Do Supervised Injecting Facilities Attract Higher-Risk Injection Drug Users?

BACKGROUND: In Western Europe and elsewhere, medically supervised safer injection facilities (SIFs) are increasingly being implemented for the prevention of health- and community-related harms among injection drug users (IDUs), although few evaluations have been conducted, and there have been questions regarding SIFs' ability to attract high-risk IDUs. We examined whether North America's first SIF was attracting IDUs who were at greatest risk of overdose and blood-borne disease infection. METHODS: We examined data from a community-recruited cohort study of IDUs. The prevalence of SIF use was determined based on questionnaire data obtained after the SIF's opening, and we determined predictors of initiating future SIF use based on behavioral information obtained from questionnaire data obtained before the SIF's opening. Pearson's chi-square test was used to compare characteristics of IDUs who did and did not subsequently initiate SIF use. RESULTS: Overall, 400 active injection drug users returned for follow-up between December 1, 2003 and May 1, 2004, among whom 178 (45%) reported ever using the SIF. When we examined behavioral data collected before the SIF's opening, those who initiated SIF use were more likely to be aged <30 years (odds ratio [OR]=1.6, 95% confidence interval [CI]=1.0-2.7], p=0.04); public injection drug users (OR=2.6, 95% CI=1.7-3.9, p<0.001); homeless or residing in unstable housing (OR=1.7, 95% CI=1.2-2.7, p=0.008); daily heroin users (OR=2.1, 95% CI=1.3-3.2, p=0.001); daily cocaine users (OR=1.6, 95% CI=1.1-2.5, p=0.025); and those who had recently had a nonfatal overdose (OR=2.7, 95% CI=1.2-6.1, p=0.016). CONCLUSIONS: This study indicated that the SIF attracted IDUs who have been shown to be at elevated risk of blood-borne disease infection and overdose, and IDUs who were contributing to the public drug use problem and unsafe syringe disposal problems stemming from public injection drug use.     

Risk factors for sporadic giardiasis: a case-control study in southwestern England

To investigate risk factors for sporadic infection with Giardia lamblia acquired in the United Kingdom, we conducted a matched case-control study in southwest England in 1998 and 1999. Response rates to a postal questionnaire were 84% (232/276) for cases and 69% (574/828) for controls. In multivariable analysis, swallowing water while swimming (p<0.0001, odds ratio [OR] 6.2, 95% confidence intervals [CI] 2.3 to 16.6), recreational fresh water contact (p=0.001, OR 5.5, 95% CI 1.9 to 15.9), drinking treated tap water (p<0.0001, OR 1.3, 95% CI 1.1 to 1.5 for each additional glass per day), and eating lettuce (p?=0.01, OR 2.2, 95% CI 1.2 to 4.3) had positive and independent associations with infection. Although case-control studies are prone to bias and the risk of Giardia infection is minimized by water treatment processes, the possibility that treated tap water is a source of sporadic giardiasis warrants further investigation.     

Differences in individual-level terrorism preparedness in Los Angeles County

BACKGROUND: Increasing individual preparedness for disasters, including large-scale terrorist attacks, is a significant concern of public health planners. As with natural disasters, individuals can help protect their health and safety by preparing for the emergency situation that may follow a terrorist event. Our study describes variations in preparedness among the population of Los Angeles County after the September 11, 2001 and subsequent anthrax attacks. METHODS: In 2004, the data were analyzed from the Los Angeles County Health Survey, a random-digit-dialed telephone survey of the non-institutionalized population in Los Angeles County fielded October 2002 through February 2003. RESULTS: Overall, 28.0% of respondents had emergency supplies, and 17.1% developed an emergency plan in the past year in response to the possibility of terrorism. Factors associated with having emergency supplies included African American (adjusted odds ratio [AOR] 1.8, 95% confidence interval [CI]=1.1-3.1) and Latino (AOR=1.5, 95% CI=1.0-2.4) race/ethnicity; having a household dependent aged相似文献   

