Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment.

OBJECTIVE--To determine the age related incidence of advanced chronic renal failure in two areas of England. DESIGN--Prospective study of patients newly identified as having advanced chronic renal failure within a two year period; subsequent monitoring of patients'' clinical course for a further 26 months. SETTING--Devon and Blackburn. SUBJECTS--Those patients in a population of 708,997 who developed advanced chronic renal failure (serum creatinine concentration greater than 500 mumol/l) for the first time during a two year period. MAIN OUTCOME MEASURES AND RESULTS--210 Patients (148 per million population per year) developed advanced chronic renal failure, 117 (51%) of whom were over 70. The age related incidence rose from 58 per million per year in those aged 20-49 to 588 per million per year in those aged 80 or over. Only 54% (113) of patients were referred to a nephrologist; 120 patients (57%) needed dialysis or died within three months of presenting without receiving dialysis, and 187 (89%) died or needed dialysis within three years. After those unsuitable for further treatment had been excluded, 78 patients per million population per year aged under 80 needed to start long term renal replacement treatment. CONCLUSIONS--Many patients suitable for renal replacement treatment are still not referred for nephrological opinion and are denied treatment. If the treatment rate in the United Kingdom rose from the 1988 rate of 55.1 per million per year to 78 per million per year then the number of patients receiving treatment would rise to about 800 per million. This is double the present number and has considerable but predictable resource implications for the NHS.     

Calving difficulty and calf survival in beef cows fed two energy levels

Angus and Hereford yearling heifers (469) were bred to either Hereford or Angus bulls and fed either a high level (13.3 Mcal of ME) or a low level of nutrition (7.3 Mcal of ME) for the last 116 days of pregnancy. The level of calving difficulty did not differ between heifers receiving the high (H) and low (L) level of nutrition the first year (36% and 34%) but was significantly higher (P < .01) in heifers receiving H the second year (33% vs. 16%). Calves born to heifers receiving H weighed at birth 2.7 kg more (P < .01) both years than calves born to heifers receiving L. In the first year of the study the size of the pelvic opening was 10 cm larger 1 week before calving (P < .01) in heifers receiving H than in heifers receiving L. Calf survival was not related to level of nutrition, breed of dam or breed of sire either year of the study.     

Absenteeism among hospital staff during an influenza epidemic: implications for immunoprophylaxis.

The 1980-81 epidemic of influenza A/Bangkok 79 was responsible for increased absenteeism (1.7 times the rate for the corresponding period of the subsequent nonepidemic year) among selected hospital staff in Winnipeg''s Health Sciences Centre. Retrospective study of employment records for 25 of the centre''s largest departments showed excess sick-leave costs of about $24 500 during the 2-week period of peak absenteeism that included the epidemic. Although the centre was sampling prospectively for the virus the first positive results became available too late for chemoprophylactic measures to have been effective. The greater increase in absenteeism among nursing staff caring for patients with chronic respiratory disease and nurses working on general medical or pediatric acute infection/isolation wards suggested that these groups be targeted for influenza vaccination in hospitals.     

The novel application of Benford's second order analysis for monitoring radiation output in interventional radiology

Benford's law is an empirical observation which predicts the expected frequency of digits in naturally occurring datasets spanning multiple orders of magnitude, with the law having been most successfully applied as an audit tool in accountancy. This study investigated the sensitivity of the technique in identifying system output changes using simulated changes in interventional radiology Dose-Area-Product (DAP) data, with any deviations from Benford's distribution identified using z-statistics.The radiation output for interventional radiology X-ray equipment is monitored annually during quality control testing; however, for a considerable portion of the year an increased output of the system, potentially caused by engineering adjustments or spontaneous system faults may go unnoticed, leading to a potential increase in the radiation dose to patients. In normal operation recorded examination radiation outputs vary over multiple orders of magnitude rendering the application of normal statistics ineffective for detecting systematic changes in the output. In this work, the annual DAP datasets complied with Benford's first order law for first, second and combinations of the first and second digits. Further, a continuous ‘rolling’ second order technique was devised for trending simulated changes over shorter timescales. This distribution analysis, the first employment of the method for radiation output trending, detected significant changes simulated on the original data, proving the technique useful in this case. The potential is demonstrated for implementation of this novel analysis for monitoring and identifying change in suitable datasets for the purpose of system process control.     

