Oral contraceptives and myocardial infarction: results of the MICA case-control study

ObjectivesTo determine the association between myocardial infarction and use of different types of oral contraception in young women.DesignCommunity based case-control study. Data from interviews and general practice records.SettingEngland, Scotland, and Wales.ParticipantsCases (n=448) were recruited from women aged between 16 and 44 who had suffered an incident myocardial infarction between 1 October 1993 and 16 October 1995. Controls (n=1728) were women without a diagnosis of myocardial infarction matched for age and general practice.ResultsThe adjusted odds ratio for myocardial infarction was 1.40 (95% confidence interval 0.78 to 2.52) for all combined oral contraceptive users, 1.10 (0.52 to 2.30) for second generation users, and 1.96 (0.87 to 4.39) for third generation users. Subgroup analysis by progestagen content did not show any significant difference from 1, and there was no effect of duration of use. The adjusted odds ratio for third generation users versus second generation users was 1.78 (0.66 to 4.83). 87% of cases were not exposed to an oral contraceptive, and 88% had clinical cardiovascular risk factors or were smokers, or both. Smoking was strongly associated with myocardial infarction: adjusted odds ratio 12.5 (7.29 to 21.5) for smoking 20 or more cigarettes a day.ConclusionsThere was no significant association between the use of oral contraceptives and myocardial infarction. The modest and non-significant point estimates for this association have wide confidence intervals. There was no significant difference between second and third generation products.

Key message

• There is no evidence of a difference between second and third generation oral contraceptives on risk of myocardial infarction
• There is no significantly increased risk of myocardial infarction in users of oral contraceptives
• Of women aged under 45 years who suffered a myocardial infarction, 87% were not taking any oral contraceptive
• Of women who suffered myocardial infarction, 88% had one or more known cardiovascular risk factors
• Young women who wish to preserve cardiovascular health should be advised to stop smoking, above all else

     

Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study

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

Key messages

• Background mortality for conditions such as abdominal aortic aneurysm in elderly patients needs to be taken into account when assessing long term survival after surgery
• Relative survival methodology can correct for background mortality
• The five year relative survival for patients surviving beyond 30 days of elective surgery for abdominal aortic aneurysm was 95% for men and 88% for women
• For octogenarians, five year survival after elective surgery was greater than that expected of an age matched population
• Age over 80 years should not preclude consideration for elective surgery for abdominal aortic aneurysm

     

Career destinations seven years on among doctors who qualified in the United Kingdom in 1988: postal questionnaire survey

ObjectiveTo report the career choices and career destinations in 1995 of doctors who qualified in the United Kingdom in 1988.DesignPostal questionnaire.SettingUnited Kingdom.SubjectsAll doctors who qualified in the United Kingdom in 1988.ResultsOf the 3724 doctors who were sent questionnaires, eight had died and three declined to participate. Of the remaining 3713 doctors, 2885 (77.7%) replied. 16.9% (608/3593; 95% confidence interval 16.1% to 17.8%) of all 1988 qualifiers from medical schools in Great Britain were not working in the NHS in Great Britain in 1995 compared with 17.0% (624/3674; 16.1% to 17.9%) of the 1983 cohort in 1990. The proportion of doctors working in general practice was lower than in previous cohorts. The percentage of women in general practice (44.3% (528/1192)) substantially exceeded that of men (33.1% (443/1340)). 53% (276/522) of the women in general practice and 20% (98/490) of the women in hospital specialties worked part time.ConclusionsConcerns about recruitment difficulties in general practice are justified. Women are now entering general practice in greater numbers than men. There is no evidence of a greater exodus from the NHS from the 1988 qualifiers than from earlier cohorts.