Occupational history and exposure and the risk of adult leukemia in Shanghai

PURPOSE: Evaluation of the association of selected occupational exposures with leukemia risk. METHODS: Population-based case-control study of 486 leukemia subjects and 502 healthy controls residing in Shanghai from 1987 to 1989. Adjusted odds ratios (OR) were calculated for the association between occupational factors and leukemia risk. RESULTS: Significant increase in leukemia risk was observed in chemical manufacturing industry workers (OR=3.1, 95% CI=1.0-9.8). Increased risks for leukemia were observed from self-reported exposures to benzene (OR=1.7, 95% CI=1.1-2.6), radioactive materials (OR=3.7, 95% CI=1.3-10.2), synthetic fiber dust (OR=2.0, 95% CI=1.2-3.5), and toluene (OR=1.6, 95% CI=1.0-2.5). Dose-response relations of leukemia risk was observed with the duration of exposure to benzene (OR=3.3, 95% CI=1.6-6.9 for >or=15 years exposure; p for trend<0.01), radioactive materials (OR=5.2, 95% CI=1.1-24.7 for >or=15 years exposure; p for trend=0.02), paints (OR=2.3, 95% CI=1.2-4.7 for >or=15 years exposure; p for trend=0.09), and toluene (OR=2.9, 95% CI=1.3-6.7 for >or=15 years exposure; p for trend=0.02). CONCLUSIONS: Adult leukemia risk may be associated with working in the chemical industry, and exposure to benzene, synthetic fiber dust, radioactive materials, and toluene in the study population.     

Prevalence and factors associated with self-medication: the Bambuí health survey

OBJECTIVE: A population-based study was carried out in the municipality of Bambuí, Brazil (population: approx. 15,000 inhabitants), to determine the prevalence of self-medication and its associated factors. METHODS: A random sample of 1,221 residents aged >18 years was selected. Of these, 796 reported use of medications in the last 90 days and were selected for this study (775 participated). Data was collected through home interviews. Study variables were divided in 3 groups: social and economic, health status and health service use indicators. Statistical analysis was performed using Pearson's Qui-square test, and odds ratios adjusted by multinomial logistic regression. RESULTS: Of the total, 419 (54.0%) reported use of only prescribed medications, 133 (17.2%) took prescribed and over-the-counter medications, and 223 (28.8%) took only over-the-counter medications in the last 90 days. After adjusting for confounders, the following variables presented significant associations with exclusive use of self-medication: female sex (OR=0.6; IC95%=0.4 - 0.9); age (OR=0.4; IC95%=0.3 - 0.6 for 40-59 years old and OR=0.2; IC95%=0.1 - 0.5 for >60 years); >5 residents in the household (OR=2.1; 1.1 - 4.0); number of visits to a doctor in the previous 12 months (OR=0.2; IC95%=0.1 - 0.4 and OR=0.1; IC95%=0.0-0.1 for 1 visit and >2 visits, respectively); report of consulting a pharmacist in the previous 12 months (OR=1.9; IC95%=1.1 - 3.3); and reports of financial expenses with medications during this period (OR=0.5; IC95%=0.3 - 0.8). CONCLUSIONS: The study results show that the prevalence of self-medication in the studied community was similar to that observed in developed countries. These results also suggest that self-medication works in place of the formal health attention in this community.     