Surgical wound sepsis

With the help of a surgical nurse and using data-processing techniques, a prospective clinical study was conducted to determine the wound infection rate in two hospitals in Calgary. The overall sepsis rate was 5.2% and the clean wound rate 3.5%. The latter is the more meaningful figure as it allows for comparison between hospitals, specialties and individuals and is a good guide for hospital morbidity reviews. The groundwork for succeeding wound infection is laid in the operating theatre, and it is believed that wound infection would be reduced more by attention to Halsted''s principles than by more rigid aseptic techniques. It is estimated that wound sepsis costs the Province of Alberta 1.5 million dollars per year for hospitalization alone. This amounts to roughly $1 per person per year. The annual cost of a prospective study such as the present one is approximately $7000. This is equivalent to the cost of hospitalizing 24 patients with infected wounds for one week (at $300 per week). One dividend of a prospective study is an associated reduction in infection rate. This reduction more than pays for the cost of the program.     

Effect of season on luteal activity during the post partum period of dairy cows in temperate areas

Seasonal effects on luteal activity during post partum were evaluated in two consecutive studies in 253 dairy cows in Northern Italy. In study 1, plasma progesterone concentrations were determined on days 14, 21, 28, 35, 42, 49 and 56 post partum and in study 2 cows were synchronized and inseminated at a fixed time using two regimes based on the 'Ovsynch' protocol. Study 1: Animals were classified as luteal (progesterone >1.5 ng/ml in at least two consecutive samples) or non-luteal (progesterone <1.5 ng/ml in all samples). The proportion of cows without luteal activity from calving to day 56 post partum was 47/253 (18.5%). Of the 47 cows without luteal activity, 42 (89%) were detected during the warm months of the year and five were detected during the cold months of the year, and the effect of season was highly significant (P < 0.001). Study 2: Three study groups were established; control (CONT, untreated cows, n = 92), GPG (cows receiving gonadotropin-releasing hormone (GnRH) on day 0, PGF2α on day 7 followed by a second dose of GnRH 24 h later, n = 80); and HPH (the same as the GPG group, but with human chorionic gonadotropin (hCG) substituted for GnRH, n = 81). In the GPG and HPH groups, cows were inseminated 16 to 22 h after the second GnRH or hCG injection. Untreated cows were inseminated at first estrus after a voluntary weaning period. Because the effects of the GPG and HPH regimes on pregnancy rate were not significantly different, data were pooled into a single treatment group (TREAT). Pregnancy rates during the warm months of the year were 16% and 15% at first service and 65% and 66% at day 135 post partum for CONT and TREAT groups, respectively. Pregnancy rates during the cold months of the year were 36% and 38% at first service and 72% and 76% at day 135 post partum for CONT and TREAT groups, respectively. There was an effect of season (P < 0.05) but not of treatment on pregnancy rate. Treatment reduced the number of days from calving to conception during both the cold (101 ± 3.2 v. 121 ± 3.1 days; P < 0.001) and warm seasons (122 ± 3.2 v. 145 ± 3.1 days; P < 0.001). In conclusion, the present study shows that (i) heat stress during the warm season can compromise luteal activity and (ii) that regimes based on the Ovsynch protocol did not improve pregnancy rate at first service or by 135 post partum, but they had a positive effect on the calving-to-conception interval.     

CRITERIA FOR BLOOD TRANSFUSIONS

A review of the use of blood transfusions used in a small community hospital over a two-year period revealed a high incidence of instances in which the clinical record did not show essential need for the procedure. Educational efforts in hospital staff meetings resulted in some improvement in this respect during the two-year period. Of single unit transfusions given during the first year, 80 per cent were deemed to have been nonessential; during the second year, 52 per cent.Methods which will reduce the use of blood except when it is essential are (1) continuation of staff education; (2) providing the staff with accurate methods of measurement of blood volume and of monitoring blood loss; (3) use of a separate blood transfusion chart in the patient''s hospital record; and (4) establishment of a hospital transfusion committee to review the criteria in all cases in which blood is transfused.     