Key messages

• This study reports the career progress to September 1995 of doctors who qualified in 1988
• Loss from the British NHS, at 16.9% (95% confidence interval, 16.1% to 17.8%), was no greater than among earlier qualifiers at the same time after qualification
• The proportion of doctors working in general practice (38%) was lower than in earlier cohorts studied
• In this generation of doctors, women in general practice now outnumber men
• Fifty three per cent of the women in general practice and 20% of the women in hospital specialties were working on a part time or flexible basis

     

Vertical transmission rates for HIV in the British Isles: estimates based on surveillance data

ObjectiveTo estimate and interpret time trends in vertical transmission rates for HIV using data from national obstetric and paediatric surveillance registers.DesignProspective study of HIV infected women reported through obstetric surveillance. HIV infection status of the child and onset of AIDS were reported through paediatric surveillance. Rates of vertical transmission and progression to AIDS rate were estimated by methods that take account of incomplete follow up of children with indeterminate infection status and delay in AIDS reporting.SettingBritish Isles.SubjectsPregnant women infected with HIV whose infection was diagnosed before delivery, and their babies.ResultsBy January 1999, 800 children born to diagnosed HIV infected women who had not breast fed had been reported. Vertical transmission rates rose to 19.6% (95% confidence interval 8.0% to 32.5%) in 1993 before falling to 2.2% (0% to 7.8%) in 1998. Between 1995 and 1998 use of antiretroviral treatment increased significantly each year, reaching 97% of live births in 1998. The rate of elective caesarean section remained constant, at around 40%, up to 1997 but increased to 62% in 1998. Caesarean section and antiretroviral treatment together were estimated to reduce risk of transmission from 31.6% (13.6% to 52.2%) to 4.2% (0.8% to 8.5%). The proportion of infected children developing AIDS in the first 6 months fell from 17.7% (6.8% to 30.8%) before 1994 to 7.2% (0% to 15.7%) after, coinciding with increased use of prophylaxis against Pneumocystis carinii pneumonia.ConclusionsIn the British Isles both HIV related morbidity and vertical transmission are being reduced through increased use of interventions.

Key messages

• Reliable estimates of HIV vertical transmission rates can be derived from surveillance data
• Infected pregnant women are increasingly taking up elective caesarean section and antiretroviral treatment to reduce the risk of transmitting HIV to their babies
• Vertical transmission rates have fallen greatly over the past four years and progression to AIDS among infected children may also have slowed
• These benefits can occur only if infected women are diagnosed before or during pregnancy

     

Family Planning Knowledge,Attitude and Practice among Married Couples in Jimma Zone,Ethiopia

Background

Understanding why people do not use family planning is critical to address unmet needs and to increase contraceptive use. According to the Ethiopian Demographic and Health Survey 2011, most women and men had knowledge on some family planning methods but only about 29% of married women were using contraceptives. 20% women had an unmet need for family planning. We examined knowledge, attitudes and contraceptive practice as well as factors related to contraceptive use in Jimma zone, Ethiopia.

Methods

Data were collected from March to May 2010 among 854 married couples using a multi-stage sampling design. Quantitative data based on semi-structured questionnaires was triangulated with qualitative data collected during focus group discussions. We compared proportions and performed logistic regression analysis.

Result

The concept of family planning was well known in the studied population. Sex-stratified analysis showed pills and injectables were commonly known by both sexes, while long-term contraceptive methods were better known by women, and traditional methods as well as emergency contraception by men. Formal education was the most important factor associated with better knowledge about contraceptive methods (aOR = 2.07, p<0.001), in particular among women (aOR_women = 2.77 vs. aOR_men = 1.49; p<0.001). In general only 4 out of 811 men ever used contraception, while 64% and 43% females ever used and were currently using contraception respectively.

Conclusion

The high knowledge on contraceptives did not match with the high contraceptive practice in the study area. The study demonstrates that mere physical access (proximity to clinics for family planning) and awareness of contraceptives are not sufficient to ensure that contraceptive needs are met. Thus, projects aiming at increasing contraceptive use should contemplate and establish better counseling about contraceptive side effects and method switch. Furthermore in all family planning activities both wives'' and husbands'' participation should be considered.     

