumption. Main outcome measures: Mortality from all causes, coronary heart disease, stroke, and alcohol related causes over 21 years of follow up related to units of alcohol consumed per week. Results: Risk for all cause mortality was similar for non-drinkers and men drinking up to 14 units a week. Mortality risk then showed a graded association with alcohol consumption (relative rate compared with non-drinkers 1.34 (95% confidence interval 1.14 to 1.58) for 15-21 units a week, 1.49 (1.27 to 1.75) for 22-34 units, 1.74 (1.47 to 2.06) for 35 or more units). Adjustment for risk factors attenuated the increased relative risks, but they remained significantly above 1 for men drinking 22 or more units a week. There was no strong relation between alcohol consumption and mortality from coronary heart disease after adjustment. A strong positive relation was seen between alcohol consumption and risk of mortality from stroke, with men drinking 35 or more units having double the risk of non-drinkers, even after adjustment. Conclusions: The overall association between alcohol consumption and mortality is unfavourable for men drinking over 22 units a week, and there is no clear evidence of any protective effect for men drinking less than this.

Objective: To describe the clinical circumstances in which psychiatric patients commit suicide. Design: National clinical survey. Setting: England and Wales. Subjects: A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death. Main outcome measures: Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending. Results: 10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases. Conclusions: Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.

OBJECTIVE: To assess the hazards at an early phase of the growing epidemic of deaths from tobacco in China. DESIGN: Smoking habits before 1980 (obtained from family or other informants) of 0.7 million adults who had died of neoplastic, respiratory, or vascular causes were compared with those of a reference group of 0.2 million who had died of other causes. SETTING: 24 urban and 74 rural areas of China. SUBJECTS: One million people who had died during 1986-8 and whose families could be interviewed. MAIN OUTCOME MEASURES: Tobacco attributable mortality in middle or old age from neoplastic, respiratory, or vascular disease. RESULTS: Among male smokers aged 35-69 there was a 51% (SE 2) excess of neoplastic deaths, a 31% (2) excess of respiratory deaths, and a 15% (2) excess of vascular deaths. All three excesses were significant (P/70 there was a 39% (3) excess of neoplastic deaths, a 54% (2) excess of respiratory deaths, and a 6% (2) excess of vascular deaths. Fewer women smoked, but those who did had tobacco attributable risks of lung cancer and respiratory disease about the same as men. For both sexes, the lung cancer rates at ages 35-69 were about three times as great in smokers as in non-smokers, but because the rates among non-smokers in different parts of China varied widely the absolute excesses of lung cancer in smokers also varied. Of all deaths attributed to tobacco, 45% were due to chronic obstructive pulmonary disease and 15% to lung cancer; oesophageal cancer, stomach cancer, liver cancer, tuberculosis, stroke, and ischaemic heart disease each caused 5-8%. Tobacco caused about 0.6 million Chinese deaths in 1990 (0.5 million men). This will rise to 0.8 million in 2000 (0.4 million at ages 35-69) or to more if the tobacco attributed fractions increase. CONCLUSIONS: At current age specific death rates in smokers and non-smokers one in four smokers would be killed by tobacco, but as the epidemic grows this proportion will roughly double. If current smoking uptake rates persist in China (where about two thirds of men but few women become smokers) tobacco will kill about 100 million of the 0.3 billion males now aged 0-29, with half these deaths in middle age and half in old age.

Objective: To determine the long term relative survival of all patients who had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Design:Population based study. Setting:Western Australia. Subjects: All patients who had had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Main outcome measures: Morbidity and mortality data of patients admitted and surgically treated for abdominal aortic aneurysm in Western Australia during 1985-94. Elective, ruptured, and acute non-ruptured cases were analysed separately. Independent analyses for sex and patients aged 80 years or more were also undertaken. Postoperative (>30 days) relative survival was assessed against age and sex matched controls. Results: Overall, 1475 (1257 men, 218 women) cases were identified. The crude five year survival after elective surgery, including deaths within 30 days of surgery, was 79% for both men and women. When compared with a matched population the five year relative survival after elective surgery was 94.9% (95% confidence interval 89.9% to 99.9%) for men but only 88.0% (76.3% to 99.7%) for women. The five year relative survival of those aged 80 years and over was good: 116.6% (89.1% to 144.0%) compared with 92.4% (87.7% to 97.0%) for those under 80 years of age (men and women combined). Cardiovascular disease caused 57.8% of the 341 deaths after 30 days. Conclusion: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.

