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Background: An admission to hospital provides an opportunity to help people stop smoking. Individuals may be more open to help at a time of perceived vulnerability, and may find it easier to quit in an environment where smoking is restricted or prohibited. Providing smoking cessation services during hospitalisation may help more people to attempt and sustain an attempt to quit. The purpose of this paper is to systematically review the effectiveness of interventions for smoking cessation in hospitalised patients.Methods: We searched the Cochrane Tobacco Addiction Group register, CINAHL, and the Smoking and Health database for studies of interventions for smoking cessation in hospitalised patients. Randomised and quasi-randomised trials of behavioural, pharmacological, or multi-component interventions to help patients stop smoking conducted with hospitalised patients who were current smokers or recent quitters were included. Studies of patients admitted for psychiatric disorders or substance abuse, those that did not report abstinence rates, and those with follow up of less than 6 months were excluded. Two of the authors extracted data independently for each paper, with assistance from others.Results: Intensive intervention (inpatient contact plus follow up for at least 1 month) was associated with a significantly higher cessation rate compared with controls (Peto odds ratio (OR) 1.82, 95% CI 1.49 to 2.22). Any contact during hospitalisation followed by minimal follow up failed to detect a statistically significant effect on cessation rate, but did not rule out a 30% increase in smoking cessation (Peto OR 1.09, 95% CI 0.91 to 1.31). There was insufficient evidence to judge the effect of interventions delivered only during the hospital stay. Although the interventions increased quit rates irrespective of whether nicotine replacement therapy (NRT) was used, the results for NRT were compatible with other data indicating that it increases quit rates. There was no strong evidence that clinical diagnosis affected the likelihood of quitting.Conclusions: High intensity behavioural interventions that include at least 1 month of follow up contact are effective in promoting smoking cessation in hospitalised patients. [ABSTRACT FROM AUTHOR]

Background Stimulated by the WHO Framework Convention on Tobacco Control, many countries in Latin America adopted comprehensive smoke-free policies. In March 2006, Uruguay became the first Latin American country to adopt 100% smoke-free national legislation, which ended smoking in all indoor public places and workplaces, including restaurants and bars. The objective of this study was to evaluate trends in hospital admissions for cardiovascular disease 2 years before and 2 years after the policy was implemented in Uruguay. Methods Reports of hospital admissions for acute myocardial infarction (AMI) (International Classification of Disease-10 I21) from 37 hospitals (79% of all hospital admissions in the country), representing the period 2 years before and 2 years after the adoption of a nationwide smoke-free policy in Uruguay (between 1 March 2004 and 29 February 2008), were reviewed. A time series analysis was undertaken to compare the average monthly number of events of hospital admission for AMI before and after the smoke-free law. Results A total of 7949 hospital admissions for AMI were identified during the 4-year study period. Two years after the smoke-free policy was enacted, hospital admissions for AMI fell by 22%. The same pattern and roughly the same magnitude of reduction in AMI admissions were observed for patients seen in public and private hospitals, men, women and people aged 40e65 years and older than 65 years. Conclusions The national smoke-free policy implemented in Uruguay in 2006 was associated with a significant reduction in hospital admissions for AMI. [ABSTRACT FROM AUTHOR]

Objective: To estimate the social costs of smoking related to inpatient care in Vietnam using 2005 data. Design: The cost of illness as a result of hospitalisation for three major smoking-related diseases combined with the prevalence-based approach to obtain the costs of smoking in Vietnam for inpatient care. Main outcome measure: Smoking-attributable costs of inpatient care for lung cancer, chronic obstructive pulmonary disease (COPD), and ischaemic heart disease. Results: The total cost of inpatient health care caused by smoking in Vietnam reached at least 1 161 829 million Vietnamese dollars ($VN) (or $US77.5 million) in 2005. This represents about 0.22% of Vietnam gross domestic product (GDP) and 4.3% of total healthcare expenditure. The majority of these expenses are related to COPD treatment ($VN1 033 541 million or $US68.9 million per year) followed by lung cancer ($VN78 143 million, or $US5.2 million per year) and ischaemic disease ($VN50 145 million, or $US3.3 million per year). The government directly finances about 51% of these costs. The rest is financed either by households (34%) or by the insurance sector (15%). Conclusions: The social costs of smoking in Vietnam as the percentage of GDP is lower compared to estimates from high-income countries. The true costs would be substantially higher if all smoking-related diseases, outpatient care and mortality-related costs are included. More research is needed to augment the estimates presented in this paper. [ABSTRACT FROM AUTHOR]

Objective: This paper aims to determine the percentage of road crashes resulting in injuries requiring hospital care that are reported to the police and to identify factors associated with reporting such crashes to the police. Design: The data of one of two hospitals in the Road Casualty Information System were matched with the police's Traffic Accident Database System. Factors affecting the police-reporting rate were examined at two levels: the different reporting rates among subgroups examined and tested with x2 tests; and multiple explanatory factors were scrutinised with a logistic regression model to arrive at the odds ratios to reflect the probability of police-reporting among subgroups. Results: The police-reporting rate was estimated to be 57.5-59.9%. In particular, under-reporting among children (reporting rate=33.6%) and cyclists (reporting rate=33.0%) was notable. Discussion: Accurate and reliable road crash data are essential for unveiling the full-scale and nature of the road safety problem. The police crash database needs to be supplemented by other data. In particular, any estimation about the social costs of road crashes must recognise the under-reporting problem. The large number of injuries not reflected in the police crash database represents a major public health issue that should be carefully examined. [ABSTRACT FROM AUTHOR]

Aims: To describe the hospitalisation history in the first five years of life for all children born in Western Australia (WA) between 1983 and 1992 and diagnosed with intellectual disability (ID). Methods: Unit record linkage of the WA Midwives Collection, WA Intellectual Disability Database, and the WA Hospital Morbidity Dataset provided the population database of WA born children with and without ID. Affected children were divided into those co-affected with autism spectrum disorders (ASD), and those whose ID had or had no known biomedical cause. Those without a biomedical cause were further subdivided into mild-moderate and severe categories. Results: On average, ID affected children were more likely than non-affected children to be admitted to hospital (RR: 1.64; 95% CI 1.6 to 1.7), on more occasions (5.3 versus 2.2 admissions), for longer (29.6 versus 8.3 days), and for a larger range of clinical diagnoses. The only exception was the group of children co-diagnosed with ASD whose hospitalisation profile resembled more that of non-affected children. Conclusions: This total population study is unique because of the availability of the system of linkable population registers and administrative health databases in WA. The results indicated that this vulnerable population of children with ID has substantial medical needs. This paper points to the need for authorities to develop supportive programmes for this population especially in the current climate of de-medicalisation of ID. More research is not only needed on the welfare of the affected children but also on the impact of the substantial medical and other needs of affected children on the rest of their immediate and extended families. [ABSTRACT FROM AUTHOR]

With the increase in the proportion of hospital deaths there is increasing debate about appropriateness of place of death. Death should be a family affair but is increasingly hidden from public view. In contrast to those who die at home, most of those who die in hospital die alone with no relatives or friends with them. Husbands and wives are less likely to have the opportunity to say 'goodbye' to their dying spouses. As people become less familiar with death they may increasingly assume that the terminally ill are better cared for in hospital. However, this need not be the case. Most people want to die at home, most do not for social rather than medical reasons. It is not the illness itself which leads to hospital admission in many cases but its duration and nature--and the type of burden it places on relatives. Although home care should be encouraged where possible, no amount of exhortation to the family or to the dying person of the advantages of home care can disguise the fact that demand for domiciliary services is greater than is now being provided. The paper is based on one read to a London Medical Group Symposium. [ABSTRACT FROM PUBLISHER]