Physical abuse during pregnancy: prevalence and risk factors

BACKGROUND: Violence during pregnancy is a health and social problem that poses particular risks to the woman and her fetus. To address the lack of Canadian information on this issue, the authors studied the prevalence and predictors of physical abuse in a sample of pregnant women in Saskatoon. METHODS: Of 728 women receiving prenatal services through the Saskatoon District public health system between Apr. 1, 1993, and Mar. 31, 1994, 605 gave informed consent to participate in the study and were interviewed in the second trimester. Of these, 543 were interviewed again late in the third trimester. During the initial interview, information was collected on the women''s sociodemographic characteristics, the current pregnancy, health practices and psychosocial variables. The second interview focused on the women''s experience of physical abuse during the pregnancy and during the preceding year, the demographic characteristics and the use of alcohol or illicit drugs by their male partner. RESULTS: In all, 31 (5.7%) of the women reported experiencing physical abuse during pregnancy; 46 (8.5%) reported experiencing it within the 12 months preceding the second interview. Of the 31 women 20 (63.3%) reported that the perpetrator was her husband, boyfriend or ex-husband. Although all ethnic groups of women suffered abuse, aboriginal women were at greater risk than nonaboriginal women (adjusted odds ratio 2.8, 95% confidence interval [CI] 1.0-7.8). Women whose partner had a drinking problem were 3.4 times (95% CI 1.2-9.9) more likely to have been abused than women whose partner did not have a drinking problem. Perceived stress and number of negative life events in the preceding year were also predictors of abuse. Abused women tended to report having fewer people with whom they could talk about personal issues or get together; however, they reported socializing with a larger number of people in the month before the second interview than did the women who were not abused. INTERPRETATION: Physical abuse affects a significant minority of pregnant women and is associated with stress, lack of perceived support and a partner with a drinking problem.     

Finding a Needle in the Haystack: The Costs and Cost-Effectiveness of Syphilis Diagnosis and Treatment during Pregnancy to Prevent Congenital Syphilis in Kalomo District of Zambia

Background

In March 2012, The Elizabeth Glaser Pediatric AIDS Foundation trained maternal and child health workers in Southern Province of Zambia to use a new rapid syphilis test (RST) during routine antenatal care. A recent study by Bonawitz et al. (2014) evaluated the impact of this roll out in Kalomo District. This paper estimates the costs and cost-effectiveness from the provider''s perspective under the actual conditions observed during the first year of the RST roll out.

Methods

Information on materials used and costs were extracted from program records. A decision-analytic model was used to evaluate the costs (2012 USD) and cost-effectiveness. Basic parameters needed for the model were based on the results from the evaluation study.

Results

During the evaluation study, 62% of patients received a RST, and 2.8% of patients tested were positive (and 10.4% of these were treated). Even with very high RST sensitivity and specificity (98%), true prevalence of active syphilis would be substantially less (estimated at <0.7%). For 1,000 new ANC patients, costs of screening and treatment were estimated at $2,136, and the cost per avoided disability-adjusted-life year lost (DALY) was estimated at $628. Costs change little if all positives are treated (because prevalence is low and treatment costs are small), but the cost-per-DALY avoided falls to just $66. With full adherence to guidelines, costs increase to $3,174 per 1,000 patients and the cost-per-DALY avoided falls to $60.

Conclusions

Screening for syphilis is only useful for reducing adverse birth outcomes if patients testing positive are actually treated. Even with very low prevalence of syphilis (a needle in the haystack), cost effectiveness improves dramatically if those found positive are treated; additional treatment costs little but DALYs avoided are substantial. Without treatment, the needle is essentially found and thrown back into the haystack.     

Direct cost associated with acquired brain injury in Ontario

ABSTRACT: BACKGROUND: Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada. METHODS: A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer's perspective. RESULTS: Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65 % of the total treatment cost in the first year overwhelming all other cost components. CONCLUSIONS: The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.     