Objective: To compare survival and cause specific mortality in hypertensive men with non-hypertensive men derived from the same random population, and to study mortality and morbidity from cardiovascular diseases in the hypertensive men in relation to effects on cardiovascular risk factors during 22-23 years of follow up. Design: Prospective, population based observational study. Subjects and methods: 686 hypertensive men aged 47-55 at screening compared with 6810 non-hypertensive men. The hypertensive men were having stepped care treatment with eitherβ adrenergic blocking drugs, thiazide diuretics, or combination treatment. Mortality, morbidity, and adverse effects were registered at yearly examinations and from death certificates. Main outcome measures: All cause mortality and cause specific mortality. Results: Treated hypertensive men had significantly impaired probability of total survival as well as survival from coronary heart disease and stroke. All cause mortality as well as coronary heart disease and stroke mortality were very similar in hypertensive men and normotensive men during the first decade, but increased steadily thereafter despite continuous good blood pressure control. Smoking, signs of target organ damage, and high serum cholesterol levels, but not blood pressure at screening, were significantly related to the incidence of coronary heart disease during follow up. In time dependent Cox9s regression analysis, the incidence of coronary heart disease was significantly related only to serum cholesterol concentrations in the study. Cancer mortality was almost similar in treated hypertensive men (61/686, 8.9%) and non-hypertensive men (732/6810, 10.8%). Conclusion: Treated hypertensive men had impaired survival and increased mortality from cardiovascular disease compared with non-hypertensive men of similar age. These differences were observed during the second decade of follow up. During an observation period of 22-23 years —about 15 000 patient years—hypertensive men receiving diuretics and β blockers had no increased risk of cancer or non-cardiovascular disease.

Objective: To investigate the association between social circumstances in childhood and mortality from various causes of death in adulthood. \ud Design: Prospective observational study. \ud Setting: 27 workplaces in the west of Scotland. \ud Subjects: 5645 men aged 35-64 years at the time of examination. \ud Main outcome measures: Death from various causes. \ud Results: Men whose fathers had manual occupations when they were children were more likely as adults to have manual jobs and be living in deprived areas. Gradients in mortality from coronary heart disease, stroke, lung cancer, stomach cancer, and respiratory disease were seen (all PConclusions: Adverse socioeconomic circumstances in childhood have a specific influence on mortality from stroke and stomach cancer in adulthood, which is not due to the continuity of social disadvantage throughout life. Deprivation in childhood influences risk of mortality from coronary heart disease and respiratory disease in adulthood, although an additive influence of adulthood circumstances is seen in these cases. Mortality from lung cancer, other cancer, and accidents and violence is predominantly influenced by risk factors that are related to social circumstances in adulthood.

Continuing to fight all causes of mortality offers no hope of success Successive governments have been committed to reducing mortality, and the recent white paper shows that the current coalition government is no exception ( BMJ 2010;341:c3796, doi:10.1136/bmj.c3796). The problem with such a commitment begins with the word: mortality means both the number of deaths in any given context but also the condition of being mortal and subject to death. We must all die, and so we must all die from something. The mortality rate for the population as a whole will always be 100%; so to what profile of causes of death should we aspire? If we continue to fight all causes of mortality, particularly in extreme old age, we have no hope of success, and we will consume an ever increasing proportion of healthcare resources for ever diminishing returns. The World Health Organization’s 2008-2013 action plan for the prevention and control of non-communicable diseases states that these diseases, mainly cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, “represent a leading threat …

Passive smoking can cause death from lung cancer and coronary heart disease, but there is little evidence for associations with other causes of death in never smokers. A recent study showed increased all cause mortality with exposure to secondhand smoke at home but did not examine associations with specific causes of death and dose-response relations.1 We have published estimates of the mortality attributable to active smoking in Hong Kong2 and now present the related findings on passive smoking at home. Details of the sample selection and data collection have been reported.2 Each person who reported a death in 1998 at four death registries was given a questionnaire which asked about the lifestyle 10 years earlier of the decedent and of a living person about the same age who was well known to the informant. Passive smoking was identified in the interview with the question, “Ten years ago, in about 1988, excluding the decedent/control, how many persons who lived with the decedent/control smoked?” Decedents or …

In 2000-2, Afghanistan had the highest number of casualties due to landmines and unexploded ordnance in the world.1 Increasing international awareness of the public health threat posed by landmines is the legacy of the International Campaign to Ban Landmines. More attention must be paid to the growing and equally deadly threat posed by unexploded ordnance. We reviewed the surveillance database on injuries due to unexploded ordnance and landmines maintained by the United Nations Mine Action Center for Afghanistan. About 70% of records in the database came from the clinic based surveillance system operated by the International Committee of the Red Cross, which, in 2002, included 390 health facilities.2 Other data were collected through mine clearance teams, education programmes to minimise the risks posed by mines, and programmes to help victims. We excluded duplicate entries by comparing the demographics, time, and location of injury of the victim. We used JMP …

Suicide rates have increased in many developing countries.1 But the reported rates are misleading because population counts are unreliable, and identifying suicides is problematic because of inefficient civil registration systems, non-reporting of deaths, variable standards in certifying death, and suicide's legal and social consequences. Suicide rates were between 8.1 and 58.3/100 000 population for different parts of India.2 Police records, which under-report, were used to calculate these rates. We used verbal autopsies in the 85 villages of the Kaniyambadi region of southern India (area 127 km2; population 108 873 in 1999) to calculate mean age and sex specific suicide rates for the period 1994-9. A community health worker (a resident of the village), health aide, community nurse, and doctor reached a consensus on the cause of death. …