Background: There is accumulating evidence from various countries, including the UK, that ground level ozone concentrations are associated with increased daily hospital admissions for respiratory diseases. This paper estimates the impact of ozone episodes on daily hospital admissions for respiratory disease in Great Britain by combining locally based exposure-response relationships with mapped estimates of ozone exposure for the population in the summers of 1993 and 1995.Methods: For the given years the available ozone measurements were used to construct maps of ozone concentrations for each day. The population exposed to a given concentration of ozone on a particular day was calculated from census data using a geographical information system. The additional hospital admissions for respiratory disease were then estimated using a regression coefficient for London.Results: It is estimated that 0.10% (a total of 184) and 0.35% (a total of 643) of hospital admissions for respiratory disorders during the summers of 1993 and 1995, respectively, can be attributed to levels of ozone above 50 ppb (the recommended air quality standard for the UK). A sensitivity analysis for 1995 found that, if no threshold is assumed, the estimate is increased by about twenty fold (6% of admissions attributable).Conclusions: The additional hospital admissions for respiratory disease attributable to ozone are very small in both absolute and relative terms if a threshold of 50 ppb is assumed, but this estimate is very sensitive to threshold assumptions. [ABSTRACT FROM AUTHOR]

Background: Patients presenting with asthma to emergency departments have lost control of their disease, have significant airways obstruction, and frequently require admission to hospital. Although even one visit is not desirable, there is a more disturbing subgroup who repeatedly visit the emergency department.Methods: To investigate the reasons for multiple emergency visits, a questionnaire was given to 448 consecutive patients presenting to the two largest adult emergency departments in Ottawa, Canada between November 1989 and April 1991. Within this cohort, those who had made at least three visits in the past year were compared with controls (only one visit in the past year).Results: Although inhaled corticosteroid use increased with multiple visits (indicating increased asthma severity), only 60% of those visiting at least three times in the past year were taking inhaled corticosteroids. Chronic undermedication relative to disease severity was apparent among the cases. The number of visits was associated with nocturnal asthma on a regular basis, work and school absenteeism, frequent visits to their regular physician, and frequent admissions to hospital. Visits were not related to psychological health, environmental allergens/irritants, or lack of perceived asthma severity.Conclusions: The recommendations of current asthma guidelines are not reaching these patients. The issue of translating guidelines from paper to practice must be addressed before highly effective medications can have an important impact on the frequency of emergency department visits. [ABSTRACT FROM AUTHOR]

We present a case where a young adult male, on treatment for multidrug-resistance tuberculosis (MDR-TB), developed drug-induced psychosis. The psychiatric symptoms were ascribed to the anti-TB drug and were duly withdrawn by the treating doctors and supplemented with other drugs. However, the victim continued to have psychiatric symptoms and committed suicide in the hospital. He ended his life in a violent manner by stabbing and cutting himself with a kitchen knife. The case is briefly reported in this paper with a discussion on anti-TB drug-induced psychiatric effects leading to suicide. [ABSTRACT FROM AUTHOR]

Background: Several studies have shown a decrease in acute coronary syndrome (ACS) admissions after the implementation of 100% smoke-free legislation. However, no studies have been conducted in developing countries. Methods: We conducted a time series analysis of ACS hospital admissions in Santa Fe province and Buenos Aires city, Argentina. In 2006, Santa Fe implemented a 100% smoke-free law and Buenos Aires implemented a partial law with designated smoking areas and exceptions. Age-standardised ACS admissions rates were compared before and after the implementation of the laws in each district. Smoking prevalence, compliance with legislation and exposure to secondhandsmoke (SHS) was also assessed in both districts. Results: In Santa Fe an immediate decrease in ACS admissions was observed after implementation (2.5 admissions per 100 000, p¼0.03; 13% reduction), compared with no change in Buenos Aires city (rate ratio Santa Fe vs Buenos Aires: 0.74, 95% CI 0.63 to 0.86, p#0.001). In Santa Fe, the immediate effect was followed by a persistent decrease in admissions due to ACS (0.26 admissions per 100 000 per month). Smoking prevalence did not change significantly in either district during the same period. In both districts, there was a reduction in self-reported SHS exposure, with a trend towards lower exposure in Santa Fe province. No other comprehensive tobacco control interventions were implemented during the study period. Conclusions: A 100% smoke-free law was more effective than a partial restriction law in reducing ACS admissions. An immediate effect was followed by a sustained decrease in ACS admissions. Smoke-free initiatives can be also effective in decreasing acute coronary events in developing countries. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess the performance of the International Classification of Diseases (ICD) based injury severity score, ICISS, when applied to two versions of the 10th edition of ICD, ICD-10 and ICD-10-AM. DESIGN: ICISS was assessed on its ability to predict threat to life using logistic regression modelling. Models used ICISS and age as predictors and survival as the outcome. SETTING: Australia and New Zealand. Patients or subjects: Hospitalisations with an ICD-10-AM principal diagnosis in the range S00–T89 from 1 July 1999 to 30 June 2001 (Australia) or 1 July 1999 to 31 December 2001 (New Zealand). INTERVENTIONS: None. MAIN OUTCOME MEASURES: The models were assessed in terms of their discrimination, measured by the concordance score, and calibration, measured using calibration curves and the Hosmer-Lemeshow statistic. RESULTS: 523 633 Australian and 124 767 New Zealand hospitalisations were selected, including 7230 and 1565 deaths respectively. Discrimination was high in all the fitted models with concordance scores of 0.885 to 0.910. Calibration results were also promising with all calibration curves being close to linear, though ICISS appeared to underestimate mortality somewhat for cases with an ICISS score less than 0.6. Overall ICISS performed better when applied to the Australian than the New Zealand hospitalisations. Australian and New Zealand hospitalisations were very similar. ICISS was also only a little more successful when ICD-10-AM rather than mapped ICD-10 was used. CONCLUSIONS: ICISS appears to be a reasonable way to estimate severity for databases using ICD-10 or ICD-10-AM. It is also likely to work well for other clinical variants of ICD-10. [ABSTRACT FROM AUTHOR]

The article presents abstracts on the history of pediatrics and child health. They include "The Hyperbaric Oxygen Controversy and the Divided Role of the Post-War Pediatrician," "Historical Ramblings in Spinal Muscular Atrophy," and "Who Let Them In? Eighteenth Century Hospital Care for Children in England and Scotland: A Multicenter Preliminary Enquiry."

A hospital admission or readmission for an exacerbation of chronic obstructive pulmonary disease (COPD) is bad news for everyone. In British hospitals emergency inpatient admission is the largest component of the total cost of respiratory disease to the NHS that amounts to over £2.5 billion. In recent years attention has focused on reducing the cost and impact of hospital admissions for COPD. The emphasis of the strategy to date has been on admission avoidance and early supported discharge schemes. These have had some success in curtailing admissions and reducing lengths of hospital stay, and are beginning to be introduced more widely into clinical practice.