Association of hepatitis B virus infection with other sexually transmitted infections in homosexual men. Omega Study Group

OBJECTIVES: This study determined the prevalence and factors associated with hepatitis B virus (HBV) infection among men who have sex with men. METHODS: At the baseline visit of an HIV study among men who have sex with men, we asked about HBV vaccination status and tested for HBV markers. RESULTS: Of 625 subjects, 48% had received at least 1 dose of HBV vaccine. Of 328 unvaccinated men, 41% had 1 or more HBV markers. HBV prevalence increased markedly with age and was associated with many sexual and drug-related behaviors. In a multivariate model, 7 variables were independently associated with HBV infection: ulcerative sexually transmitted diseases (odds ratio [OR] = 10.1; 95% confidence interval [CI] = 2.6, 54); injection drug use (OR = 5.2; 95% CI = 1.2, 26); gonorrhea or chlamydia (OR = 4.0; 95% CI = 1.9, 8.9); sexual partner with HIV/AIDS (OR = 3.6; 95% CI = 1.8, 7.1); 50 or more casual partners (OR = 3.4; 95% CI = 1.6, 7.1); received money for sex (OR = 3.0; 95% CI = 1.2, 7.8); and 20 or more regular partners (OR = 2.5; 95% CI = 1.1, 6.1). CONCLUSIONS: In Montreal, men who have sex with men are at risk for HBV infection, but a substantial proportion remain unvaccinated; new strategies are required to improve coverage. Men who have sex with men and who have a sexually transmitted infection, especially a genito-ulcerative infection, appear to be at particularly high risk for HBV infection.     

Maternal, delivery, and perinatal characteristics associated with cryptorchidism: a population-based case-control study among births in Washington State

BACKGROUND: The etiology of cryptorchidism is largely unknown. To identify maternal, perinatal, and delivery characteristics associated with cryptorchidism at birth, we conducted a population-based case-control study using Washington State birth certificates linked to birth hospitalization records. METHODS: We identified 2,395 cases of cryptorchidism among male infants born in Washington State during 1986-1996, and, for comparison, we randomly selected four controls per case (N = 9,580), frequency-matched by year of birth. RESULTS: Infant characteristics associated with cryptorchidism included low birth weight (OR = 1.5; 95% CI = 1.3-1.8), small size for gestational age (OR = 1.9; 95% CI = 1.6-2.2), and breech presentation (OR = 1.7; 95% CI = 1.4-2.1). In addition to cryptorchidism, cases were more likely to have another type of congenital malformation (OR = 3.7; 95% CI = 3.2-4.2), particularly digestive (OR = 6.8; 95% CI = 3.7-12.7) or genitourinary (OR = 4.1; 95% CI = 3.0-5.6). Maternal and pregnancy characteristics associated with cryptorchidism included nulliparity (OR = 1.2; 95% CI = 1.1-1.3), maternal smoking during pregnancy (OR = 1.2; 95% CI = 1.1-1.4), and the following pregnancy complications: oligohydramnios (OR = 1.8; 95% CI = 1.3-2.6), placental abnormality (OR = 1.3; 95% CI = 1.0-1.8), and pregnancy-induced hypertension (OR = 1.6; 95% CI = 1.4-1.9). Odds ratios were similar when the analysis was restricted to term infants. CONCLUSIONS: These findings suggest that factors affecting fetal growth and development may increase the risk of cryptorchidism.     

Salmonellosis in North Thames (East), UK: associated risk factors.