The potential health hazards of breast implants have been heavily debated for the past decade, yet only one study has reported on long term mortality among women with such implants, and around one fifth of the participants were lost to follow up. 1 2 We assessed total and cause specific mortality among Swedish women who underwent augmentation mammoplasty between 1965 and 1993. As a desire for cosmetic surgery represents underlying psychopathology in some patients, we hypothesised that deaths due to suicide may be over-represented.3 Details about accrual of the cohort have been given elsewhere.4 We obtained records from the Swedish Inpatient Register of all 15–69 year old women who had had breast implants (n=7585) in 1965-93. We identified records with erroneous registration numbers or where emigration or death occurred before surgery through linkages with registers held by Statistics Sweden, using the unique national registration numbers. We excluded such records and records where surgery occurred …

Magnetic resonance imaging is useful in postmortem examination of neonates.1 As an alternative to invasive autopsy, the Jewish community asked for magnetic resonance imaging to be used in postmortem examinations in the general population. This service was established with the cooperation of the local coroner, and started in March 1997. Three private magnetic resonance imaging facilities take work for six coroners. Though funded, for religious reasons, by the local Jewish community, the service has also examined Muslim and Christian bodies. We describe the first fully operational service of its kind. Since the inception of the service, the bodies of 53 people (28 women and 25 men), …

Evidence for an inverse association of impaired fetal growth with stroke is less securely established than that with coronary heart disease. Even less is known about the association of fetal growth with occlusive stroke and haemorrhagic stroke. The cohort comprises all 14 611 births in the Uppsala Academic Hospital between 1915 and 1929.1 Socioeconomic circumstances and neonatal characteristics, including gestational age (number of completed weeks since last menstrual period), were available for 96% of the subjects from hospital records and follow up is 98% complete. Analyses were restricted to singletons born at 30-45 weeks' gestation for whom information was available in the 1960 and 1970 censuses. Data on occurrence of first stroke were obtained from the Swedish national hospital discharge register2 and from the national cause of death register. Two subtypes of stroke were defined—haemorrhagic (ICD-8 (international classification of diseases, …

Injuries are a leading cause of death and disability among children in the United Kingdom, costing an estimated £200 million annually in direct costs to the NHS.1 Recent research from England and Wales suggests that death rates from injury and poisoning have fallen in both sexes and all social classes.2 The decline in those of lower social class has been much smaller, however, resulting in widening socioeconomic differentials in mortality from injury. To determine whether this phenomenon has also occurred in Scotland we examined time trends in mortality from injury in Scottish children for 1981-95. National data on external cause of death (injury and poisoning; E800-999 of the ninth edition of the International Classification of Diseases) for children aged 0-14years were obtained from the registrar general for Scotland for the period 1981-95.Socioeconomic status was measured with Carstairs' deprivation index on the basis of characteristics of Scottish postcode sectors. …

Longstanding and recurrent depressive disorders are quite common in elderly people. 1 2 Not much is known, however, of their clinical course and prognosis, including mortality. The need for treatment of longstanding, less severe depressive disorders is a matter of discussion. We studied the relation between longstanding or recurrent depressive disorders and mortality and that between recovery from depressive disorders and mortality in elderly people. This study is based on the Ahtari longitudinal epidemiological research project concerning depression in elderly people.1–3 The initial series consisted of people born in 1923or earlier and living in the municipality of Ahtari, Finland, on 1January 1984(n=1529). In the first study in 1984-5the participation rate was 91%. The follow up study was performed in 1989-90with a participation rate of 94%. Depression was determined after semistructured interviews by the criteria of the Diagnostic and Statistical Manual of Mental Disorders , third edition (DSM-III).1–3 View this table: Predictors of mortality …

Objective To estimate deaths from passive smoking in employees of the hospitality industry as well as in the general workforce and general population of the United Kingdom.Design Calculation, using the formula for population attributable proportion, of deaths likely to have been caused by passive smoking at home and at work in the UK according to occupation. Sensitivity analyses to examine impact of varying assumptions regarding prevalence and risks of exposure.Setting National UK databases of causes of death, employment, structure of households, and prevalences of active and passive smoking.Main outcome measures Estimates of deaths due to passive smoking according to age group (< 65 or ≥ 65) and site of exposure (domestic or workplace).Results Across the United Kingdom as a whole, passive smoking at work is likely to be responsible for the deaths of more than two employed people per working day (617 deaths per year), including 54 deaths in the hospitality industry each year. Each year passive smoking at home might account for another 2700 deaths in persons aged 20-64 years and 8000 deaths among people aged ≥ 65.Conclusion Exposure at work might contribute up to one fifth of all deaths from passive smoking in the general population aged 20-64 years, and up to half of such deaths among employees of the hospitality industry. Adoption of smoke free policies in all workplaces and reductions in the general prevalence of active smoking would lead to substantial reductions in these avoidable deaths.