The article discusses a population based cohort study from England for determining the risk of first venous thromboembolism in pregnant women in hospitals. According to the authors of the study, there is an increase in overall rate of antepartum venous thromboembolism during admissions to hospital not related to delivery. The article also discusses the high rate during inpatient admissions among pregnant women, wherein the high rate persists for 28 days after discharge.

The article discusses a study conducted to assess if bicycle helmet legislation in Canada reduces cycling related head injuries. The study results suggest that helmet legislation led to a reduced rate of hospital admissions due to cycling related head injuries among young people and adults in Canada.

Background Cost-effectiveness studies have been increasingly part of decision processes for incorporating new vaccines into the Brazilian National Immunisation Program. This study aimed to evaluate the cost-effectiveness of 10-valent pneumococcal conjugate vaccine (PCV10) in the universal childhood immunisation programme in Brazil. Methods A decision-tree analytical model based on the ProVac Initiative pneumococcus model was used, following 25 successive cohorts from birth until 5 years of age. Two strategies were compared: (1) status quo and (2) universal childhood immunisation programme with PCV10. Epidemiological and cost estimates for pneumococcal disease were based on National Health Information Systems and literature. A 'top-down' costing approach was employed. Costs are reported in 2004 Brazilian reals. Costs and benefits were discounted at 3%. Results 25 years after implementing the PCV10 immunisation programme, 10 226 deaths, 360 657 disability-adjusted life years (DALYs), 433 808 hospitalisations and 5 117 109 outpatient visits would be avoided. The cost of the immunisation programme would be R$10 674 478 765, and the expected savings on direct medical costs and family costs would be R$1 036 958 639 and R$209 919 404, respectively. This resulted in an incremental cost-effectiveness ratio of R$778 145/death avoided and R$22 066/DALY avoided from the society perspective. Conclusion The PCV10 universal infant immunisation programme is a cost-effective intervention (1-3 GDP per capita/DALY avoided). Owing to the uncertain burden of disease data, as well as unclear long-term vaccine effects, surveillance systems to monitor the long-term effects of this programme will be essential. [ABSTRACT FROM AUTHOR]

Background This study investigated the impact of the Healthy Housing Programme in reducing acute hospitalisations in South Auckland, New Zealand. The programme involved house modifications to reduce overcrowding, insulation and ventilation improvements, and health and social service assessments, referrals and linkages. Methods An intervention evaluation was used. Participants in the programme were considered cases following their house's intervention and counterfactuals/ controls prior to the intervention. Rigorous age-censoring was used to construct a case-counterfactual comparison. 9736 residents of 3410 homes were involved in the programme from September 2001 to December 2007. All lived in areas of relative deprivation (NZDep01=decile 10) and almost all self-identified as Pacific ethnic group. The main outcome measure was acute hospitalisation rates before, during and after a health and housing intervention. Hospital data were gathered from July 1999 to January 2009. Results In the post-intervention group, people aged 5-34 years had a HR of 0.77 (95% CI 0.70 to 0.85) for acute hospitalisations compared to the counterfactual (pre-intervention). For children aged 0-4 years the HR was 0.89 (95% CI 0.79 to 0.99); a non-significant increase occurred in adults aged 35 years plus. When the causes of hospitalisation were restricted to those related to housing, further falls in the HRs were seen: 0.88 (95% CI 0.74 to 1.05) for 0e4 year olds and 0.73 (95% CI 0.58 to 0.91) for 5-34 year olds. Conclusion A package of care that addresses housing conditions that impact on health and improves access to health and social services is associated with a reduced acute hospitalisation rate for 0-34 year olds. [ABSTRACT FROM AUTHOR]

The article discusses the study by L. Turner-Stokes and colleagues published in the May 2006 issue of the "Journal of Neurology, Neurosurgery and Psychiatry," which discusses the cost efficiency of neurorehabilitation. Assessment of the patient's dependency was used to estimate the daily cost of care. Dependency of admission were compared to those at discharge and the reduction in daily continuing care cost were calculated

Objectives To determine whether children who have child maltreatment allegation or substantiation have a higher rate of general hospital admissions and injury related admissions when compared to other children and to investigate other types of admissions, such as mental health, infections and admissions due to external causes. Study design A prospective matched case-control study of children born in Western Australia between 1990 and 2005 using de-identified record linked Child Protection and Hospital Morbidity data. Rates of prior hospital admissions for cases versus controls were calculated, and conditional logistic regression was used to estimate the effect of hospital admission rate on the risk of child maltreatment allegation and substantiated allegation. Results Children with child maltreatment allegations and substantiations had higher mean prior admission rates compared to controls. Higher rates of general admissions and admissions for injuries, infections, mental and behavioural disorders, and external causes of morbidity, were associated with a markedly increased risk of child maltreatment allegations and substantiation. Conclusions The hospital system plays not only an important role both in the surveillance of maltreatment-related injuries and conditions but also in the role of prevention in the referral of families who may need support and assistance in ensuring the health and safety of their children. This research highlights the importance of moving to electronic patient records in identifying children who have high rates of admissions and the types of conditions they have previously presented with, particularly for injuries, mental and behavioural disorders and external causes of admissions. [ABSTRACT FROM AUTHOR]

Background: Chronic obstructive pulmonary disease (COPD) is a progressive disabling condition, for which tobacco smoking, environmental pollution, inherited α-antitrypsin deficiency and their interactions are predisposing factors. We carried out a family study on COPD in order to address the role of heritable and environmental risk factors at a population level. Methods: In a nationwide study on familial risks for COPD the Multigeneration Register on 0-72-year-old subjects was linked to the Hospital Discharge Register from years 1987 to 2004. Standardised incidence ratios (SIRs) were calculated for affected singleton siblings, twins and spouses by comparing them with those whose siblings or spouses had no hospitalisation for COPD. Results: More than 14 300 hospitalised cases and 604 affected siblings were identified. The familial SIR for obstructive chronic bronchitis was 4.65, which was higher for those diagnosed at young age but independent of sex or the age differences between the siblings. When both siblings were diagnosed with obstructive chronic bronchitis or emphysema the SIRs were 4.45 and 14.22, respectively. The SIR for obstructive chronic bronchitis in 24 twin pairs was 11.87. The SIR for spouses was about 1.6. Conclusions: The much higher risk for siblings of patients with COPD than the risk for spouses suggests that heritable effects underlie familial susceptibility to this disease. For the rare familial emphysema, α-antitrypsin deficiency may be an important cause. To what extent it also contributes to familial obstructive chronic bronchitis remains to be established. The anticipated gene-environment interactions with sufficient sample size need to be accommodated in future aetiological studies on COPD. [ABSTRACT FROM AUTHOR]

Background: Poor prognosis in heart failure (HF) patients with diabetes is often attributed to increased comorbidity and advanced disease. Further, this effect may be worse in women. Objective: To determine whether the effect of diabetes on outcomes and the sex-related variation persisted in a propensity score-matched HF population, and whether the sex-related variation was a function of age. Methods: Of the 7788 HF patients in the Digitalis Investigation Group trial, 2218 had a history of diabetes. Propensity score for diabetes was calculated for each patient using a non-parsimonious logistic regression model incorporating all measured baseline covariates, and was used to match 2056 (93%) diabetic patients with 2056 non-diabetic patients. Results: All-cause mortality occurred in 135 (25%) and 216 (39%) women without and with diabetes (adjusted HR = 1.67; 95% CI = 1.34 to 2.08; p < 0.001). Among men, 535 (36%) and 609 (41%) patients without and with diabetes died from all causes (adjusted HR = 1.21; 95% CI = 1.07 to 1.36; p = 0.002). Sex-diabetes interaction (overall adjusted p < 0.001) was only significant in patients ⩾65 years (15% absolute risk increase in women; multivariable p for interaction = 0.005), but not in younger patients (2% increase in women; p for interaction = 0.173). Risk-adjusted HR (95% CI) for all-cause hospitalisation for women and men were 1.49 (1.28 to 1.72) and 1.21 (1.11 to 1.32), respectively, also with significant sex-diabetes interaction (p = 0.011). Conclusions: Diabetes-associated increases in morbidity and mortality in chronic HF were more pronounced in women, and theses sex-related differences in outcomes were primarily observed in elderly patients. [ABSTRACT FROM AUTHOR]