We assessed the rate of salmonella infections and risk factors associated with infection in North East Thames in 1993. Cases of culture confirmed infection were identified through microbiology laboratories and environmental health officers in the North East Thames. A total of 1730 cases were reported and 209 of these individuals (those who could be contacted within a 3-week interval after onset of symptoms) and matched controls were interviewed by telephone. In addition randomly selected controls were interviewed over a 4-month period about recent gastric acid lowering medication and antimicrobial ingestion. Sixty-six serotypes were identified: S. enteritidis was isolated from 1179 (69%) cases, S. typhimurium from 221 (13%), S. virchow from 77 (4%) and S. newport 25 (1%). Infections were more frequent in summer months. Highest rates were documented in children under 2 years of age for S. enteritidis (108/100,000) and under 1 year for S. typhimurium (36/100,000). Using the Townsend score, highest isolation rates of S. enteritidis were in more prosperous areas (36/100,000 vs. 27/100,000; odds ratio (OR) 1.3, 95% confidence intervals (CIs) 1.2-1.6, P < 0.0001), while for S. typhimurium, there was no relation between deprivation index and isolation rates areas (6.4/100,000 vs. 6.1/100,000; OR 1.1, 95% CIs 0.8-1.5, P = 0.77). The case control study showed a significant association between ingestion of products containing raw eggs and S. enteritidis infection (8/111 cases vs. 0/110 controls; OR undefined, lower 95% CIs 3.4). Individuals with salmonella infection were significantly more likely to have travelled abroad in the week before the onset of illness [42/186 (23%) vs. 1/182 (0.5%); OR 40, 95% CIs = 5.5-291, P < 0.001] and to report gastroduodenal disease [11/143 (7%) vs. 3/143 (2%); OR 5.0, 95% CIs = 1.1-23, P = 0.04]. There was an association between illness and gastric acid-lowering medications [unmatched controls OR 22.3 (95% CIs 1.5-3.7, P = 0.0002), matched controls OR 3.7 (95% CIs 1.0-3.8, P = 0.07)], but no association with antimicrobial ingestion.     

Routinely Assessed Biochemical Markers Tested on Admission as Predictors of Adverse Outcomes in Hospitalized Elderly Patients

Abstract

Aim: To explore whether routinely assessed biochemical markers tested on admission will predict 3 predefined adverse outcomes for hospitalized elderly patients: discharge to a long-term care facility, in-hospital mortality, and prolonged hospital length of stay (> 14 days). Methods: A prospective observational study of elderly patients (aged ≥ 75 years) admitted to an acute-care geriatric ward over a 6-month period. Patients were assessed on admission and baseline characteristics were collected. Activities of daily living were assessed by the Barthel Index and cognitive function by the abbreviated mental test. Results from biochemical markers tested on admission were downloaded from the pathology laboratory database using patient details. Patients were folio wed-up with until discharge or in-hospital mortality. Results: A total of 392 patients formed the study population. Mean (standard deviation) age was 83.2 (± 5.5) years and 283 (72%) patients were men. Thirty-eight (10%) patients were discharged to a long-term care facility, 134 (34%) had a prolonged hospital length of stay, and 33 (8%) died in the hospital. Results from testing 5 biochemical markers independently predicted in-hospital mortality: hypoalbuminemia (adjusted odds ratio [OR], 2.5; 95% CI, 0.9–6.7; P = 0.04), low total cholesterol level (adjusted OR, 2.9; 95% CI, 1.3–6.3; P = 0.01), hyperglycemia (adjusted OR, 2.9; 95% CI, 1.2–7.4; P = 0.02), high C-reactive protein level (adjusted OR, 4.2; 95% CI, 1.3–13.4; P = 0.01), and renal impairment (adjusted OR, 3.8; 95% CI, 1.7–8.7; P = 0.002). High C-reactive protein level independently predicted prolonged hospital length of stay (OR, 1.7; 95% CI, 1.1–2.9; P = 0.03). Hypoalbuminemia predicted discharge to a long-term care facility independent of confounding factors except for physical dysfunction (OR, 2.4; 95% CI, 1.1–5.1; P = 0.03). Significance was reduced after adjustment for Barthel Index score (OR, 1.9; 95% CI, 0.9–4.1; P = 0.08). Conclusion: Testing of routinely assessed biochemical markers on admission predicted adverse hospital outcomes for elderly patients. Their inclusion in a standardized prediction tool may help to create interventions to improve such outcomes.     