To determine whether starvation during periods of increased growth after birth have long term health consequences.Analysis of cardiovascular risk factors and mortality in a longitudinal follow up after the 1941-4 siege of Leningrad. Mortality measured from 1975 up to the end of 1999.St Petersburg, Russia (formerly Leningrad).5000 men born 1916-35 who lived in Leningrad, randomly selected to take part in health examinations in 1975-7. Of the 3905 men who participated, a third had experienced the siege.Relative risk of ischaemic heart disease and mortality from stroke by siege exposure. Odds ratios and means for several cardiovascular risk factors.Three to six decades after the siege, in men who experienced the siege around the age of puberty blood pressure was raised (mean difference in systolic 3.3 mm Hg, in diastolic 1.3 mm Hg) as was mortality from ischaemic heart disease (relative risk 1.39, 95% confidence interval 1.07 to 1.79) and stroke (1.67, 1.15 to 2.43), including haemorrhagic stroke (1.71, 0.90 to 3.22). The effect on mortality was partly mediated via blood pressure but not by any other measured biological, behavioural, or social factor.Starvation, or accompanying chronic stress, particularly at the onset of or during puberty, may increase vulnerability to later cardiovascular disease.

Objectives To investigate trends in Russian mortality for 1991-2001 with particular reference to trends since the Russian economic crisis in 1998 and to geographical differences within Russia. Design Analysis of data obtained from the Russian State statistics committee for 1991-2001. All cause mortality was compared between seven federal regions. Comparison of cause specific rates was conducted for young (15-34 years) and middle aged adults (35-69 years). The number of Russian adults who died before age 70 in the period 1992-2001 and whose deaths were attributable to increased mortality was calculated. Main outcome measures Age, sex, and cause specific mortality standardised to the world population. Results Mortality increased substantially after the economic crisis in 1998, with life expectancy falling to 58.9 years among men and 71.8 years among women by 2001. Most of these fluctuations were due to changes in mortality from vascular disease and violent deaths (mainly suicides, homicides, unintentional poisoning, and traffic incidents) among young and middle aged adults. Trends were similar in all parts of Russia. An extra 2.5-3 million Russian adults died in middle age in the period 1992-2001 than would have been expected based on 1991 mortality. Conclusions Russian mortality was already high in 1991 and has increased further in the subsequent decade. Fluctuations in mortality seem to correlate strongly with underlying economic and societal factors. On an individual level, alcohol consumption is strongly implicated in being at least partially responsible for many of these trends.

Objective To compare the effectiveness of β lactam monotherapy versus β lactam-aminoglycoside combination therapy in the treatment of patients with fever and neutropenia. Data sources Medline, Embase, Lilacs, the Cochrane Library, and conference proceedings to 2002. References of included studies and contact with authors. No restrictions on language, year of publication, or publication status. Study selection All randomised trials of β lactam monotherapy compared with β lactam-minoglycoside combination therapy as empirical treatment for patients with fever and neutropenia. Data selection Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. An intention to treat approach was used. Relative risks were pooled with the random effect model. Main outcome measure All cause fatality. Results Forty seven trials with 7807 patients met inclusion criteria. Nine trials compared the same β lactam. There was no significant difference in all cause fatality (relative risk 0.85, 95% confidence interval 0.72 to 1.02). For success of treatment there was a significant advantage with monotherapy (0.92, 0.85 to 0.99), though there was considerable heterogeneity among trials. There was no significant difference between monotherapy and combination treatment in trials that compared the same β lactam, whereas there was major advantage with monotherapy in trials that compared different β lactams (0.87, 0.80 to 0.93). Rates of superinfection were similar. Adverse events, including those associated with severe morbidity, were significantly more common in the combination treatment group. Detected flaws in methods did not affect results. Conclusions For patients with fever and neutropenia there is no clinical advantage in treatment with β lactam-aminoglycoside combination therapy. Broad spectrum β lactams as monotherapy should be regarded as the standard of care for such patients.