Aspects of the Ecology of an Invasive Plant, Garlic Mustard (Alliaria petiolata), in Central Illinois

Alliaria petiolata (garlic mustard), an exotic plant species, has invaded woodlands in several areas in mid-western and northeastern United States and adjacent Canada, and it is displacing the indigenous under-story flora. This study was conducted to provide information about the species' biology that might be useful in controlling its spread in native woodlands. The plant is a strict biennial in North America, spending the first year of growth as a basal rosette. This period of relatively slow growth is followed by a period of rapid shoot elongation (1.9 cm/day) during early spring of the second growing season. The plant is capable of cross- and self-pollination, although pollination and stigma receptivity occur before the flower is open, so autogamy is the most likely breeding system. Garlic mustard invests 20.4% of its biomass in reproductive effort, with an annual seed rain of 15,000 seeds/m². Seed dispersal from fruits begins in early July and continues into October. Most seeds germinate in the spring following the year in which they were produced. Seedling recruitment is high (8.3–18.0 seedlings/cm²), but only about 7.5% of the plants survive to maturity. The success of the plant in invading woodlands appears to be related to (1) its autogamous breeding system that allows a single individual, or a few individuals, to establish populations of genetically similar but interfertile individuals; (2) high seed production, permitting establishment of large numbers of individuals; and (3) rapid growth during the second growing season, which increases its competitive ability. Because of garlic mustard's ability to occupy understory habitats successfully, it may be unrealistic to expect to eliminate the plant from many habitats it has already invaded.     

Carbon sequestration in a high-elevation, subalpine forest

We studied net ecosystem CO₂ exchange (NEE) dynamics in a high‐elevation, subalpine forest in Colorado, USA, over a two‐year period. Annual carbon sequestration for the forest was 6.71 mol C m^?2 (80.5 g C m^?2) for the year between November 1, 1998 and October 31, 1999, and 4.80 mol C m^?2 (57.6 g C m^?2) for the year between November 1, 1999 and October 31, 2000. Despite its evergreen nature, the forest did not exhibit net CO₂ uptake during the winter, even during periods of favourable weather. The largest fraction of annual carbon sequestration occurred in the early growing‐season; during the first 30 days of both years. Reductions in the rate of carbon sequestration after the first 30 days were due to higher ecosystem respiration rates when mid‐summer moisture was adequate (as in the first year of the study) or lower mid‐day photosynthesis rates when mid‐summer moisture was not adequate (as in the second year of the study). The lower annual rate of carbon sequestration during the second year of the study was due to lower rates of CO₂ uptake during both the first 30 days of the growing season and the mid‐summer months. The reduction in CO₂ uptake during the first 30 days of the second year was due to an earlier‐than‐normal spring warm‐up, which caused snow melt during a period when air temperatures were lower and atmospheric vapour pressure deficits were higher, compared to the first 30 days of the first year. The reduction in CO₂ uptake during the mid‐summer of the second year was due to an extended drought, which was accompanied by reduced latent heat exchange and increased sensible heat exchange. Day‐to‐day variation in the daily integrated NEE during the summers of both years was high, and was correlated with frequent convective storm clouds and concomitant variation in the photosynthetic photon flux density (PPFD). Carbon sequestration rates were highest when some cloud cover was present, which tended to diffuse the photosynthetic photon flux, compared to periods with completely clear weather. The results of this study are in contrast to those of other studies that have reported increased annual NEE during years with earlier‐than‐normal spring warming. In the current study, the lower annual NEE during 2000, the year with the earlier spring warm‐up, was due to (1) coupling of the highest seasonal rates of carbon sequestration to the spring climate, rather than the summer climate as in other forest ecosystems that have been studied, and (2) delivery of snow melt water to the soil when the spring climate was cooler and the atmosphere drier than in years with a later spring warm‐up. Furthermore, the strong influence of mid‐summer precipitation on CO₂ uptake rates make it clear that water supplied by the spring snow melt is a seasonally limited resource, and summer rains are critical for sustaining high rates of annual carbon sequestration.     

Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care

Objective To evaluate the cost effectiveness of acupuncture in the management of chronic headache.Design Cost effectiveness analysis of a randomised controlled trial.Setting General practices in England and Wales.Participants 401 patients with chronic headache, predominantly migraine.Interventions Patients were randomly allocated to receive up to 12 acupuncture treatments over three months from appropriately trained physiotherapists, or to usual care alone.Main outcome measure Incremental cost per quality adjusted life year (QALY) gained.Results Total costs during the one year period of the study were on average higher for the acupuncture group (£403; $768; €598) than for controls (£217) because of the acupuncture practitioners'' costs. The mean health gain from acupuncture during the one year of the trial was 0.021 quality adjusted life years (QALYs), leading to a base case estimate of £9180 per QALY gained. This result was robust to sensitivity analysis. Cost per QALY dropped substantially when the analysis incorporated likely QALY differences for the years after the trial.Conclusions Acupuncture for chronic headache improves health related quality of life at a small additional cost; it is relatively cost effective compared with a number of other interventions provided by the NHS.     