Predictors of stroke - associated mortality in Africans

BACKGROUND: The objective of the study was to examine the association of the stroke-related mortality with gender, age, ethnicity, social class, blood pressure, fibrinogen, selected clinical data and meteorologic parameters in hospitalized Africans. METHODS: A series of 1032 consecutively hospitalized incident cases of acute stroke between 1987 and 1991 was studied. Univariate and multivariate analyses were used to estimate the risk (odds ratio=OR) of stroke mortality for meteorologic parameters on the month before the accident onset and selected sociodemophysiological variables on the day of admission. RESULTS: The variables significantly associated with stroke mortality in multivariate analysis were male sex (OR= 2.3 [1.3 - 4.1]), low social class (OR= 2.0 [1.2 - 4.0]), migrant tribes (OR= 1.7 [1.5 - 1.8]), ischemic stroke (OR= 1.4 [1.2 - 1.6]), heart rate >=100 bpm (OR= 1.1 [1.0 - 1.2]), age > or =60 years (OR= 1.03 [1.01 - 1.06]), systolic blood pressure> 160 mmHg (OR= 1. 02 [1.01 - 1.03]), and fibrinogen > or =400 mg/dl (OR= 1.01 [1.002 - 1. 02]). However, diastolic blood pressure > 90 mmHg and global radiation< 340 Cal/cm(2)/day were significantly (p< 0.05) and inversely associated with stroke mortality. CONCLUSION: Our results indicate that male sex, older age, low social class, migration, ischemic stroke and higher baseline levels of heart rate, systolic blood pressure and fibrinogen are significant predictors of stroke mortality, but lower global radiation and higher diastolic blood pressure are inversely linked.     

Occupational and environmental risk factors for idiopathic pulmonary fibrosis: a multicenter case-control study. Collaborating Centers

Occupational exposures were investigated in a multicenter case-control study of clinically and histologically diagnosed idiopathic pulmonary fibrosis (IPF), a chronic diffuse interstitial lung disease of unknown etiology. Results are based on 248 cases, aged 20-75 years, diagnosed at 16 referral centers between January 1989 and July 1993. There were 491 controls ascertained by random digit dialing and matched to cases on sex, age, and geographic region. Data were collected using a standard telephone questionnaire. Occupational factors were based on a detailed history of jobs lasting 6 months or more and job activity, hobby, and specific substance checklists. Several occupational factors, adjusted for age and smoking in conditional multivariate logistic regression analyses, were significantly associated with IPF: farming (odds ratio (OR) = 1.6, 95% confidence interval (CI): 1.0, 2.5); livestock (OR = 2.7, 95% CI: 1.3, 5.5); hairdressing (OR = 4.4, 95% CI: 1.2, 16.3); metal dust (OR = 2.0, 95% CI: 1.0, 4.0); raising birds (OR = 4.7, 95% CI: 1.6, 14.1); stone cutting/polishing (OR = 3.9, 95% CI: 1.2, 12.7); and vegetable dust/animal dust (OR = 4.7, 95% CI: 2.1, 10.4). Interaction was detected between smoking and exposure to livestock (p = 0.06) and farming (p = 0.08). Results confirm previous studies showing increased risk associated with dusty environments.     

A population-based case-control study of occupation and renal cell carcinoma risk in Iowa

A case-control study involving 406 incident cases and 2,434 controls was conducted in Iowa to examine the association between occupational exposures and renal cell carcinoma risk. After adjusting for major confounders, an increased risk was observed for men among mechanics and repairers (odds ratio [OR] 1.9, 95% confidence interval [CI] = 1.2-2.9); assemblers (OR 2.5, 95% CI = 0.8-7.6); automotive dealership and service station employees (OR 1.9, 95% CI = 0.9-3.9); wholesale traders of durable goods (OR 1.5, 95% CI = 0.7-3.2); farm product vendors (OR 4.4, 95% CI = 1.3-15.5); service organization managers (OR 2.2, 95% CI = 1.0-5.1); financial specialists (OR 2.7, 95% CI = 1.0-7.6); sales occupation supervisors (OR 1.8, 95% CI = 1.0-3.3); guards (OR 5.4, 95% CI = 1.4-20.7); and general farm workers (OR 1.9, 95% CI = 1.0-3.7). Among women, an increased risk was found for employees in depository institutions (OR 3.6, 95% CI = 1.1-11.3); colleges and universities (OR 7.6-95% CI = 2.3-25.6); and retail, including those in grocery stores (OR 2.2, 95% CI = 1.0-4.7). Our results indicate that occupational exposures may increase the risk of renal cell carcinoma.     