Objectives: To investigate whether the accelerated immunisation programme in the United Kingdom is associated, after adjustment for potential confounding, with the sudden infant death syndrome. Design: Population based case-control study, February 1993 to March 1996. Parental interviews were conducted for each death and for four controls matched for age, locality, and time of sleep. Immunisation status was taken from records held by the parents. Setting: Five regions in England with a combined population of over 17 million. Subjects: Immunisation details were available for 93% (303/325) of infants whose deaths were attributed to the sudden infant death syndrome (SIDS); 90% (65/72) of infants with explained sudden deaths; and 95% (1515/1588) of controls. Results: After all potential confounding factors were controlled for, immunisation uptake was strongly associated with a lower risk of SIDS (odds ratio 0.45 (95% confidence interval 0.24 to 0.85)). This difference became non-significant (0.67 (0.31 to 1.43)) after further adjustment for other factors specific to the infant9s sleeping environment. Similar proportions of SIDS deaths and reference sleeps (corresponding to the time of day during which the index baby had died) among the controls occurred within 48 hours of the last vaccination (5% (7/149) v 5% (41/822)) and within two weeks (21% (31/149) v 27% (224/822)). No longer term temporal association with immunisation was found (P=0.78). Of the SIDS infants who died within two weeks of vaccination, 16% (5/31) had signs and symptoms of illness that suggested that medical contact was required, compared with 26% (16/61) of the non-immunised SIDS infants of similar age. The findings for the infants who died suddenly and unexpectedly but of explained causes mirrored those for SIDS infants. Conclusions: Immunisation does not lead to sudden unexpected death in infancy, and the direction of the relation is towards protection rather than risk. What is already known on this topic Some studies have suggested a link between the sudden infant death syndrome and primary immunisation, but most have failed to show a link Potential bias in the studies includes lack of a comparative control group with similar low immunisation uptake and misclassification of cause of death What this study adds This study investigated explained sudden infant deaths as well as the sudden infant death syndrome and took into account potential bias After confounding was controlled for, immunisation uptake was lowest among the infants who died, with no temporal relation or correlation with signs and symptoms of illness

A total of 178 patients with obstructive airways disease were studied between 1966 and 1972, a period which followed a substantial fall in atmospheric pollution in Sheffield. Compared with patients from an earlier study of the same age and smoking habits they had less productive cough, fewer winter illnesses, less severe breathlessness, and only one-third of the rate of decline of forced expiratory volume (FEV). The analysis of the change in the annual loss of FEV was complicated. There were virtually no sudden steep falls of respiratory function, and patients with very low values of FEV survived for long periods. The predominant cause of death was cor pulmonale. Chronic hypoxia may be more of a problem in the next few years than bronchial infection. I believe that the clean air policy has effected an improvement and that the nature of chronic bronchitis with severe obstructive airways disease is changing, but further studies will be needed to confirm this.

Routine sources of data on chickenpox morbidity and mortality in England and Wales were reviewed for 1967-85. Only two epidemics occurred, one in 1967 and one in 1980, both of which were immediately followed by two to three years of low incidence. The age distribution of the disease appears to be changing, with more cases now being reported in children aged 0-4 years. The number of deaths in adults have, however, increased, particularly those deaths that are associated with pneumonia and immunosuppression. At present in England and Wales more deaths are attributed to chickenpox than to whooping cough and mumps. Widespread use of selective immunisation against chickenpox might be justified in England and Wales, but before routine immunisation of the child population can be considered special surveys to determine the incidence and severity of chickenpox and the effect of the vaccine on the subsequent development of herpes zoster are needed as well as cost-benefit studies of immunisation.

High doses of colistin were used in the treatment of severely ill patients with refractory klebsiella chest and urinary tract infections. At the same time renal function was monitored to determine possible nephrotoxicity. In all patients it produced acute renal failure and in some acute tubular necrosis. Though renal failure contributed to the final cause of death in some cases, in the majority death was due to the primary neurological illness.

Editor—We believe that we have behaved ethically. We emphasised the preliminary nature of our findings and submitted our paper as a research pointer. We worked with the press offices of our universities, the BMJ, and the Department of Health to promote responsible media coverage. The journalist working for the tabloid referred to by Stirrat did not speak to us. Although we agree that media reporting of scientific articles might be improved, we do not think that suppression of research findings is justified. Greenland et al have argued empirical observations should be reported so that they can be used to develop and test theoretical understandings of disease aetiology.1 It might be more appropriate to ask whether it is ethical not to conduct long term follow up of large randomised trials that produced immediate effects. Participants in this trial were sequentially allocated to receive pills of different colours. Neither the investigator nor the subjects knew which colour was which. So, as folate does not produce any side effects that would lead the investigators to break the code, the treatment was concealed and this was a double blind trial. Although strictly speaking the allocation was not the same as random allocation, we used the term random because the process was essentially random. As Chalmers and Altman and Bland have pointed out,2,3 sequential allocation should be unbiased providing concealment is adequate. As previously described there was no other treatment arm in this trial and the assignment ratios were as specified. This could be confirmed by reading the paper that we referenced.4 We are happy to send Bland a copy of this paper, but we note from the website of the library at his institution, the University of York, that the journal is available there. We made it clear that our findings were not prespecified and agree that the P values should be interpreted with caution.