Objectives: The prognosis for individuals infected with HIV has changed dramatically over the past 10 years, with patients living longer and requiring other specialist services. It is apparent that access of other healthcare professionals to clinical information about a patient's HIV care differs between centres in the UK. Lack of awareness of an individual's HIV status may compromise their clinical care. Aim: To establish current practice and identify the views of clinicians caring for patients infected with HIV. Methods: Lead consultants in all genitourinary medicine departments in the UK were invited to complete a questionnaire regarding use of combined HIV and hospital notes and ability of general practitioners and other hospital specialists to access information about individual patient's HIV care. Clinician's opinions on the "normalisation" of HIV management were also sought. Results: Combined notes (outpatient and inpatient) were used by 12% (16/130) of respondents. The patient's identifying number was used to request blood tests in 86%. Of the respondents, 42% had encountered difficulties in communication that affected delivery of care for an HIV-positive patient. Conclusions: Centres using combined notes identified a higher frequency of communication with other doctors and specialties, suggesting a higher standard of care. Physicians involved in HIV care should consider combining patients' HIV and hospital notes for improved clinical care. [ABSTRACT FROM AUTHOR]

Background: Intraventricular rupture of brain abscesses (IVRBA) remains a catastrophic and fatal complication of bacterial brain abscess (BBA). However, no information has been reported about the risk factors that are predictive of intraventricular rupture. Methods: This study was undertaken to determine the potential risk factors that are predictive of intraventricular ruptures in patients with BBA but without intraventricular rupture when arriving at the hospital. A comparison is also made between patients who already have IVRBA at the time of admission (initial IVRBA) and those who have the episode during hospitalisation (subsequent IVRBA). Results: 62 patients, including 45 who had initial IVRBA and 17 who had subsequent IVRBA, were examined. Stepwise logistic regression analysis showed that the adjusted risk of intraventricular rupture during hospitalisation for patients with multiloculated brain abscesses had an odds ratio (OR) of 4.2 (95% confidence interval (CI) 1.24 to 14.3; p = 0.02) compared with those without multiloculated brain abscesses (referent); a reduction of 1 mm in the distance between the ventricle and brain abscesses would increase the rupture rate by 10% (p=0.006, OR 0.9, 95% CI 0.83 to 0.97). Conclusion: This study shows that if the abscess is deep seated, multiloculated and close to the ventricle wall, a reduction of 1 mm in the distance between the ventricle and brain abscesses will increase the rupture rate by 10%. Despite aggressive medical and surgical management shown in this series, many patients continue to progress poorly. [ABSTRACT FROM AUTHOR]

Background: The Global Initiative on Obstructive Lung Disease stages for chronic obstructive pulmonary disease (COPD) uses a fixed ratio of the post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) of 0.70 as a threshold. Since the FEV1/FVC ratio declines with age, using the fixed ratio to define COPD may "overdiagnose" COPD in older populations. Objective: To determine morbidity and mortality among older adults whose FEV1/FVC is less than 0.70 but more than the lower limit of normal (LLN). Methods: The severity of COPD was classified in 4965 participants aged ⩾65 years in the Cardiovascular Health Study using these two methods and the age-adjusted proportion of the population who had died or had a COPD-related hospitalisation in up to 11 years of follow-up was determined. Results: 1621(32.6%) subjects died and 935 (18.8%) had at least one COPD-related hospitalisation during the follow-up period. Subjects (n = 11 34) whose FEV1/FYC fell between the LLN and the fixed ratio had an increased adjusted risk of death (hazard ratio (HR) 1.3, 95% Cl 1.1 to 1.5) and COPD-related hospitalisation (HR 2.6, 95% Cl 2.0 to 3.3) during follow-up compared with asymptomatic individuals with normal lung function. Conclusion: In this cohort, subjects classified as "normal" using the LLN but abnormal using the fixed ratio were more likely to die and to have a COPD-related hospitalisation during follow-up. This suggests that a fixed FEV1/FVC ratio of <0.70 may identify at-risk patients, even among older adults. [ABSTRACT FROM AUTHOR]

Background: Nerve, nerve root and plexus disorders are common diseases, but little is known about familial clustering in these diseases. This is, to our knowledge, the first systematic family study carried out on these diseases. Methods: Familial risks for siblings who were hospitalised for nerve, nerve root and plexus disorders in Sweden were defined. A nationwide database for neurological diseases was constructed by linking the Multigeneration Register on 0-69-year-old siblings to the Hospital Discharge Register covering the years 1987-2001. Standardised risk ratios (SIRs) were calculated for affected sibling pairs by comparing them with those whose siblings had no neurological disease. Results: 29 686 patients, 43% men and 57% women, were diagnosed at a mean age of 37.5 years. 191 siblings were hospitalised for these disorders, giving an overall SIR of 2.59 (95% CI 1 .58 to 4.22), with no sex difference. Plantar nerve mononeuritis and carpal tunnel syndrome showed the highest familial risks: 4.82 (1.08 to 16.04) and 4.08 (2.07 to 7.84), respectively. Lateral poplitean and plantar nerve neuritis preferentially affected women, with SIRs of >8; disorders of the other cranial nerves affected only men, with an SIR of >10. Concordant trigeminal neuralgia, Bell's palsy and carpal tunnel syndrome showed familial risks, but, with the exception of Bell's palsy, they also showed correlation between spouses, implying environmental sharing of risk factors. Conclusions: The results cannot distinguish between inheritable or shared environmental factors, or their interactions, but they clearly show familial clustering, suggestive of multifactorial aetiology and inviting for aetiological research. [ABSTRACT FROM AUTHOR]

Trends in asthma indicators from population surveys (prevalence) and routine statistics (primary care, prescriptions, hospital admissions and mortality) in the UK were reviewed from 1955 to 2004. The prevalence of asthma increased in children by 2 to 3-fold, but may have flattened or even fallen recently. Current trends in adult prevalence are flat. The prevalence of a life-time diagnosis of asthma increased in all age groups. The incidence of new asthma episodes presenting to general practitioners increased in all ages to a plateau in the mid 1990s and has declined since. During the 1990s, the annual prevalence of new cases of asthma and of treated asthma in general practice showed no major change. Hospital admissions increased from the early 1960s, more so in children, until the late 1980s and have fallen since. Asthma mortality showed two waves, a shorter and more intense one in the mid 1960s and a longer and less intense one in the late 1970s and early 1980s. The relative roles of diagnostic transfer, coding changes, medical care and epidemiological factors are discussed. [ABSTRACT FROM AUTHOR]