Household exposure to pesticides and risk of childhood hematopoietic malignancies: The ESCALE study (SFCE)

OBJECTIVES: We investigated the role of household exposure to pesticides in the etiology of childhood hematopoietic malignancies. METHODS: The national registry-based case-control study ESCALE (Etude sur les cancers de l'enfant) was carried out in France over the period 2003-2004. Population controls were frequency matched with the cases on age and sex. Maternal household use of pesticides during pregnancy and paternal use during pregnancy or childhood were reported by the mothers in a structured telephone questionnaire. Insecticides (used at home, on pets, or for garden crops), herbicides, and fungicides were distinguished. We estimated odds ratios (ORs) using unconditional regression models closely adjusting for age, sex, degree of urbanization, and type of housing (flat or house). RESULTS: We included a total of 764 cases of acute leukemia (AL), 130 of Hodgkin lymphoma (HL), 166 of non-Hodgkin lymphoma (NHL), and 1,681 controls. Insecticide use during pregnancy was significantly associated with childhood AL [OR = 2.1; 95% confidence interval (CI), 1.7-2.5], both lymphoblastic and myeloblastic, NHL (OR = 1.8; 95% CI, 1.3-2.6), mainly for Burkitt lymphoma (OR = 2.7; 95% CI, 1.6-4.5), and mixed-cell HL (OR = 4.1; 95% CI, 1.4-11.8), but not nodular sclerosis HL (OR = 1.1; 95% CI, 0.6-1.9). Paternal household use of pesticides was also related to AL (OR = 1.5; 95% CI, 1.2-1.8) and NHL (OR = 1.7; 95% CI, 1.2-2.6); but for AL the relationships did not remain after adjustment for maternal pesticide use during pregnancy. CONCLUSION: The study findings strengthen the hypothesis that domestic use of pesticides may play a role in the etiology of childhood hematopoietic malignancies. The consistency of the findings with those of previous studies on AL raises the question of the advisability of preventing pesticide use by pregnant women.     

Are Health Behaviors and Self-Rated Health Related to Cardiovascular Health and Functional Performance? Results from the Lookup 7+ Cross-Sectional Survey among Persons Aged 65+

Objectives

Cardiovascular health (CVH) and physical performance (PP) are key factors of successful ageing. This study investigated whether self-reported CVH behaviours and self-rated health (SRH) are related to ideal CVH and PP.

Design

Cross-sectional survey.

Setting

Public places in Italy (e.g. exhibitions, malls, health promotion campaigns), outside of conventional healthcare settings.

Participants

1415 community-living persons aged 65+ years (mean age 72.2 ± 5.4; 58.4% female).

Measurements

Three ideal CVH behaviors [regular physical activity (PA), healthy diet, no smoking] and SRH (1 excellent — 4 poor) were assessed through a brief questionnaire. Four ideal CVH factors [iBMI ≤ 25 kg/m2, untreated random total blood cholesterol ≤200 mg/dl, absence of diabetes (untreated random blood glucose ≤200 mg/dl), untreated blood pressure (iBP) <140/90mmHg] and two ideal PP factors [grip strength (iGrip), 5-repetition chair-stand test <10 seconds (iStand)] were measured.