Health care cost of crusted scabies in Aboriginal communities in the Northern Territory,Australia

BackgroundCrusted scabies is a debilitating dermatological condition. Although still relatively rare in the urban areas of Australia, rates of crusted scabies in remote Aboriginal communities in the Northern Territory (NT) are reported to be among the highest in the world.ObjectiveTo estimate the health system costs associated with diagnosing, treating and managing crusted scabies.MethodsA disease pathway model was developed to identify the major phases of managing crusted scabies. In recognition of the higher resource use required to treat more severe cases, the pathway differentiates between crusted scabies severity grades. The disease pathway model was populated with data from a clinical audit of 42 crusted scabies patients diagnosed in the Top-End of Australia’s Northern Territory between July 1, 2016 and May 1, 2018. These data were combined with standard Australian unit costs to calculate the expected costs per patient over a 12-month period, as well as the overall population cost for treating crusted scabies.FindingsThe expected health care cost per patient diagnosed with crusted scabies is $35,418 Australian dollars (AUD) (95% CI: $27,000 to $43,800), resulting in an overall cost of $1,558,392AUD (95% CI: $1,188,000 to $1,927,200) for managing all patients diagnosed in the Northern Territory in a given year (2018). By far, the biggest component of the health care costs falls on the hospital system.DiscussionThis is the first cost-of-illness analysis for treating crusted scabies. Such analysis will be of value to policy makers and researchers by informing future evaluations of crusted scabies prevention programs and resource allocation decisions. Further research is needed on the wider costs of crusted scabies including non-financial impacts such as the loss in quality of life as well as the burden of care and loss of well-being for patients, families and communities.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

Acupuncture or Low Frequency Infrared Treatment for Low Back Pain in Chinese Patients: A Discrete Choice Experiment

Acupuncture is a popular but controversial treatment option for low back pain. In China, it is practised as traditional Chinese medicine; other treatment strategies for low back pain are commonly practised as Western medicine. Research on patient preference for low back-pain treatment options has been mainly conducted in Western countries and is limited to a willingness-to-pay approach. A stated-preference, discrete choice experiment was conducted to determine Chinese patient preferences and trade-offs for acupuncture and low frequency infrared treatment in low back pain from September 2011 to August 2012 after approval from the Department of Scientific Research in the study settings. Eight-six adult outpatients who visited the ‘traditional medicine department’ at a traditional Chinese medicine hospital and the ‘rehabilitation department’ at a Western medicine hospital in Guangdong Province of China for chronic low back pain during study period participated in an interview survey. A questionnaire containing 10 scenarios (5 attributes in each scenario) was used to ask participants'' preference for acupuncture, low frequency infrared treatment or neither option. Validated responses were analysed using a nested-logit model. The decision on whether to receive a therapy was not associated with the expected utility of receiving therapy, female gender and higher out-of-pocket payment significantly decreased chance to receive treatments. Of the utility of receiving either acupuncture or low frequency infrared treatment, the treatment sensation was the most important attribute as an indicator of treatment efficacy, followed by the maximum efficacy, maintenance duration and onset of efficacy, and the out-of-pocket payment. The willingness-to-pay for acupuncture and low frequency infrared treatment were about $618.6 and $592.4 USD per course respectively, demonstrated patients'' demand of pain management. The treatment sensation was regarded as an indicator of treatment efficacy and the most important attribute for choosing acupuncture or low frequency infrared treatment. The high willingness-to-pay demonstrated patients'' demand of pain management. However, there may be other factors influencing patients'' preference to receive treatments.     

Long term effects of an integrated care intervention on hospital utilization in patients with severe COPD: a single centre controlled study

Abstract

Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality globally. In Trondheim in 2008 an integrated care model (COPD-Home) consisting of an education program, self-management plan, home visits and a call centre for patient support and communication was developed. The objective was to determine the efficacy of an intervention according to the COPD-Home model in reducing hospital utilization among patients with COPD stage III and IV (GOLD 2007) discharged after hospitalization for acute exacerbations of COPD (AECOPD).