Background: Antibiotics are commonly prescribed in exacerbations of chronic obstructive pulmonary disease (COPD). However, the role of bacteria in these exacerbations is controversial. Objective: To identify clinical predictors of bacterial infection as a cause of exacerbation, considering the protected specimen brush (PSB) as the gold standard. Methods: Clinical data, sputum and PSB samples were collected from 40 patients with COPD requiring hospitalisation due to severe exacerbations who had not received previous antibiotic treatment. Results: Quantitative cultures of PSB samples (n = 40) yielded 23 potential pathogenic microorganisms (PPMs) at concentrations of ⩾10² colony-forming units/ml in 18 (45%) patients. Sputum samples were obtained from all 40 patients. Culture of good-quality sputum samples (n = 18) yielded 16 PPMs corresponding to 14 (35%) patients. The concordance between the PSB and sputum rate was high (K=0.85, p<0.002). The self-reporting patient observation of sputum purulence (odds ratio (OR) 27.20 (95% confidence interval (CI) 4.60 to 60.69), p =0.001), the percentage predicted forced expiratory volume in 1 s (FEV1%) <50 (OR 2.27(95% CI 1.55 to 3.21), p=0.014), >4 exacerbations in the past year (OR 6.9 (95% CI 0.08 to 1.08), p=0.028) and previous hospitalisations due to COPD (OR 4.13 (95% CI 1.02 to 16.07), p=0.041) were associated with the presence of PPMs in the distal airways. The operative characteristics for predicting distal airway infection when patients presented with purulent exacerbation were as follows: sensitivity 89.5%, specificity 76.2%, positive predicted value 77.3% and negative predicted value 88.9%. Conclusions: The self-reporting presence of purulence in the sputum, as well as common previous exacerbations and hospitalisations due to COPD in patients with severe airflow obstruction (FEV1% <50) predict the presence of bacterial infection in the distal airways. The use of these clinical variables may help in selecting candidates to receive antibiotic treatment. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor in response to the article "Proximity to Coke Works and Hospital Admissions for Respiratory and Cardiovascular Disease in England and Wales," by researcher K. Amos, M. Carson, and S. Goodfellow, P. Homan, and G. Phull.

Objectives: To determine whether socioeconomic status (SES) influences clinical outcomes and quality of life after percutaneous coronary intervention (PCI). Design: Prospective observational study. Setting: Two interventional cardiac centres. Participants: 1346 consecutive patients undergoing PCI over a 1 2-month period. Outcomes: Self reported health-related quality of life (HRQoL; EuroQol-5 Dimensions (EQ-5D); EuroQol Visual Analogue Scale (EQ-VAS)), repeat angiography, revascularisation, hospital admission, myocardial infarction and death within 12 months, by SES derived using postal address code. Main results: No significant differences were found between patients with high and low SES in the occurrence of repeat angiography (p=0.55), repeat revascularisation (PCI, p=0.88, CAEG, p=0.27), total cardiac hospitalisation (p=0.10), myocardial infarction (p=0.97) or death 12 months after PCI (p=0.88). Non-procedure-related readmissions were higher in patients with low SES (18.6% v 13.7%; p=0.025). After adjustment for confounding factors, patients with low SES had lower HRQoL scores at baseline (95% CI for difference 0.01 to 0.14; p=0.003) and at 12 months (95% CI 0.07 to 0.17; p<0.001) compared with those with high SES. Conclusions: Clinical outcomes were similar for patients in different SES groups. Patients with low SES had considerably more non-procedure-related readmissions and lower quality-of-life scores. Future studies on HRQoL after coronary revascularisation should take account of these important differences related to SES. [ABSTRACT FROM AUTHOR]

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) have a high rate of mortality which gets worse with advancing age. It is unknown whether this is due to age related deficiencies in process of care. A study was undertaken in patients with COPD exacerbations admitted to UK hospitals to assess whether there were age related differences in the process of care that might affect outcome, and whether different models of care affected process and outcome. Methods: 247 hospital units audited activity and outcomes (inpatient death, death within 90 days, length of stay (LOS), readmission within 90 days) for 40 consecutive COPD exacerbation admissions in autumn 2003. Logistic regression methods were used to assess relationships between process and outcome at p < 0.001. Results: 7514 patients (36% aged > or = 75 years) were included. Patients aged > or = 75 years were less likely to have blood gases documented, to have FEV1 recorded, or to be given systemic corticosteroids. Those admitted under care of the elderly (CoE) physicians were less likely to enter early discharge schemes or to receive non-invasive ventilation when acidotic. Overall inpatient and 90 day mortality was 7.4% and 15.3%, respectively. Inpatient and 90 day adjusted odds mortality rates for those aged > or = 85 years (versus < or = 65 years) were 3.25 and 2.54, respectively. Mortality was unaffected by admitting physician (CoE v general v respiratory). Age predicted LOS but not readmission. Age related deficiencies in process of care did not predict inpatient or 90 day mortality, readmission, or LOS. Conclusions: Management of COPD exacerbations varies with age in UK hospitals. Inpatient and 90 day mortality is approximately three times higher in very elderly patients with a COPD exacerbation than in younger patients. Age related deficiencies in the process of care were not associated with mortality, but it is likely that they represent poorer quality of care and patient experience. Recommended standards of care should be applied equally to elderly patients with an exacerbation of COPD. [ABSTRACT FROM AUTHOR]

Background: Acute chronic obstructive pulmonary disease (COPD) exacerbations use many hospital bed days and have a high rate of mortality. Previous audits have shown wide variability in the length of stay and mortality between units not explained by patient factors. This study aimed to explore associations between resources and organisation of care and patient outcomes. Methods: 234 UK acute hospitals each prospectively identified 40 consecutive acute COPD admissions, documenting process of care and outcomes from a retrospective case note audit. Units also completed a resources and organisation of care proforma. Results: Data for 7529 patients were received. Inpatient mortality was 7.4% and mortality at 90 days was 15.3%; the readmission rate was 31.4%. Mean length of stay for discharged patients was 8.7 days (median 6 days). Wide variation was observed in all outcomes between hospitals. Both inpatient mortality (odds ratio (OR) 0.67, CI 0.50 to 0.90) and 90 day mortality (OR 0.75, CI 0.60 to 0.94) were associated with a staff ratio of four or more respiratory consultants per 1000 hospital beds. The length of stay was reduced in units with more respiratory consultants, better organisation of care scores, an early discharge scheme, and local COPD management guidelines. Conclusions: Units with more respiratory consultants and better quality organised care have lower mortality and reduced length of hospital stay. This may reflect unit resource richness. Dissemination of good organisational practice and recruitment of more respiratory specialists offers the potential for improved outcomes for hospitalised COPD patients. [ABSTRACT FROM AUTHOR]

