Collaborative survey of perinatal loss in planned and unplanned home births. Northern Region Perinatal Mortality Survey Coordinating Group.

OBJECTIVE: To document the outcome of planned and unplanned births outside hospital. DESIGN: Confidential review of every pregnancy ending in stillbirth or neonatal death in which plans had been made for home delivery, irrespective of where delivery eventually occurred. The review was part of a sustained collaborative survey of all perinatal deaths. SETTING: Northern Regional Health Authority area. SUBJECTS: All 558,691 registered births to women normally resident in the former Northern Regional Health Authority area during 1981-94. MAIN OUTCOME MEASURE: Perinatal death. RESULTS: The estimated perinatal mortality during 1981-94 among women booked for a home birth was 14 deaths in 2888 births. This was less than half that among all women in the region. Only three of the 14 women delivered outside hospital. Independent review suggested that two of the 14 deaths might have been averted by different management. Both births occurred in hospital, and in only one was management before admission of the mother judged inappropriate. Perinatal loss to the 64 women who booked for hospital delivery but delivered outside and to the 67 women who delivered outside hospital without ever making arrangements to receive professional care during labour accounted for the high perinatal mortality (134 deaths in 3466 deliveries) among all births outside hospital. CONCLUSIONS: The perinatal hazard associated with planned home birth in the few women who exercised this option (< 1%) was low and mostly unavoidable. Health authorities purchasing maternity care need to address the much greater hazard associated with unplanned delivery outside hospital.     

Survey of neonatal screening for primary hypothyroidism in England,Wales, and Northern Ireland 1982-4

National screening for congenital hypothyroidism was established in the United Kingdom in 1982. During 1982-4, 488 infants with primary congenital hypothyroidism were detected by the 25 regional screening laboratories in England, Wales, and Northern Ireland. In addition, one infant had signs of cretinism at birth and was investigated before the screening test was done and four infants were known to have been missed by the screening programme; among these four infants the initial thyroid stimulating hormone concentrations were normal in two with inherited defects of synthesis of thyroxine, not measured in one, and false negative in one. The overall incidence of primary hypothyroidism was 1:3937 births (boys 1:6640, girls 1:2756). The incidence seemed to be reduced in infants born to black mothers (two cases only) and increased in those born to Asian mothers (61 cases). Congenital anomalies other than those of the thyroid gland were reported in 36 children (7%), and 15 (3%) died from various causes before the age of 4. Infants who were considered to show unequivocal evidence of hypothyroidism started treatment at a median age of 17 days (5th and 95th centiles 10 and 42 days) compared with a median age of 14 days (5th and 95th centiles 9 and 21 days) for infants with classic phenylketonuria also detected by national screening.     

Cutaneous malignant melanoma in Scotland: incidence,survival, and mortality, 1979-94. The Scottish Melanoma Group.

OBJECTIVE: To determine the changing incidence of and mortality from cutaneous malignant melanoma in Scotland from 1979 to 1994. DESIGN: Detailed registration of clinical and pathological features, surgical and other treatment, and follow up of all cases of cutaneous malignant melanoma diagnosed from 1979 to 1994 and registered with specialist database for Scotland. SETTING: Scotland. SUBJECTS: 6288 patients with invasive primary cutaneous malignant melanoma diagnosed between 1 January 1979 and 31 December 1994. RESULTS: The annual age standardised incidence of cutaneous malignant melanoma rose significantly from 3.5 to 7.8 per 100,000 per year in men and from 6.8 to 12.3 per 100,000 per year in women (P < 0.001 for both). World standardised rates increased from 2.7 to 6.0 per 100,000 per year in men and 4.6 to 8.50 per 100,000 in women. The incidence of melanoma continued to increase significantly in men of all ages during the study, but the rate stabilised in women after 1986. Mortality from cutaneous malignant melanoma was 1.3 per million per annum in men in 1979, rising to 2.3 per million per annum in 1994 (P < 0.01); it was 2.4 per million per annum in women in 1979, falling to 1.9 per million per annum in 1994 (P = 0.09). The underlying mortality trends showed a continuing rise for men but a downward trend for women that was not significant (P = 0.09). In men, melanoma free survival was 69% at 5 years and 61% at 10 years; in women the corresponding rates were 82% and 75%. Younger patients had higher survival rates, which were not entirely explained by thinner tumours. Over the 15 year period, survival rates improved by 12% overall, only partly owing to thinner tumours. CONCLUSIONS: In Scotland the incidence of melanoma in women has stabilised, while mortality associated with melanoma in women shows a downward trend.     

Widening inequality of health in northern England, 1981-91.