Use of Contraception and Attitudes towards Contraceptive Use in Swedish Women - A Nationwide Survey

ObjectiveTo describe contraceptive use and attitudes towards contraceptive use in Sweden which has the highest abortion rate in Western Europe. Secondary objectives were to investigate knowledge of contraceptive methods and outcomes of unplanned and unwanted pregnancies.DesignTelephone survey.SettingNational survey of women living in Sweden.PopulationWomen between 16 and 49 years.MethodsThe survey contained 22 questions with free text and multi choice answers on demographics, contraceptive use, knowledge of and attitudes towards contraception, the importance of monthly bleeding and experience of unintended pregnancy.ResultsA total of 1001 women participated in the survey. Of all women, 721/1001 (72.1%) currently used contraception whereas 268/1001 (26.8%) women did not. Long acting reversible contraception, (LARC; implant and intra uterine contraception) was used by 24.3% of women. The unmet need of contraception in Sweden was estimated at 8.9% (89/1001 women). A total of 781 (78%) women had never experienced an unintended pregnancy whereas 220 (22%) women had had at least one unintended pregnancy. Users and non-users alike stated that one of the most important characteristics of a contraceptive method is its effectiveness.ConclusionsSweden has a large unmet need for contraception. Furthermore, a large proportion of women have experienced at least one unintended pregnancy. Increasing contraceptive use and promotion of LARC is a possible way forward in the effort to reduce the rates of unwanted pregnancies.     

Prevalence of anxiety and depressive illness and help seeking behaviour in African Caribbeans and white Europeans: two phase general population survey

ObjectiveTo determine the prevalence of common mental disorders (anxiety and depression) and help seeking behaviour in African Caribbeans and white Europeans.DesignTwo phase survey in a general population sample. The first phase comprised screening with the 12 item general health questionnaire; the second phase was standardised psychiatric assessment and interview about help seeking.SettingPeople registered with four general practices in central Manchester.ParticipantsOf 1467 people randomly selected from family health services authority lists, 864 were still resident. 337 African Caribbeans and 275 white Europeans completed the screening phase (response rate 71%); 127 African Caribbeans and 103 white Europeans were interviewed in the second phase.Results13% of African Caribbeans (95% confidence interval 10% to 16%) and 14% (10% to 18%) of white Europeans had one or more disorder. Anxiety disorders were significantly less common among African Caribbeans (3% (1% to 5%) v 9% (6% to 12%) in white Europeans). Depressive disorders were significantly more common among African Caribbean women than white women (difference 8% (1% to 15%)). Medical help seeking was similar in the two groups, but African Caribbeans with mental disorders were more likely to seek additional help from non-medical sources (12/29 v 5/29, P=0.082).ConclusionsIn an inner city setting the prevalence of common mental disorders is similar in these two ethnic groups.

Key messages

• Most studies of ethnic differences in mental health focus on psychotic illness rather than common mental disorders
• In this inner city study the prevalence of anxiety and depression was similar in African Caribbeans and white Europeans
• Anxiety disorders were less common, and depression more common, in African Caribbeans than white Europeans
• Improved recognition and treatment of non-psychotic disorders are necessary, taking into account patients’ views of their illnesses

     

Contraceptive use dynamics of Asian women in Britain

In-depth interviews were conducted with married Asian women from Indian, Pakistani and Bangladeshi backgrounds, to investigate patterns of contraceptive use and influences on contraceptive decision making. The results show two distinctively different contraceptive 'lifecycles'. Non-professional women typically have little knowledge about contraception until after their marriage or first birth. Their patterns of contraceptive behaviour show low levels of contraceptive use until after their first birth, when condom use is most prevalent. Non-professional women are influenced by their extended family, religion and cultural expectations on their fertility and family planning decisions. Professional women show an entirely different pattern of contraceptive behaviour. They are more likely to have knowledge about contraception before marriage, use some method of contraception throughout their childbearing years (typically the pill) and cite personal, practical or economic considerations in their fertility decisions rather than religious, cultural or extended family influences.     

Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial

ObjectiveTo compare perinatal outcome and glycaemic control in two groups of pregnant diabetic patients receiving two insulin regimens.DesignRandomised controlled open label study.SettingUniversity affiliated hospital, Israel.Participants138 patients with gestational diabetes mellitus and 58 patients with pregestational diabetes mellitus received insulin four times daily, and 136 patients with gestational diabetes and 60 patients with pregestational diabetes received insulin twice daily.InterventionThree doses of regular insulin before meals and an intermediate insulin dose before bedtime (four times daily regimen), and a combination of regular and intermediate insulin in the morning and evening (twice daily regimen).ResultsMean daily insulin concentration before birth was higher in the women receiving insulin four times daily compared with twice daily: by 22 units (95% confidence interval 12 to 32) in patients with gestational diabetes and by 28 units (15 to 41) in patients with pregestational diabetes. Glycaemic control was better with the four times daily regimen than with the twice daily regimen: in patients with gestational diabetes mean blood glucose concentrations decreased by 0.19 mmol/l (0.13 to 0.25), HbA_1c by 0.3% (0.2% to 0.4%), and fructosamine by 41 μmol/l (37 to 45), and adequate glycaemic control (mean blood glucose concentration <5.8 mmol/l) was achieved in 17% (8% to 26%) more women; in patients with pregestational diabetes mean blood glucose concentration decreased by 0.44 mmol/l (0.28 to 0.60), HbA_1c by 0.5% (0.2% to 0.8%), and fructosamine by 51 μmol/l (45 to 57), and adequate glycaemic control was achieved in 31% (15% to 47%) more women. Maternal severe hypoglycaemic events, caesarean section, preterm birth, macrosomia, and low Apgar scores were similar in both dose groups. In women with gestational diabetes the four times daily regimen resulted in a lower rate of overall neonatal morbidity than the twice daily regimen (relative risk 0.59, 0.38 to 0.92), and the relative risk for hyperbilirubinaemia and hypoglycaemia was lower (0.51, 0.29 to 0.91 and 0.12, 0.02 to 0.97 respectively). The relative risk of hypoglycaemia in newborn infants to mothers with pregestational diabetes was 0.17 (0.04 to 0.74).ConclusionsGiving insulin four times rather than twice daily in pregnancy improved glycaemic control and perinatal outcome without further risking the mother.

Key messages

• Improving maternal glycaemic control during pregnancy is the key to better perinatal outcome
• In pregnant diabetic women insulin four times daily achieved better glycaemic control and lower rate of perinatal complications (hypoglycaemia, hyperbilirubinaemia) than insulin twice daily
• Better glycaemic control resulted from a larger total daily insulin dose
• The intensified regimen did not lead to higher rate of severe maternal hypoglycaemia

     

Migraine and stroke in young women: case-control study

ObjectiveTo investigate the association between migraine and ischaemic or haemorrhagic stroke in young women.DesignHospital based case-control study.SettingFive European centres participating in the World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.Subjects291 women aged 20-44 years with ischaemic, haemorrhagic, or unclassified arterial stroke compared with 736 age and hospital matched controls.InterventionQuestionnaire.ResultsAdjusted odds ratios associated with a personal history of migraine were 1.78 (95% confidence intervals, 1.14 to 2.77), 3.54 (1.30 to 9.61), and 1.10 (0.63 to 1.94) for all stroke, ischaemic stroke, and haemorrhagic stroke respectively. Odds ratios for ischaemic stroke were similar for classical migraine (with aura) (3.81, 1.26 to 11.5) and simple migraine (without aura) (2.97, 0.66 to 13.5). A family history of migraine, irrespective of personal history, was also associated with increased odds ratios, not only for ischaemic stroke but also haemorrhagic stroke. In migrainous women, coexistent use of oral contraceptives or a history of high blood pressure or smoking had greater than multiplicative effects on the odds ratios for ischaemic stroke associated with migraine alone. Change in the frequency or type of migraine on using oral contraceptives did not predict subsequent stroke. Between 20% and 40% of strokes in women with migraine seemed to develop directly from a migraine attack.ConclusionsMigraine in women of childbearing age significantly increases the risk of ischaemic but not haemorrhagic stroke. The coexistence of oral contraceptive use, high blood pressure, or smoking seems to exert a greater than multiplicative effect on the risk of ischaemic stroke associated with migraine.