EDITOR—As a simple measure of human nature, I suspect the initial impact of the paper by White et al on alcohol consumption and mortality will depend on the age of the reader1; as someone in the two unit a week group (by a whisker of course) I was drawn to read the article in more depth. Although it is clear what the paper adds, it is harder to decide how it affects what …

Deaths during clinical trials or outcome review studies could be due to the disease being studied; adverse complications of interventions in the study; intercurrent disease unrelated to the initial condition or interventions; or unnatural events. Accurate ascertainment of the causes of deaths is therefore required to establish whether treatment has prevented deaths from the investigated disease without concomitant increases in death or morbidity from other causes. We assessed the methods used to evaluate causes of death in published clinical research. All 879 papers published in 1994 in the Lancet , BMJ , Annals of Internal Medicine , and New England Journal of Medicine were reviewed; the methods used to evaluate the causes of death in each paper were recorded using 11 categories (table 1). Death was an outcome measure in 223 papers (25%). …

Cancer is now responsible for twice as many deaths as cardiovascular disease (CVD) in high income countries, according to two new papers published in the Lancet . The studies said that while CVD remains the leading cause of mortality among middle aged adults globally, accounting for 40% of all deaths, this is no longer the case in high income countries. The researchers estimated that of 55 million deaths that occurred in the world in 2017, approximately 17.7 million were from CVD. The findings come from the PURE study, a large prospective international cohort study that involves substantial data from a large number of middle, low, and high income countries. Countries analysed in the two reports include: Argentina, Bangladesh, Brazil, Canada, Chile, China, Colombia, India, Iran, Malaysia, Pakistan, Palestine, Philippines, Poland, Saudi Arabia, South Africa, Sweden, …

For debate {#article-title-2} The increased awareness of deliberate harm to infants by parents and carers has prompted debate on the terminology used for “cot deaths.” These two papers give historical context of the debate and consider whether the use of “sudden infant death syndrome” should be abandoned. # Time to put “cot death” to bed? {#article-title-3} In a recent editorial in the Journal of Clinical Pathology I argued that pathologists should approach sudden and unexpected death in the first year of life with greater caution than may have been applied in recent years.1 In consequence of the increased awareness of deliberate harm by parents and carers reported by Meadow and so graphically captured on video recordings by Southall and Banks,2–4 I said that the term “not ascertained” should be used much more widely than it is at present. I am fully aware of the distress that such an approach may cause to recently bereaved and totally innocent parents. I am also old enough to recall the “bad old days” of the 1960s, when deaths were wrongly attributed to unsuitable bedding or inappropriate care, leading to unnecessary inquests and pillorying of the parents in the local press. At the other end of the spectrum we used to invent meaningless diagnoses such as “acute interstitial pneumonitis” and “viral bronchiolitis.” Until late 1971 the registrar general would not accept the sudden infant death syndrome or any of its synonyms as a cause of death. This refusal had two undesirable consequences. Firstly, we had no idea of the true incidence of such deaths in the United Kingdom (or any other society) until reports such as that of Banks gave an indication of the size of the problem.5 Secondly, we focused our attention on an ever enlarging battery of laboratory investigations, rather than closely scrutinising the child's and the parents' histories, especially …

Over the past two decades mortality and admissions to hospital have fallen markedly among Medicare patients, while health outcomes have improved, a new study has reported.1 The study appears in this week’s issue of the Journal of the American Medical Association ( JAMA ), which features articles marking Medicare’s 50th anniversary. In an audio summary accompanying the paper, the lead author, Harlan M Krumholz, of Yale University School of Medicine in New Haven, Connecticut, said that the report “suggests we are in the midst of a remarkable improvement in health and healthcare.” “The improvements we observed were extraordinarily broad based,” Krumholz added. “We looked at various different subgroups: we looked by age, we looked by sex, …

Not yet, but new findings justify trials in this age group Vascular events of the heart (myocardial infarction) and brain (stroke) are the world’s leading cause of death and disability. Most events occur in older people without previous symptomatic vascular disease. Although this group has a lower relative risk of vascular events than people with a previous history, they are substantially more prevalent and so account for a greater absolute number of events.1 Strategies to reduce the burden of vascular events include lipid lowering with statins. Every 1.0 mmol/L reduction in low density lipoprotein cholesterol reduces major vascular events by one fifth in populations of mean age 63 years, among whom many (60%) have previous vascular disease.2 The absolute benefit of statins is also proportional to the absolute risk of vascular events,2 so guidelines recommend adding statins to lifestyle changes if the 10 year risk exceeds 7.5-10%.3 4 Nevertheless, guidelines do not generally recommend statins for adults aged over 75 years without vascular disease because robust evidence is limited.5 6 7 In a linked paper (doi:10.1136/bmj.h2335), Alperovitch and colleagues report that use of statins or fibrates to lower serum cholesterol was associated with a one third lower risk of stroke …