Results

Adjusted for age and gender, regular PA was positively related to CVH factor score (β = 0.1; p = <.001), iBMI (OR = 1.8; 95% CI = 1.5-2.3), iBP (OR = 1.3; 95% CI = 1.1-1.6) and iStand (OR = 1.6; 95% CI = 1.3-2.1). Healthy diet was positively related to CVH factor score (β = 0.1; p = <.05) and iGrip (OR = 1.4; 95% CI = 1.1-1.8). Participants rating SRH as “good” (OR = 2.0; 95% CI = 1.1-3.9) and “not so good” (OR = 2.3; 95% CI = 1.2-4.5) met iDiabetes more often than those with poor SRH. Moreover, iStand (OR = 3.2; 95% CI = 1.6-6.6) and iGrip (OR = 4.2; 95% = CI 2.0-8.8) were more prevalent among participants with excellent SRH compared with those with poor SRH.

Conclusions

Physical activity, diet and self-rated health may provide quick and easy-to-assess metrics to identify persons aged 65+ years at risk of cardiovascular events and functional impairment, who could particularly benefit from engaging in health promotion programs.

     

An epidemiologic study of craniosynostosis: risk indicators for the occurrence of craniosynostosis in Colorado

This population-based case-control study was designed to investigate risk indicators for the occurrence of the birth defect craniosynostosis in Colorado. A total of 173 children who underwent craniectomy for craniosynostosis and 759 children without craniosynostosis were included in the study. Multivariable logistic regression analysis of birth certificate data showed that male sex (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.1-2.2), maternal five-year age "increase" (OR = 1.3, 95% CI = 1.1-1.5), plural birth (OR = 3.0, 95% CI = 1.2-7.1) and black maternal race (OR = 0.0, 95 per cent CI = 0.0-0.6) were independently associated with craniosynostosis. There was a weak positive association between craniosynostosis and the altitude of the town closest to the maternal residence, but no association was found with maternal education, marital status, number of previous births, or previous pregnancy termination. The association of craniosynostosis with plural birth is consistent with the hypothesis of fetal head constraint.     

Epidemiological models and related simulation results for understanding of contraceptive adoption in India

BACKGROUND: For the first time, models using multilevel analysis of Indian data and related simulation results are reported. They take hierarchical structure into account and incorporate variables from all levels to get correct analysis and proper interpretation of data on current contraceptive use (including sterilization and modern methods). METHODS: The data from an Indian State, Uttar Pradesh (UP), collected by the National Family Health Survey (NFHS) conducted during 10 October 1992 to 22 February 1993 was used. For model I, 7851 currently married women who were neither pregnant nor had continuing post-partum amenorrhoea (PPA) were considered. For model II, these women with at least one child (n = 6748) were used. Two-level logistic regression analysis was carried out for which women's level (level 1) and PSU (Primary Sampling Unit) level (level 2) variables were considered. The results were considered significant at the 5% level of significance. Simulation analysis using each model was also carried out. RESULTS: Model I reveals that those more likely to adopt contraception were women exposed to a TV message (odds ratio [OR] = 1.3; 95% CI: 1.1-1.6); whose houses were pucca (bricks and mortar) (OR = 1.3; 95% CI: 1.1-1.5); who were educated to high school level and above (OR = 2.9; 95% CI: 2.2-3.7); whose husbands were literate with schooling of > or =11 years (OR = 1.7; 95% CI: 1.4-2.1); and who had > or =2 living sons (OR = 2.2; 95% CI: 1.1-4.4). Muslim and other religious women were less likely than Hindu women to adopt contraception (OR = 0.5; 95% CI: 0.4-0.6). Also, the PSU level availability of all weather road was positively associated with contraceptive adoption (OR = 1.4; 95% CI: 1.1-1.7). The PSU level variance, which is the unexplained PSU level variation after controlling for the considered characteristics, was significantly higher. The simulation results revealed that public health education (a TV message) was found to be more effective among less educated women. The PSU level availability of all weather road was as effective as public health education. Similar results were evident from the analysis of second data set (model II) with the noticeable finding that those whose last child is surviving are most likely to adopt contraception (OR = 8.82; 95% CI: 1.01-77.38). CONCLUSIONS: These results reveal that the survival status of the last child has a marked effect on the adoption of contraception in UP. They further support the idea that public health education (a TV message) is more effective among less educated women. Also, the PSU level presence of all weather road is equally effective. Consideration of higher level variables provides not only more accurate results but also important public health clues to help the policy planners.     