OBJECTIVE--To identify relative and absolute changes in mortality in the Northern region of England between 1981 and 1991. DESIGN--1981 and 1991 census data were used to rank 678 wards on an index of material deprivation composed of four variables (unemployment, car ownership, housing tenure, household overcrowding). Standardised mortality ratios (all causes) were calculated for various periods between 1981 and 1991 and for different age categories. SETTING--Counties of Cleveland, Cumbria, Durham, Northumberland, and Tyne and Wear. RESULTS--During 1981-91 mortality differentials widened between the most affluent and deprived fifths of wards in all age categories under 75 years. The decline in the relative position of the poorest areas was particularly great, and there was no narrowing of inequalities across the remainder of the socioeconomic spectrum. In absolute terms, there were improvements in mortality in all age categories in the most affluent areas. In the poorest areas improvements in the 55-64 age group were balanced by increased mortality among men aged 15-44, a slight rise among women aged 65-74, and static rates among men aged 45-54. CONCLUSIONS--These results re-emphasise the case for linking mortality patterns with material conditions rather than individual behaviour.     

Age specific trends in asthma mortality in England and Wales, 1983-95: results of an observational study.

OBJECTIVE: To determine trends in asthma mortality by age group in England and Wales during 1983-95. DESIGN: Observational study. SETTING: England and Wales. SUBJECTS: All deaths classified as having an underlying cause of asthma registered from 1 January 1983 to 31 December 1995. MAIN OUTCOME MEASURE: Time trends for age specific asthma deaths. RESULTS: Deaths in the age group 5-14 years showed an irregular downward trend during 1983-95; deaths in the age groups 15-44, 45-64, and 65-74 years peaked before 1989 and then showed a downward trend; and deaths in the age group 75-84 years peaked between 1988 and 1993 and subsequently dropped. Trends were: age group 5-14 years, 6% (95% confidence interval 3% to 9%); 15-44 years, 6% (5% to 7%); 45-64 years, 5% (4% to 6%); 65-74 years, 2% (1% to 3%). Deaths in the 75-84 and 85 and over categories plateaued. CONCLUSIONS: There are downward trends in asthma mortality in Britain, which may be due to increased use of prophylactic treatment.     

Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery.

A survey was carried out of all 8856 births occurring at home in England and Wales in 1979. Of these births, 67% had been booked for delivery at home, 21% had been booked for delivery in hospital, 3% had not been booked, and for 9% the intended place of delivery was unknown. The perinatal mortality varied almost 50-fold according to the intended place of delivery, ranging from 4.1/1000 births in those booked for delivery at home to 196.6/1000 unbooked births. Deliveries that occurred at home but had been booked for a hospital consultant unit were associated with a perinatal mortality of 67.5/1000. Births that had been booked for delivery at home included the smallest proportion of babies of low birth weight: 2.5% weighed 2500 g or less compared with 18% of those booked for consultant units and 29% of those not booked. Within these low birthweight groups there were noticeable differences in perinatal mortality; births booked to occur at home had the lowest mortality and unbooked births had the highest. Perinatal mortality among babies who weighed more than 2500 g was generally low irrespective of the intended place of delivery; the only exception was in babies whose delivery had not been booked. In all groups perinatal mortality was considerably higher in nulliparous than parous women. Women booking a delivery at home are clearly a selected group, and some may have been transferred to hospital during labour and were thus not included in the survey. Nevertheless, these data suggest that the perinatal mortality among births booked to occur at home is low, especially for parous women.     

Time trends in testicular cancer in Croatia 1983-2007: rapid increases in incidence, no declines in mortality

Testicular cancer, although a rare malignancy, represents the most common cancer in young male populations of Western origin. While increasing incidence trends of testicular cancer have been reported, mortality is declining in many high-resource settings. Using national data from the Croatian National Cancer Registry for the period 1983-2007, time trends were analysed by joinpoint regression and Age-Period-Cohort models. The present study is the first to analyse the testicular cancer trends in the Croatian population. Over the 25-year period, a mean number of 89 incident cases and 13 deaths were reported annually. The observed mean annual increases in age-standardised rates were 7.0% for incidence and 1.6% for mortality, with no abrupt linear changes (joinpoints) identified. The incidence rates of testicular cancer incidence have been steeply increasing in successive cohorts born since the mid-1930s. The rapid rise in testicular cancer incidence in the Croatian population appears to be one of the highest rates of increase recorded in Europe and worldwide. The lack of decline in the mortality rates over time, while based on relatively few deaths, highlights a need for improvements in diagnostics and management of therapy in Croatia in order to improve the survival and quality-of-life of testicular cancer patients.     

Insulin dependent diabetes in childhood and material deprivation in northern England, 1977-86.

OBJECTIVE--To determine the incidence of insulin dependent diabetes in the Northern region of England in children less than 16 years old in the period 1977 to 1986 and to relate the incidence data to an index of deprivation. DESIGN--Retrospective analysis of hospital case records identified from the regional health authority''s computer; validation of the primary source with hospital clinic registers and community paediatric registers. SETTING--Northern region, excluding South Cumbria District Health Authority (659,300 children under 16 in 1981). PATIENTS--All children diagnosed with insulin dependent diabetes before the age of 16 and resident in the region at time of diagnosis. MAIN OUTCOME MEASURES--Incidence rates for the 10 year period and analysis of incidence rates within categories of deprivation. RESULTS--919 incident cases were identified. The validation procedure covered 54% of all cases identified and gave 95% completeness of ascertainment. The average annual incidence over the 10 year period was 14.8/100,000 for girls and 13.4/100,000 for boys. The annual incidence for the most and least deprived areas of the region was 18.7/100,000 (95% confidence interval 16.2 to 21.5) for boys and 7/100,000 (5.6 to 8.8) for girls. There was a highly significant trend (p less than 0.001) of decreasing incidence with decreasing level of deprivation. CONCLUSIONS--In the north of England the incidence of childhood diabetes is related to material deprivation.     

Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study

Objectives To investigate time trends in mortality after admission to hospital for fractured neck of femur from 1968 to 1998, and to report on the effects of demographic factors on mortality.Design Analysis of hospital inpatient statistics for fractured neck of femur, incorporating linkage to death certificates.Setting Four counties in southern England.Subjects 32 590 people aged 65 years or over admitted to hospital with fractured neck of femur between 1968 and 1998.Main outcome measures Case fatality rates at 30, 90, and 365 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results Case fatality rates declined between the 1960s and the early 1980s, but there was no appreciable fall thereafter. They increased sharply with increasing age: for example, fatality rates at 30 days in 1984-98 increased from 4% in men aged 64-69 years to 31% in those aged ≥ 90. They were higher in men than women, and in social classes IV and V than in classes I and II. In the first month after fracture, standardised mortality ratios in women were 16 times higher, and those in men 12 times higher, than mortality in the same age group in the general population.Conclusions The high mortality rates, and the fact that they have not fallen over the past 20 years, reinforce the need for measures to prevent osteoporosis and falls and their consequences in elderly people. Whether post-fracture mortality has fallen to an irreducible minimum, or whether further decline is possible, is unclear.     

Analysis of trends in cancer mortality in England and Wales during 1951-80 separating changes associated with period of birth and period of death.

Cancer mortality rates in England and Wales were analysed so to describe simultaneously changes affecting successive generations--that is, associated with period of birth--as well as changes associated with the period of which the deaths took place. When mortality from all cancers was considered the analysis implied that, contrary to a widely held view, the rate of death from cancer had been declining in each sex in successive generations. For men the decline had occurred in generations born since 1900, whereas for women the peak came in the 1925 birth group. On the other hand, there had been little decline in the rates associated with period of death. Five examples of cancers of specific organs for which the trends contrasted are shown.     

"I'm all right,John": voting patterns and mortality in England and Wales, 1981-92.

OBJECTIVE: To investigate the association between voting patterns, deprivation, and mortality across England and Wales. DESIGN: Ecological study. SETTING: All the electoral constituencies of England and Wales. MAIN OUTCOME MEASURES: Combined and sex specific standardised mortality ratios. RESULTS: For the years surrounding the three elections of 1983, 1987, and 1992 overall standardised mortality ratios showed substantial negative correlations of -0.74 to -0.76 with Conservative voting and substantial positive correlations of 0.73 to 0.77 with Labour voting (all P < 0.0001). Correlations were higher for male than female mortality. Conservative voting was strongly negatively correlated (r = -0.84) with the Townsend deprivation score, while Labour voting was positively correlated (r = 0.74) with this. Labour and Conservative voting explained more of the variance in mortality than did the Townsend score. In multiple regression analyses for the 1992 election Labour voting (P < 0.0001), Conservative voting (P < 0.0001), the Townsend score (P = 0.016), and abstentions (P = 0.032) were all associated with mortality. Labour and conservative voting explained 61% of the variance in mortality between constituencies; when Townsend score and abstentions were added this increased to 63%. CONCLUSIONS: Conservative and Labour voting are at least as strongly associated with mortality as is a standard deprivation index. Voting patterns may add information above that provided by indicators of material deprivation. People living in better circumstances and who have better health, who are least likely to require unemployment benefit and free school meals or to rely on a state pension in old age, and who are most able to opt out of state subsidised provision of transport, education, and the NHS, vote for the party that is most likely to dismantle the welfare state.     

Ethnic differences in mortality from acute rheumatic fever and chronic rheumatic heart disease in New Mexico, 1958-1982.

To examine time trends and differences in mortality rates from acute rheumatic fever and chronic rheumatic heart disease in New Mexico''s Hispanic, American Indian, and non-Hispanic white populations, we analyzed vital records data for 1958 through 1982. Age-adjusted mortality rates for acute rheumatic fever were low and showed no consistent temporal trends among the three ethnic groups over the study period. Age-adjusted and age-specific mortality rates for chronic rheumatic heart disease in Hispanic and non-Hispanic whites decreased over the 25-year period, although rates were higher among Hispanics than among non-Hispanics during most of the time period. In American Indians, age-adjusted mortality rates for chronic rheumatic heart disease increased between 1968 and 1977 to twice the non-Indian mortality rates during the same period. Despite this increase in mortality from chronic rheumatic heart disease among New Mexico''s American Indians from 1968 to 1977, the New Mexico data generally reflect national trends of decreasing mortality from chronic rheumatic heart disease.