Objective To investigate whether an intervention to improve treatment of depression in older adults in primary care modified the increased risk of death associated with depression. Design Long term follow-up of multi-site practice randomized controlled trial (PROSPECT—Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Setting 20 primary care practices in New York City, Philadelphia, and Pittsburgh, USA, randomized to intervention or usual care. Participants 1226 participants identified between May 1999 and August 2001 through a two stage, age stratified (60-74; ≥75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of patients who screened negative. Intervention For two years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm based care for depression, offering psychotherapy, increasing antidepressant dose if indicated, and monitoring symptoms, adverse effects of drugs, and adherence to treatment. This paper reports the long term follow-up. Main outcome measure Mortality risk based on a median follow-up of 98 (range 0.8-116.4) months through 2008. Results In baseline clinical interviews, 396 people were classified as having major depression, 203 had clinically significant minor depression, and 627 did not meet criteria for depression. At follow-up, 405 patients had died. Patients with major depression in usual care were more likely to die than were those without depression (hazard ratio 1.90, 95% confidence interval 1.57 to 2.31). In contrast, patients with major depression in intervention practices were at no greater risk than were people without depression (hazard ratio 1.09, 0.83 to 1.44). Patients with major depression in intervention practices, relative to usual care, were 24% less likely to have died (hazard ratio 0.76, 0.57 to 1.00; P=0.05). Preliminary data on cause of death are provided. No significant effect on mortality was found for minor depression. Conclusions Older adults with major depression in practices provided with additional resources to intensively manage depression had a mortality risk lower than that observed in usual care and similar to older adults without depression. Trial registration Clinical trials NCT00000367.

Each new intake of medical students to my surgical “firm” started off with a tutorial where I posed a rhetorical question: “Why do we screen for cancer?” To which the inevitable answer would be, “To catch it early, sir.” Wrong. The question should be reframed, as “Does screening for cancer improve length or quality of life?” All other outcomes are surrogates. The clinical trials of screening for breast cancer that informed the recent Marmot review1 made no attempt to measure quality of life, but a surrogate for that might be mastectomy rate in screened compared with unscreened populations. On that measure alone, screening fails: the hazard ratio for mastectomy of 1.2 favours the unscreened population.2 So, does screening improve length of life? Sadly, the Marmot committee chose to duck that one and rely on another surrogate outcome measure, cause specific mortality, with the rather lame excuse that the trials weren’t powered to detect any impact on all cause mortality. Well shame on them, I say. The ProtecT trial of prostate specific antigen screening for prostate cancer gives equal weight to cause specific and all cause mortality by accepting that overdiagnosis and overtreatment might lead to an increase in all cause mortality.3 Here I estimate the additional non-breast cancer deaths that might be the consequence of screening for breast cancer. The CRC1 trial was published in the BMJ in 1989.4 Patients were randomised to mastectomy with or without radiotherapy. This cohort of 2800 women was recruited contemporaneously with those in the old randomised trials of screening by mammography. Note in figure 1 of this paper that the 10 year survival was about 55%. Also, after …

Papers p 1070 Drowning is a significant cause of childhood death in many parts of the world. It is estimated that in 1998 almost half a million deaths worldwide were caused by drowning, 57% of which were among children aged up to 14 years.1 A recent Unicef report found that, in 26 of the world's richest nations, injuries were the leading cause of death among children. Drowning was the second leading cause of injury related death, exceeded only by deaths due to road traffic crashes.2 Drowning is also unique in that case fatality rates are as high as 50% and medical care makes little difference in outcomes for victims brought to the emergency department without spontaneous respiration. The study by Sibert et al in this week's journal (p 1070) identified a significant decline in the incidence of childhood drowning in the United Kingdom between 1988-89 and 1998-99.3 A strength of the study was the use …

Summary points Clostridium difficile infection was cited in one of every 250 death certificates completed in the United Kingdom in 2005,1 and it has become the leading cause of death from healthcare associated infections in much of the industrialised world.2 More than 50 000 cases of C difficile infection were reported in England in 2007—a 50-fold increase since 1990.1 Pseudomembranous colitis was first described in 1935, but it took another 40 years for C difficile to be identified as the causative organism.3 4 C difficile associated disease accounts for 15-25% of antibiotic associated diarrhoea,5 and its incidence is rising. The overall prevalence in patients admitted to hospital is around 1%; it can be as high as 20% in those who stay for more than one week and 50% in those who stay for at least four weeks.6 7 This review aims to draw attention to the symptoms of C difficile infection and to summarise evidence on the indications and optimum timing of surgical intervention for C difficile associated colitis. The quality of evidence for the treatment of C difficile associated disease is poor, and the recommendations in this review are based mainly on non-randomised observational studies (level III evidence). #### Sources and selection criteria We did a PubMed search for English language articles on Clostridium difficile colitis, fulminant colitis, and surgery. Further papers were identified from the reference lists of relevant major articles. C difficile causes a wide spectrum of disease, ranging from asymptomatic colonisation of …

Editor—Blair et al investigated the factors influencing the risk of the sudden infant death syndrome.1 In an increasing number of infant deaths that we have investigated over recent years we have found several recurring themes: infant under 3 months; shared sleeping arrangements, particularly sharing a sofa; young carer; consumption of alcohol the night before the infant was found dead. Typically, the infant is found between the adult and the back of the sofa, often covered by a duvet. Sharing a sofa seems to be particularly common in single parent households with poor socioeconomic support, in which the mother sleeps on the sofa, often with more than one child, simply because it is the warmest place in the house. Some of the risk factors highlighted by Blair et al have long been recognised in law in the Children and Young Persons Act 1933. We are concerned with the use of the term sudden infant death syndrome in this paper because it is potentially misleading in deaths associated with cosleeping. In such cases the infant may have been accidentally overlaid, smothered by the bedclothes, or squashed between the adult and back of the sofa. We accept that this cannot, at present, be proved beyond reasonable doubt, but we found in a recent study that intra-alveolar haemorrhage was increased in infants who died in the context of bed sharing and that this may be a marker of accidental asphyxia.2 This often manifests as bloodstained fluid issuing from the nose and mouth with consequent bloodstaining of the bedding and infant's clothing. Examination of the clothing and bedding is therefore essential. It is inappropriate to accuse a carer unjustly in a cosleeping death. Nevertheless, it strikes us as being more honest to raise the suspicion that accidental upper airway obstruction may be a factor in the death and to give the cause of death as unascertained while giving appropriate support to parents.