Background: Information about the influence of regular physical activity on the course of chronic obstructive pulmonary disease (COPD) is scarce. A study was undertaken to examine the association between regular physical activity and both hospital admissions for COPD and all-cause and specific mortality in COPD subjects. Methods: From a population-based sample recruited in Copenhagen in 1981-3 and 1991-4, 2386 individuals with COPD (according to lung function tests) were identified and followed until 2000. Self-reported regular physical activity at baseline was classified into four categories (very low, low, moderate, and high). Dates and causes of hospital admissions and mortality were obtained from Danish registers. Adjusted associations between physical activity and hospital admissions for COPD and mortality were obtained using negative binomial and Cox regression models, respectively. Results: After adjustment for relevant confounders, subjects reporting low, moderate or high physical activity had a lower risk of hospital admission for COPD during the follow up period than those who reported very low physical activity (incidence rate ratio 0.72, 95% confidence interval (CI) 0.53 to 0.97). Low, moderate and high levels of regular physical activity were associated with an adjusted lower risk of all-cause mortality (hazard ratio (HR) 0.76, 95% CI 0.65 to 0.90) and respiratory mortality (HR 0.70, 95% CI 0.48 to 1.02). No effect modification was found for sex, age group, COPD severity, or a background of ischaemic heart disease. Conclusions: Subjects with COPD who perform some level of regular physical activity have a lower risk of both COPD admissions and mortality. The recommendation that COPD patients be encouraged to maintain or increase their levels of regular physical activity should be considered in future COPD guidelines, since it is likely to result in a relevant public health benefit. [ABSTRACT FROM AUTHOR]

Background: Tobacco control in hospital settings is characterised by a focus on protection strategies and an increasing expectation that health practitioners provide cessation support to patients. While practitioners claim to have positive attitudes toward supporting patient cessation efforts, missed opportunities are the practice norm. Objective: To study hospital workplace culture relevant to tobacco use and control as part of a mixed-methods research project that investigated hospital-based registered nurses' integration of cessation interventions. Design: The study was conducted at two hospitals situated in British Columbia, Canada. Data collection included 135 hours of field work including observations of ward activities and designated smoking areas, 85 unstructured conversations with nurses, and the collection of patient-care documents on 16 adult in-patient wards. Results: The findings demonstrate that protection strategies (for example, smoking restrictions) were relatively well integrated into organisational culture and practice activities but the same was not true for cessation strategies. An analysis of resources and documentation relevant to tobacco revealed an absence of support for addressing tobacco use and cessation. Nurses Framed patients' tobacco use as a relational issue, a risk to patient safety, and a burden. Furthermore, conversations revealed that nurses tended to possess only a vague awareness of nicotine dependence. Conclusion: Overcoming challenges to extending tobacco control within hospitals could be enhanced by emphasising the value of addressing patients' tobacco use, raising awareness of nicotine dependence, and improving the availability of resources to address addiction issues. [ABSTRACT FROM AUTHOR]

Background: influenza pandemics result in excess mortality and social disruption. To assist health authorities update the French pandemic plan, the authors estimated the number of health events (cases, hospitalisations, and deaths) in a pandemic and compared interventions in terms of impact and efficiency. Method: A Monte Carlo simulation model, incorporating probability distributions of key variables, provided estimates of health events (HE) by age and risk group. input variables were set after literature and expert consultation. The impact of targeted influenza vaccination and antiviral prophylaxis/treatment (oseltamivir) in high risk groups (elderly, chronic diseases), priority (essential professionals), and total populations was compared. Outcome measures were HE avoided, number of doses needed, and direct cost per HE avoided. Results: Without intervention, an influenza pandemic could result in 14.9 million cases, 0.12 million deaths, and 0.6 million hospitalisations in France. Twenty four per cent of deaths and 40% of hospitalisations would be among high risk groups. With a 25% attack rate, 2000-86 000 deaths could be avoided, depending on population targeted and intervention, if available initially, vaccination of the total population is preferred. if not, for priority populations, seasonal prophylaxis seems the best strategy. For high risk groups, antiviral treatment, although less effective, seems more feasible and cost effective than prophylaxis (respectively 29% deaths avoided; 1800 doses/death avoided and 56% deaths avoided; 18 500 doses/death avoided) and should be chosen, especially if limited drug availability. Conclusion: The results suggest a strong role for antivirals in an influenza pandemic. While this model can compare the impact of different intervention strategies, there remains uncertainty surrounding key variables. [ABSTRACT FROM AUTHOR]

Aim: To study temporal trends in the incidence of hospitalisations due to infection in children in Denmark. Methods: A national register based cohort of 1 892 711 Danish children aged 0-5 years were studied from 1980 to 2001. Child and family characteristics were identified in the Danish Civil Registration System; hospitalisations were identified in the Danish National Patient Registry. Annual incidence rates were estimated using log-linear Poisson regression. Results: During the studied period, the incidence of hospitalisations from infection increased by 62% in 0–5 year old children. The increase was mainly due to a sevenfold increase in the incidence of infections leading to short term hospitalisation in children aged 0–1 years. Since the increase in incidence was contrasted with a decrease in duration of hospitalisation, no further strain was put on the health services in Denmark. Conclusion: During the last two decades, the incidence of short term hospitalisations due to infections increased markedly among the youngest children. However, the strain on the health services remained constant. The observed increase in the incidence of short term hospitalisations among the youngest children may reflect changes in hospitalisation practices and utilisation, rather than an increase in incidence of infections. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness and safety of pharmacological conversion of persistent atrial fibrillation (AF) with a combined propafenone plus ibutilide regimen. Methods and results: 100 consecutive patients (66 men, mean (SD) age 65 (10) years) with persistent AF (mean (SD) duration 99 (92) days) admitted for elective pharmacological cardioversion were randomly assigned to treatment with either intravenous ibutilide (1 mg plus an additional 1 mg, if required; n = 51) or oral propafenone (600 mg) plus intravenous ibutilide at the same dose (n = 49). Success rates were 41.1% (21 of 51 patients) for ibutilide alone and 71.4% (35 of 49 patients) for propafenone plus ibutilide (p = 0.0044). However, cardioversion occurred earlier in the ibutilide alone group (55 (20) minutes) compared with the combination group (81 (32) minutes, p = 0.0019). A comparable increase in the QTc interval was observed in both groups but one case of sustained torsade de pointes, requiring electrical cardioversion, was observed in the propafenone plus ibutilide group. No other complications were noted during the hospitalisation period. Conclusion: Concurrent administration of propafenone plus ibutilide for pharmacological cardioversion of persistent AF is safe and more effective than ibutilide alone. [ABSTRACT FROM AUTHOR]

Objective: To study the change in incidence of hospitalisation for a first acute myocardial infarction (AMI) in the Netherlands from 1995 to 2000. Methods: Patients hospitalised with their first AMI in the Netherlands in 1995 and 2000 were identified through linkage of the national hospital discharge register and the population register. Results: 21 565 patients hospitalised for their first AMI in 1995 and 19 058 patients hospitalised for their first AMI in 2000 were identified. In both years, the age specific incidence of hospitalisation for a first AMI was higher in men than in women and increased with age (up to 90 years). In both men and women, the age standardised incidence was lower in 2000 than in 1995, a decline of 19% (95% confidence interval 17% to 21%) and 17% (95% confidence interval 14% to 19%), respectively. Conclusions: Our study provides the first nationwide incidence estimates of first AMI in the Netherlands. From 1995 to 2000, the risk of AMI declined considerably. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic gradients in the occurrence of myocardial infarction are well known, but few studies have examined socioeconomic disparities in post-infarction outcomes. The objective of this study was to explore relations of socioeconomic status with the incidence, treatment, and outcome of first coronary event in Rome, Italy, during the period 1998-2000, examining effect modification by gender. Methods: Subjects were Rome residents aged 35-84 years who died from first acute coronary event before reaching the hospital (n = 3470) or were hospitalised for first acute myocardial infarction (n = 8467). Area based deprivation status and patients' educational attainment were the exposure variables. The outcomes were: incidence of coronary event; recanalisation at the index hospitalisation and fatality within 28 days of hospitalisation; cardiac readmissions and fatality between 28 days and one year of index hospitalisation. Results: Incidence rates increased as area based deprivation status increased; the effect was stronger among women than among men (men RR = 1.40, 95%CI: 1.30, 1.50, women RR =1.78, 95%Cl: 1.60, 1.98, most compared with least deprived). Rates of recanalisation were significantly lower in the most deprived patients than in the least deprived (OR = 0.77, 95%Cl:0.59, 0.99) and in the less educated than in the highly educated (OR = 0.73, 95%CI:0.58, 0.90). Associations of short term fatality with area based deprivation status and educational attainment were weak and inconsistent. However, neither deprivation status nor education was associated with one year outcomes. Conclusions: Area based deprivation status is strongly related to incidence of coronary events, and more so among women than among men. Deprivation status and educational attainment are weakly and inconsistently associated with short term fatality but seem not to influence one year prognosis of acute myocardial infarction. Deprived and less educated patients experience limited access to recanalisation procedures. [ABSTRACT FROM AUTHOR]