Key messages

• A personal history of migraine was associated with increased risk of ischaemic but not haemorrhagic stroke
• Coexistence of risk factors—use of oral contraceptives, high blood pressure, or smoking had more than multiplicative effects on odds ratios for ischaemic stroke associated with migraine alone
• A family history of migraine, irrespective of a personal migraine history, was associated with increased risk of ischaemic and haemorrhagic stroke
• Up to 40% of strokes in migrainous women develop directly out of a migraine attack—so called migrainous strokes
• A change in type or frequency of migraine with use of oral contraceptives did not predict subsequent stroke

     

Contraceptive use and method preference among women in Soweto, South Africa: the influence of expanding access to HIV care and treatment services

Objective

Preventing unintended pregnancy among HIV-positive women constitutes a critical and cost-effective approach to primary prevention of mother-to-child transmission of HIV and is a global public health priority for addressing the desperate state of maternal and child health in HIV hyper-endemic settings. We sought to investigate whether the prevalence of contraceptive use and method preferences varied by HIV status and receipt of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa.

Methods

We used survey data from 563 sexually active, non-pregnant women (18–44 years) recruited from the Perinatal HIV Research Unit in Soweto (May–December, 2007); 171 women were HIV-positive and receiving HAART (median duration of use = 31 months; IQR = 28, 33), 178 were HIV-positive and HAART-naïve, and 214 were HIV-negative. Medical record review was conducted to confirm HIV status and clinical variables. Logistic regression models estimated adjusted associations between HIV status, receipt of HAART, and contraceptive use.

Results

Overall, 78% of women reported using contraception, with significant variation by HIV status: 86% of HAART users, 82% of HAART-naïve women, and 69% of HIV-negative women (p<0.0001). In adjusted models, compared with HIV-negative women, women receiving HAART were significantly more likely to use contraception while HAART-naïve women were non-significantly more likely (AOR: 2.40; 95% CI: 1.25, 4.62 and AOR: 1.59; 95% CI: 0.88, 2.85; respectively). Among HIV-positive women, HAART users were non-significantly more likely to use contraception compared with HAART-naïve women (AOR: 1.55; 95% CI: 0.84, 2.88). Similar patterns held for specific use of barrier (primarily male condoms), permanent, and dual protection contraceptive methods.

Conclusion

Among HIV-positive women receiving HAART, the observed higher prevalence of contraceptive use overall and condoms in particular promises to yield fewer unintended pregnancies and reduced risks of vertical and sexual HIV transmission. These findings highlight the potential of integrated HIV and reproductive health services to positively impact maternal, partner, and child health.     

Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users who are carriers of hereditary prothrombotic conditions

Objective: To investigate whether users of oral contraceptives who are carriers of a hereditary prothrombotic condition (factor V Leiden mutation, protein C, S, or antithrombin deficiency) have an increased risk of cerebral sinus thrombosis. Design: Comparison of a prospective series of cases of cerebral sinus thrombosis with population data. Setting: Neurological teaching hospitals from different regions in the Netherlands (cases) and a representative sample of the non-institutionalised Dutch population (controls). Subjects: 40 women aged 18-54 years with cerebral sinus thrombosis (cases) and 2248 women aged 18-49 years (controls). Main outcome measure: Current use of oral contraceptives at the time of the thrombosis (cases) or at the time of the questionnaire (controls). Prevalences of a hereditary prothrombotic condition in patients and in the population with odds ratios. Results: 34 of 40 (85%) women with cerebral sinus thrombosis used oral contraceptives, versus 1007 of 2248 (45%) of the control women; the age adjusted odds ratio was 13 (95% confidence interval 5 to 37). Seven of 36 patients (19%) had a prothrombotic deficiency, versus 7% expected in the population; this corresponds to a threefold to fourfold increase in risk. In women who used oral contraceptives and also carried a prothrombotic defect, the odds ratio for cerebral sinus thrombosis was about 30 relative to women who had neither risk factor. Conclusion: The use of oral contraceptives and being a carrier of a hereditary prothrombotic condition increase the risk of and interact in a multiplicative way in the development of cerebral sinus thrombosis.