This week two papers argue about cause of death in cases that purport to be the sudden infant death syndrome, and in particular, how suspicious an investigator should be that the child has been killed by one of its carers. In perhaps 1 …

Editor—Leon et al claim that their study is “the most persuasive evidence of a real association between size at birth and mortality from ischaemic heart disease.”1 However, the study is open to different interpretations and, in my view, inflicts a serious wound on the birth measurement and adult disease hypothesis. Their table 3 shows that there was no significant association between birth weight and all cause mortality in either sex. Both sexes showed a positive association between birth weight and death from neoplasms and respiratory disease, though none of these were significant. The negative association between birth weight and deaths from circulatory disease was significant only in men. In women there were no significant associations between birth weight and any cause of death. Subsequently, most of the analysis concentrates on the association of death from ischaemic disease and birth measurements in men. This study is claimed (probably correctly) to have unique features. It certainly has large numbers of deaths to analyse. Yet no significant association was found in women, and that in men, with ischaemic heart disease, was presumably compensated for by other causes of death, which made the association with all cause mortality non-significant. Thus, of all the possible associations with birth weight, and despite the large number of deaths, only the association between birth weight and death from ischaemic heart disease in men remains significant. I do not see how these data justify the key message “adult mortality from ischaemic disease increases as size at birth declines.” There is also the question of socioeconomic confounding. Leon et al state that adjustment for socioeconomic circumstances produced only a small reduction in the strength of the association between birth weight and mortality from ischaemic heart disease. The problem of adjusting for socioeconomic factors in this context has been much debated. In this paper the adjustment brought the upper limit of the confidence intervals perilously near unity. If the precision of this measurement matched that of the others, even the single significant result might be in peril.

Certain points were omitted from the paper because of lack of space. During the eight-month study all children found in the mortuary at 0730 six days a week were tested for human immunodeficiency virus (HIV). The HIV-negative children who were chosen for necropsy were selected by lot. Over 408 children in the hospital and the community died; cadavers were not taken to the mortuary in a larger proportion of pediatric than adult deaths. The adult necropsy study showed that causes of death in patients with HIV infection were similar for those dying in and outside the hospital as was the case for children. Although accurate ascertainment of the cause of death based on combined clinical laboratory and necropsy data is ideal it is rarely attainable; necropsy data are used internationally for comparative purposes and with full histopathological examination as in these studies provide superior information to clinical data alone. Necropsies do underestimate bacteremia and enteritis. Pyogenic pneumonia which was diagnosed on the basis of large zones of the lungs with polymorphs in the alveoli was the primary cause of death in 32% (49/155) of the children and was found in 37% (57/155). It was the primary cause of death in 8% of HIV-infected adults and was found in 30%. The common diseases of childhood (acute respiratory infection malnutrition meningitis) were found frequently in both HIV-positive and HIV-negative children. Clinical syndromes are similar in the two groups and signs and symptoms are poorly predictive of HIV status. With the exception of Pneumocystis carinii infection individual infections which define acquired immunodeficiency syndrome (AIDS) were uncommon in HIV-positive children. In contrast the range of disease in HIV-positive adults in Abidjan is different from that in HIV-negative adults as is the case in Nairobi. The rarity of tuberculosis in the children is consistent with the annual risk of infection with Mycobacterium tuberculosis in sub-Saharan Africa about 2%. With a median age at death of less than two years most African children with HIV die before encountering the mycobacterium. The 1991 article by Chin was referenced to emphasize the prevalence of HIV infection in Africa; other articles which include projections beyond 1991 by the same author could have been used.

AIDS has joined suicide as a barrier to the accurate certification of death as required by law in Great Britain and the U.S. Despite acknowledging the importance of accurate records for medical, epidemiological, and insurance purposes, and because registers of death are public records, sympathetic physicians may substitute other causes of death or omit stating the underlying diagnosis of HIV infection in order to spare families of the deceased the added psychological stress caused by stigmatization. Many physicians believe that informing public health authorities is sufficient. To preserve privacy and the confidentiality of medical information a British government paper has suggested that, with reference to sensitive causes of death, recent records be available only to those who have a legitimate reason for wanting them. In the U.S., the adoption of a two-part death certificate has been proposed, one for immediate legal purposes and the other for medical certification.