Objective: The field of clinical ethics is relatively new and expanding. Best practices in clinical ethics against which one can benchmark performance have not been clearly articulated. The first step in developing benchmarks of clinical ethics services is to identify and understand current practices. Design and setting: Using a retrospective case study approach, the structure, activities, and resources of nine clinical ethics services in a large metropolitan centre are described, compared, and contrasted. Results: The data yielded a unique and detailed account of the nature and scope of clinical ethics services across a spectrum of facilities. General themes emerged in four areas--variability, visibility, accountability, and complexity. There was a high degree of variability in the structures, activities, and resources across the clinical ethics services. Increasing visibility was identified as a significant challenge within organisations and externally. Although each service had a formal system for maintaining accountability and measuring performance, differences in the type, frequency, and content of reporting impacted service delivery. One of the most salient findings was the complexity inherent in the provision of clinical ethics services, which requires of clinical ethicists a broad and varied skill set and knowledge base. Benchmarks including the average number of consults/ethicist per year and the hospital beds/ethicist ratio are presented. Conclusion: The findings will be of interest to clinical ethicists locally, nationally, and internationally as they provide a preliminary framework from which further benchmarking measures and best practices in clinical ethics can be identified, developed, and evaluated. [ABSTRACT FROM AUTHOR]

Ethical dilemmas in community mental health care is the focus of this article. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. The different stakeholders are confronted with the following dilemmas: community care versus hospital care (clients); a life with care versus a life without care (informal carers); stimulation of the client toward greater responsibility versus protection against such responsibility (professionals); budgetary control versus financial incentives (policy makers), and respect for the client versus particular private needs (neighbourhood residents). These dilemmas are interpreted against the background of a value based ethical model. This model offers an integral approach to the dilemmas and can be used to determine policy. The dilemmas are discussed here as the result of conflicting values-namely autonomy and privacy, support and safety, justice and participation, and trust and solidarity. [ABSTRACT FROM AUTHOR]

The "lone" clinical bioethicist working in a large, multisite hospital faces considerable challenges. While attempting to build ethics capacity and sustain a demanding range of responsibilities, he or she must also achieve an acceptable level of integration, sustainability, and accountability within a complex organisational structure. In an effort to address such inherent demands and to create a platform towards better evaluation and effectiveness, the Clinical Ethics Group at the Joint Centre for Bioethics at the University of Toronto is implementing the Hub and Spokes Strategy at seven hospitals. The goal of the Hub and Spokes Strategy is to foster an ethical climate and strengthen ethics capacity broadly throughout healthcare settings as well as create models in clinical bioethics that are excellent and effective. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate late mortality and morbidity after an atrial switch procedure for correction of transposition of the great arteries (TGA) and to assess predictive factors for adverse outcome. Setting: Tertiary referral centre. Design and Patients: Retrospective follow up study of 137 patients surviving hospitalisation for TGA atrial switch procedure (Mustard or Senning) in a single institution and divided into two groups (simple and complex) depending on presurgical anatomy. Several surgical and follow up factors were evaluated during 16.7 (5.6) years' follow up. Results: Late mortality was 5.1% (95% confidence interval 1.37% to 8.84%) with sudden death as the most common cause. No significant difference was found between Mustard and Senning procedures and between the complex and simple groups in terms of mortality. Independent predictive factors for late mortality were a history of supraventricular tachyarrhythmias and advanced New York Heart Association (NYHA) functional class during follow up. A very common finding was development of sinus node dysfunction (47.6%), which had no influence on mortality. There was little need for reintervention (5.1%) and relatively few cases of right ventricular systolic dysfunction (14.6%). During follow up, most patients (96.2%) were in NYHA functional class I-II. Conclusions: Overall long term outcomes of patients with atrial repair of TGA in the present era are encouraging in terms of late mortality and quality of life. Nevertheless, better outcomes may be offered through improved diagnostic methods for right ventricular function and better management of supraventricular tachyarrhythmias. [ABSTRACT FROM AUTHOR]

Aims: To study neuropsychological functioning of newly diagnosed children with acute lymphoblastic leukaemia (ALL) within two weeks after diagnosis in order to determine the feasibility of a sibling controlled prospective study design. Methods: Fifty consecutive patients (median age at testing 6.6 years, range 4-12) were included in a prospective, longitudinal, nationwide study. Treatment would include intrathecal and systemic chemotherapy according to the DCLSG ALL-9 protocol. Children were evaluated with an extensive neuropsychological battery including measures of intelligence, memory, attention, language, visual.. constructive function, and fine-motor abilities within two weeks after start of the chemotherapy. The control group consisted of 29 healthy siblings (median age at testing 8.2 years, range 4-12), who were tested <4 weeks after the patients' assessment. Results: Mean scores on Wechsler Intelligence Scales did not differ significantly between patients and siblings; mean IQ scores for both the patients and the controls were high average. To examine specific neuropsychological functions, norm scores based on the exact age were acquired by fitting procedures, but no significant differences were found. Conclusions: Neuropsychological assessment of patients during early hospitalisation is feasible. The results indicate no adverse effect of illness and psychological factors on IQ and neuropsychological functioning of patients with recently diagnosed ALL. The prospective design of this study of cognitive late effects of chemotherapy will allow discrimination between adverse sequelae of disease and treatment. [ABSTRACT FROM AUTHOR]

Aim: To analyse rehospitalisation of newborns of all gestations. Methods: A total of 33 276 surviving infants of all gestations born between 1 October 1998 and 31 March 2000 at seven Kaiser Permanente Medical Care Program (KPMCP) delivery services were studied retrospectively. Results: Rehospitalisation rates within two weeks after nursery discharge ranged from 1.0% to 3.7%. The most common reason for rehospitalisation was jaundice. Among babies &ges;34 weeks, the most important factor with respect to rehospitalisation was use of home phototherapy. Among babies who were not rehospitalised for jaundice, African-American race (adjusted odds ratio (AOR) = 0.56), and having a scheduled outpatient visit (AOR =0.73) or a home visit (AOR =0.59) within 72 hours after discharge were protective. Factors associated with increased risk were: being small for gestational age (AOR =1.83), gestational age of 34-36 weeks without admission to the neonatal intensive care unit (AOR =1.65), Score for Neonatal Acute Physiology, version II, &ges; 10 (AOR =1.95), male gender (AOR =1.24), having both a home as well as a clinic visit within 72 hours after discharge (AOR = 1.84), and birth facility (range of AORs =1.52-2.36). Asian race was associated with rehospitalisation (AOR =1.49) when all hospitalisations were considered, but this association did not persist if hospitalisations for jaundice were excluded. Conclusions: In this insured population with access to integrated care, rehospitalisation rates for jaundice were strongly affected by availability of home phototherapy and by follow up. For other causes, moderate prematurity and follow up visits played a large role, but variation between centres persisted even after controlling for multiple factors. Future research should include development of better process measures for evaluation of follow up strategies. [ABSTRACT FROM AUTHOR]