Methods

A single centre, prospective, open, controlled clinical study comparing COPD-Home integrated care (IC) with usual care (UC).

Results

Ninety-one versus 81 patients mean age 73.4 ± 9.3 years (57% women) were included in the IC group (ICG) and the UC group (UCG) respectively, and after 2 years 51 and 49 patients were available for control in the respective groups. During the year prior to study start there were 71 hospital admissions (HA) in the ICG and 84 in the UCG. There was a 12.6% reduction in HA in the ICG during the first year of follow-up and a 46.5% reduction during the second year (p = 0.01) compared to an 8.3% increase during the first year and no change during the second year in the ICG. During the year prior to study start, the number of hospital days (HD) was 468 in the ICG and 479 in the UCG. In the IC group, the number of HD was reduced by 48.3% during the first year (p = 0.01), and remained low during the second year of follow-up (p=0.02). In the UC group, the number of HD remained unchanged during the follow-up period. There was a trend towards a shorter survival time among patients in the ICG compared to the UCG, hazard ratio 1.33 [95% CI 0.77 to 2.33].

Conclusion

Intervention according to the COPD-Home model reduced hospital utilization in patients with COPD III and IV with a persisting effect throughout the 2 years of follow-up. However, there was a trend towards a shorter survival time in the intervention group.     

Secular decline in mortality from coronary heart disease in adults with diabetes mellitus: cohort study

Objective To examine trends in fatal coronary heart disease in adults with and without diabetes.Design Cohort study.Setting Two surveys of the Nord-Trøndelag health study (HUNT), a population based study in Norway.Participants 74 914 men and women from the first survey (1984-6) and 64 829 from the second survey (1995-7).Main outcome measure Age specific mortality from coronary heart disease among adults with and without diabetes during two consecutive nine year follow-up periods.Results A total of 2623 men and 1583 women died from coronary heart disease. Mortality rates were substantially lower during the most recent follow-up period: among men aged 70-79 without diabetes, deaths per 1000 person years declined from 16.38 to 8.79 (reduction 48%, 95% confidence interval 39% to 55%) and among women aged 70-79 from 6.84 to 2.68 (62%, 52% to 70%). Among the same age group with diabetes, deaths per 1000 person years in men declined from 38.97 to 17.89 (54%, 32% to 69%) and in women from 28.15 to 11.83 (59%, 37% to 73%). The reduction was more noticeable in age groups younger than 70 at baseline, and less pronounced among people aged 80 or more. Mortality from coronary heart disease was more than twofold higher in people with than without diabetes, with a slightly stronger association in women. The difference in mortality by diabetes status remained almost unchanged from the first to the second survey.Conclusion The strong general reduction in mortality rates from coronary heart disease from the first to the second follow-up period also benefited people with diabetes, but the more than twofold higher mortality from coronary heart disease associated with diabetes persisted over time.     

Evaluating second year cropping on jhum fallows in Mizoram, north-eastern India: Soil fertility

Changes in soil fertility were evaluated on young (6 year) and old (20 year) jhum fields in Mizoram, north-eastern India in response to various operations involved injhum such as slashing and burning of vegetation, cropping period, and intervening fallow period between first and second year cropping. The results demonstrate that the soil is richer in nutrients in old than young field prior to the start of jhum cultivation. Slash burning depletes soil acidity, carbon and nitrogen but elevates phosphorus and cations. Soil fertility declined during first cropping phase, and further declined during second cropping phase. After two cropping years, soil fertility of old field was almost at par with that of young field, signifying that the loss of soil fertility was more in old than young field. A short intervening fallow period between first and second year of cropping did not show any pronounced improvement in soil fertility, though it provided some biomass for second burning. Tilling caused maximum loss to soil fertility. The fertilizer treatments ended with comparable or better soil fertility in comparison to no-treatment plot. There seems to be none of the fertilizer treatments superior over others from the standpoint of ending soil fertility. The unifying conclusions of this series of investigations support the hypothesis that the second year cropping holds promise to reduce the demand for forested land for jhum, and lengthen the jhum cycle substantially.