Key messages

• The use of oral contraceptives is associated with an increased risk of cerebral venous sinus thrombosis
• This risk of cerebral venous sinus thrombosis in women who use oral contraceptives is larger if there is an additional hereditary prothombotic factor (protein C, S, or antithrombin deficiency, factor V Leiden mutation)
• The association between oral contraceptives, thrombophilia, and deep vein thrombosis is also valid for cerebral sinus thrombosis
• Women do not need to stop using oral contraceptives as the absolute risk of cerebral sinus thrombosis is very small

     

Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey

ObjectiveTo determine the career destinations, by 1995, of doctors who qualified in the United Kingdom in 1977; the relation between their destinations and early career choice; and their intentions regarding retirement age.DesignPostal questionnaire.SettingUnited Kingdom.SubjectsAll (n=3135) medical qualifiers of 1977.ResultsAfter about 12 years the distribution of respondents by type of employment, and, for women, the percentage of doctors in part time rather than full time medical work, had stabilised. Of all 2997 qualifiers from medical schools in Great Britain, 2399 (80.0% (95% confidence interval 79.5% to 80.6%)) were working in medicine in the NHS in Great Britain 18 years after qualifying. Almost half the women (318/656) worked in the NHS part time. Of 1714 doctors in the NHS, 1125 intended to work in the NHS until normal retirement age, 392 did not, and 197 were undecided. Of the 1548 doctors for whom we had sufficient information, career destinations at 18 years matched the choices made at 1, 3, and 5 years in 58.9% (912), 78.2% (1211), and 86.6% (1341) of cases respectively.ConclusionsPlanning for the medical workforce needs to be supported by information about doctors’ career plans, destinations, and whole time equivalent years of work. Postgraduate training needs to take account of doctors’ eventual choice of specialty (and the timing of this choice).

Key messages

• A large scale national study in the United Kingdom followed doctors from qualification to mid-career and beyond
• Most doctors had made their choice of eventual career—at least in terms of broadly defined specialty—within 5 years of qualifying
• Eighteen years on, 80% of the doctors were working in the NHS and nearly half of women doctors were working part time
• Almost a quarter of NHS doctors planned to retire early

     

Outcome of low back pain in general practice: a prospective study

Objectives: To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month. Design: Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation. Setting: Two general practices in south Manchester. Subjects: 490 subjects (203 men, 287 women) aged 18-75 years. Main outcome measures: Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months. Results: Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability. Conclusions: The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.

Key messages

• It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month
• In a large population based study we examined the outcome of episodes of low back pain in general practice with respect to both consultation behaviour and self reported pain and disability
• While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability
• Only 25% of the patients who consulted about low back pain had fully recovered 12 months later
• Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact

     

Violations of the international code of marketing of breast milk substitutes: prevalence in four countries

Objective: To estimate the prevalence of violations of the international code of marketing of substitutes for breast milk in one city in each of Bangladesh, Poland, South Africa, and Thailand. Design: Multistage random sampling was used to select pregnant women and mothers of infants ⩽6 months old to interview at health facilities. Women were asked whether they had received free samples of substitutes for breast milk (including infant formula designed to meet the nutritional needs of infants from birth to 4 to 6 months of age, follow on formula designed to replace infant formula at the age of 4 to 6 months, and complementary foods for infants aged ⩽6 months), bottles, or teats. The source of the free sample and when it had been given to the women was also determined. 3 health workers were interviewed at each facility to assess whether the facility had received free samples, to determine how they had been used, and to determine whether gifts had been given to health workers by companies that manufactured or distributed breast milk substitutes. Compliance with the marketing code for information given to health workers was evaluated using a checklist. Setting: Health facilities in Dhaka, Bangladesh; Warsaw, Poland; Durban, South Africa; and Bangkok, Thailand. Subjects: 1468 pregnant women, 1582 mothers of infants aged ⩽6 months, and 466 health workers at 165 health facilities. Main outcome measures: Number of free samples received by pregnant women, mothers, and health workers; number of gifts given to health workers; and availability of information that violated the code in health facilities. Results: 97 out of 370 (26%) mothers in Bangkok reported receiving free samples of breast milk substitutes, infant formula, bottles, or teats compared with only 1 out of 385 mothers in Dhaka. Across the four cities from 3 out of 40 (8%) to 20 out of 40 (50%) health facilities had received free samples which were not being used for research or professional evaluation; from 2 out of 123 (2%) to 21 out of 119 (18%) health workers had received gifts from companies involved in the manufacturing or distribution of breast milk substitutes. From 6 out of 40 (15%) to 22 out of 39 (56%) health facilities information that violated the code had been provided by companies and was available to staff. Conclusion: Violations of the code were detected with a simple survey instrument in all of the four countries studied. Governmental and non-governmental agencies should monitor the prevalence of code violations using the simple methodology developed for this study.