Aims: It has previously been shown that the low necropsy request rate at the University Hospital of the West Indies (UHWI) in Jamaica (35.3%) results primarily from clinicians' confidence in clinical diagnoses and laboratory investigations. This study aimed to determine the rates of discrepancy between clinical and necropsy diagnoses at the UHWI, because many previous studies from other institutions have shown persistent high rates of discrepancy, despite advances in medical investigative technology over the past several years. Methods: Data were extracted retrospectively from consecutive necropsies performed at the UHWI over a two year period. The data were analysed to determine the categories and rates of discrepancy, and to determine the relation between discrepancy rates and age, sex, type and number of diagnoses for each patient, hospital service, and length of hospitalisation. Results: Necropsies were performed on 446 patients; 348 were suitable for further analysis. The overall discrepancy rate was 48.4% and the diagnoses with the highest individual discrepancy rates were pneumonia (73.5%), pulmonary thromboembolism (68.3%), and myocardial infarction (66.7%). Males and older patients were more likely to have discrepant diagnoses. There was a high frequency of discrepancies in patients who died within 24 hours of admission, but there was no consistent relation between length of hospitalisation and discrepancy rate. Conclusions: The high discrepancy rates documented at the UHWI are similar to those reported globally. This study supports previous attestations that the necropsy remains a vital tool for determining diagnostic accuracy, despite modern modalities of clinical investigation and diagnosis. [ABSTRACT FROM AUTHOR]

Study objective: To evaluate whether cognitive performance in childhood is an early determinant of adult illness. Design: Prospective cohort study covering over 30 years. Setting: Providence, Rhode Island, USA. Participants: 633 people ages 30-39 followed up since birth as part of the Providence cohort of the national collaborative perinatal project. Main results: Higher cognitive performance at age 7 was related to a significantly reduced risk of serious illness in adulthood, OR =0.65 (95%Cl: 0.47 to 0.89) for a one standard deviation (15 point) increase in IQ score. This association was independent of both parental socioeconomic status and participant's attained level of education. Conclusions: General cognitive performance may be an important and informative early determinant of adult health. Further evaluation of this association and mechanisms linking cognitive performance and health may provide new and innovative strategies to improve disease management and reduce morbidity. [ABSTRACT FROM AUTHOR]

Aims: To document gastroenteritis hospitalizations of the 1995-96 cohort of infants born in Western Australia to mid-2002, and to assess factors associated with their hospitalizations and readmissions. Methods: Retrospective analysis of the State's hospitalization data, Midwives' Notification of Births data, the Australian Bureau of Statistics mortality data and clinical and demographic information. Results: Aboriginal infants were hospitalized for gastroenteritis eight times more frequently than their non-Aboriginal peers, and were readmitted more frequently and sooner for diarrhoeal illnesses than the other group. They also stayed in hospital for twice as long and many Aboriginal patients were hospitalized on numerous occasions. Hospitalization rates were higher in remote areas and were significantly associated with co-morbidities such as undernutrition, anemia, co-existing infections, and intestinal carbohydrate intolerance. Conclusions: Gastroenteritis is very prevalent in Australian Aboriginal infants and children and is a major cause of their hospitalization in Western Australia. It is often associated with undernutrition, anaemia, intestinal parasitic infestations, other infections, intestinal carbohydrate intolerance, and, in some instances, with low birth weight. This is often due to unhygienic living conditions and behaviors and presents major challenges to public health, health promotion, and clinical personnel, particularly pediatric services. Childhood diarrhoeal diseases occur commonly in other indigenous groups but have not received the attention that they deserve. [ABSTRACT FROM AUTHOR]

Objectives: To find out the effect of early neurological consultation using a real time video link on the care of patients with neurological symptoms admitted to hospitals without neurologists on site. Methods: A cohort study was performed in two small rural hospitals: Tyrone County Hospital (TCH), Omagh, and Erne Hospital, Enniskillen. All patients over 12 years of age who had been admitted because of neurological symptoms, over a 24 week period, to either hospital were studied. Patients admitted to TCH, in addition to receiving usual care, were offered a neurological consultation with a neurologist 120 km away at the Neurology Department of the Royal Victoria Hospital, Belfast, using a real time video link. The main outcome measure was length of hospital stay; change of diagnosis, mortality at 3 months, inpatient investigation, and transfer rate and use of healthcare resources within 3 months of admission were also studied. Results: Hospital stay was significantly shorter for those admitted to TCH (hazard ratio 1.1 3; approximate 95% CI 1.003 to 1.282; p=0.045). No patients diagnosed by the neurologist using the video link subsequently had their diagnosis changed at follow up. There was no difference in overall mortality between the groups. There were no differences in the use of inpatient hospital resources and medical services in the follow up period between TCH and Erne patients. Conclusions: Early neurological assessment reduces hospital stay for patients with neurological conditions outside of neurological centres. This can be achieved safely at a distance using a real time video link. [ABSTRACT FROM AUTHOR]

Objective: To determine the ethnic variation of short and long term female vulnerability after an acute coronary event in a population of Chinese, Indians, and Malays. Design: Population based registry. Patients: Residents of Singapore between the ages of 20-64 years with coronary events. Case identification and classification procedures were modified from the MONICA (monitoring trends and determinants in cardiovascular disease) project. Main outcome measures: Adjusted 28 day case fatality and long term mortality. Results: From 1991 to 1999, there were 16 320 acute coronary events, including 3497 women. Age adjusted 28 day case fatality was greater in women (51 .5% v 38.6%, p < 0.001), with a larger sex difference evident among younger Malay patients. This inequality between the sexes was observed in both the pre-hospitalisation and post-admission periods. Among hospitalised patients, women were older, were less likely to have suffered from a previous Q wave or anterior wall myocardial infarction, and had lower peak creatine kinase concentrations. Case fatality was higher among women, with adjusted hazard ratios of 1.64 (95% confidence interval (CI) 1 .43 to 1 .88) and 1 .50 (95% CI 1 .37 to 1.64) for 28 day and mean four year follow up periods. There were significant interactions of sex and age with ethnic group (p = 0.017). The adjusted hazards for mortality among Chinese, Indian, and Malay women versus men were 1.30, 1.71, and 1.96, respectively. The excess mortality among women diminished with age. Conclusion: In this multiethnic population, both pre-hospitalisation and post-admission case fatality rates were substantially higher among women. The sex discrepancy in long term mortality was greatest among Malays and in the younger age groups. [ABSTRACT FROM AUTHOR]

The article focuses on the effective management of exacerbations of chronic obstructive pulmonary disease (COPD) in Great Britain. It mentions that exacerbations can be managed at home and in few cases need hospitalisation, which depends on the severity of the exacerbation. It stresses that advanced discharge planning reduces the risk of readmission and unnecessary hospital bed occupancy.