Key messages

• A simple multistage random sampling procedure can be used to interview women and health professionals to assess whether violations of the international code of marketing of substitutes for breast milk are occurring
• 3050 women and 466 health professionals were interviewed at 165 health facilities in Bangladesh, Poland, South Africa, and Thailand
• 97 out of 370 mothers in Bangkok reported receiving free samples of breast milk substitutes, infant formula, bottles, or teats compared with only 1 out of 385 mothers in Dhaka. In Bangkok health workers reported that 20 out of 40 health facilities had also received free samples. Most free samples were distributed by health facilities
• In Warsaw 56% of facilities surveyed were found to have information available for health workers that had been provided by manufacturers or distributors of breast milk substitutes in contravention of the code; 18% of health workers in Warsaw had received free gifts from manufacturers

     

Emerging tobacco hazards in China: 1. Retrospective proportional mortality study of one million deaths

ObjectiveTo assess the hazards at an early phase of the growing epidemic of deaths from tobacco in China.DesignSmoking habits before 1980 (obtained from family or other informants) of 0.7 million adults who had died of neoplastic, respiratory, or vascular causes were compared with those of a reference group of 0.2 million who had died of other causes.Setting24 urban and 74 rural areas of China.SubjectsOne million people who had died during 1986-8 and whose families could be interviewed.ResultsAmong male smokers aged 35-69 there was a 51% (SE 2) excess of neoplastic deaths, a 31% (2) excess of respiratory deaths, and a 15% (2) excess of vascular deaths. All three excesses were significant (P<0.0001). Among male smokers aged ⩾70 there was a 39% (3) excess of neoplastic deaths, a 54% (2) excess of respiratory deaths, and a 6% (2) excess of vascular deaths. Fewer women smoked, but those who did had tobacco attributable risks of lung cancer and respiratory disease about the same as men. For both sexes, the lung cancer rates at ages 35-69 were about three times as great in smokers as in non-smokers, but because the rates among non-smokers in different parts of China varied widely the absolute excesses of lung cancer in smokers also varied. Of all deaths attributed to tobacco, 45% were due to chronic obstructive pulmonary disease and 15% to lung cancer; oesophageal cancer, stomach cancer, liver cancer, tuberculosis, stroke, and ischaemic heart disease each caused 5-8%. Tobacco caused about 0.6 million Chinese deaths in 1990 (0.5 million men). This will rise to 0.8 million in 2000 (0.4 million at ages 35-69) or to more if the tobacco attributed fractions increase.ConclusionsAt current age specific death rates in smokers and non-smokers one in four smokers would be killed by tobacco, but as the epidemic grows this proportion will roughly double. If current smoking uptake rates persist in China (where about two thirds of men but few women become smokers) tobacco will kill about 100 million of the 0.3 billion males now aged 0-29, with half these deaths in middle age and half in old age.

Key messages

• Of the Chinese deaths now being caused by tobacco, 45% are from chronic lung disease, 15% from lung cancer, and 5-8% from each of oesophageal cancer, stomach cancer, liver cancer, stroke, ischaemic heart disease, and tuberculosis
• Tobacco now causes 13% (and will probably eventually cause about 33%) of deaths in men but only 3% (and perhaps eventually about 1%) of deaths in women as the proportion of young women who smoke has become small
• Two thirds of men now become smokers before age 25; few give up, and about half of those who persist will be killed by tobacco in middle or old age
• If present smoking patterns continue about 100 million of the 0.3 billion Chinese males now aged 0-29 will eventually be killed by tobacco
• Tobacco caused 0.6 million deaths in 1990 and will cause at least 0.8 million in 2000 (0.7 million in men) and about 3 million a year by the middle of the century on the basis of current smoking patterns

     

Confidential inquiry into quality of care before admission to intensive care

Objective: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions. Design: Prospective confidential inquiry on the basis of structured interviews and questionnaires. Setting: A large district general hospital and a teaching hospital. Subjects: A cohort of 100 consecutive adult emergency admissions, 50 in each centre. Main outcome measures: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring. Results: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. Conclusions: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.

Key messages

• Suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring before admission to intensive care occurred in over half of a consecutive cohort of acute adult emergency patients. This may be associated with increased morbidity, mortality, and avoidable admissions to intensive care
• At least 39% of acute adult emergency patients were admitted to intensive care late in the clinical course of the illness
• Major causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice
• A medical emergency team may be useful in responding pre-emptively to the clinical signs of life threatening dysfunction of airway, breathing, and circulation, rather than relying on a cardiac arrest team
• The structure and process of acute care and their importance require major re-evaluation and debate

     

A controlled trial of the knowledge impact of tuberculosis information leaflets among staff supporting substance misusers: pilot study

Background

Information leaflets are widely used to increase awareness and knowledge of disease. Limited research has, to date, been undertaken to evaluate the efficacy of these information resources. This pilot study sought to determine whether information leaflets developed specifically for staff working with substance mis-users improved knowledge of tuberculosis (TB).

Method

Staffs working with individuals affected by substance mis-use were recruited between January and May 2008. All participants were subjectively allocated by their line manager either to receive the TB-specific leaflet or a control leaflet providing information on mental health. Level of knowledge of TB was assessed using questionnaires before and after the intervention and data analysed using McNemar''s exact test for matched pairs.

Results

The control group showed no evidence of a change in knowledge of TB, whereas the TB questionnaire group demonstrated a significant increase in knowledge including TB being curable (81% correct before to 100% correct after), length of treatment required (42% before to 73% after), need to support direct observation (18% to 62%) and persistent fever being a symptom (56% to 87%). Among key workers, who have a central role in implementing a care plan, 88% reported never receiving any TB awareness-raising intervention prior to this study, despite 11% of all respondents having TB diagnosed among their clients.

Conclusion

Further randomized controlled trials are required to confirm the observed increase in short-term gain in knowledge and to investigate whether knowledge gain leads to change in health status.     

High incidence of unplanned pregnancy after antiretroviral therapy initiation: findings from a prospective cohort study in South Africa

Background

Increased fertility rates in HIV-infected women receiving antiretroviral therapy (ART) have been attributed to improved immunological function; it is unknown to what extent the rise in pregnancy rates is due to unintended pregnancies.

Methods

Non-pregnant women ages 18–35 from four public-sector ART clinics in Johannesburg, South Africa, were enrolled into a prospective cohort and followed from August 2009–March 2011. Fertility intentions, contraception and pregnancy status were measured longitudinally at participants'' routine ART clinic visits.

Findings

Of the 850 women enrolled, 822 (97%) had at least one follow-up visit and contributed 745.2 person-years (PY) at-risk for incident pregnancy. Overall, 170 pregnancies were detected in 161 women (incidence rate [IR]: 21.6/100 PY [95% confidence interval (CI): 18.5–25.2]). Of the 170 pregnancies, 105 (62%) were unplanned. Unmet need for contraception was 50% higher in women initiating ART in the past year as compared to women on ART>1 year (prevalence ratio 1.5 [95% CI: 1.1–2.0]); by two years post-ART initiation, nearly one quarter of women had at least one unplanned pregnancy. Cumulative incidence of pregnancy was equally high among recent ART initiators and ART experienced participants: 23.9% [95% CI: 16.4–34.1], 15.9% [12.0–20.8], and 21.0% [16.8–26.1] for women on ART 0–1 yr, >1 yr–2 yrs, and >2 yrs respectively (log-rank, p = 0.54). Eight hormonal contraceptive failures were detected [IR: 4.4 [95% CI: 2.2–8.9], 7/8 among women using injectable methods. Overall 47% (80/170) of pregnancies were not carried to term.

Conclusions

Rates of unintended pregnancies among women on ART are high, including women recently initiating ART with lower CD4 counts and higher viral loads. A substantial burden of pregnancy loss was observed. Integration of contraceptive services and counselling into ART care is necessary to reduce maternal and child health risks related to mistimed and unwanted pregnancies. Further research into injectable contraceptive failures on ART is warranted.