Referral and delivery outcomes in Kivu,Democratic Republic of Congo

BACKGROUND: The process of referral between the first and the second level of the health system in the Democratic Republic of Congo is poorly understood. This report intends to study the association between the referral and the hospital perinatal outcomes. METHODS: Delivery outcomes in a retrospective cohort of 1162 women admitted between June 95 and May 96, in two referral hospitals in Kivu were analyzed according to the referral status and the women's characteristics. RESULTS: Forty-three percent (n=492)of women admitted, corresponding to 2.3% of expected pregnant women, were referred. Referred women had higher risks of obstetrical complications (OR=2.0; CI95%: 1.3-3.1) and intervention (OR=1.5; CI95%: 1.0-2.3) and similar risks of low birth weight and perinatal mortality. Women with complications during the antenatal period had a double risk of intervention and perinatal mortality. The risk of obstetrical intervention was lower when women had attended 2 visits (OR=0.5; CI95%: 0.3-0.8); the risk of low birth weight was lowest only for mothers who had attended one visit (OR=0.5; CI95%: 0.3-0.9). Distance > or =90 minutes walking from home to hospital raised the risk of obstetrical complication (OR=1.7; CI95%: 1.1-2.5), the risk of obstetrical intervention (OR=1.5; CI95%: 1.0-2.1), and the risk of perinatal mortality (OR=1.6; CI95%: 1.0-2.7). Late admission raised the risk of perinatal mortality (OR=1.8; CI95%: 1.2-2.9) and lowered the risk of obstetrical complication (OR=0.7; CI95%: 0.5-1.0). Part payment of care was associated with higher risks of low birth weight (OR=1.9; CI95%: 1.3-2.9), perinatal mortality (OR=2.2; CI95%: 1.4-3.5) and obstetrical intervention (OR=2.4; CI95%: 1.7-3.4). CONCLUSION: These results suggest a deficit of referred cases considering that 15% of pregnant women in the area covered by the referral hospitals should have been referred. They confirm the negative influence of economic and geographic constraints on the delivery outcomes. They point out the relevance of making reorganization of the referral system a priority.     

Does concordance with guideline triage recommendations affect clinical care of patients with possible acute coronary syndrome?

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear. METHODS: This analysis included 7466 adults who presented to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS) and who participated in 3 prospective clinical effectiveness trials during the period 1993 to 2001. The authors used logistic regression to assess the impact of concordance with guideline triage recommendations on subsequent diagnostic testing, follow-up care, and 30-day mortality and applied propensity score methods to adjust for selection bias. RESULTS: Among low-risk patients (n = 1099), ED discharge was not associated with higher mortality and did not increase the need for emergency care or hospitalization during follow-up (adjusted odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.63-1.6 for ED revisits); however, 1.7% of discharged low-risk patients had confirmed ACS. Among intermediate- to high-risk patients (n = 6367), admission to a monitored bed was not associated with reduction in 30-day mortality but significantly reduced the need for follow-up ED care (adjusted OR = 0.81, 95% CI = 0.69-0.96). CONCLUSIONS: This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.     

Prognostic factors of pneumococcal meningitis. Retrospective study of 31 cases

AIM: Our aim was to study the susceptibility of Streptococcus pneumoniae to antibiotics in patients with pneumococcal meningitis and to search for the prognosis factors in those patients. METHODS: We have studied retrospectively 31 cases of pneumococcal meningitis. Comparaisons were performed with univariate analysis. RESULTS: The mean age was 36.7 +/- 20.5 years (ranged: 9 and 78 years). The sex ratio was 3,4. The susceptibility of Streptococcus pneumoniae to penicillin G was affected in 10 cases (33% of isolated pneumococcus. The MIC to penicillin G was > or =2 in only one case. The hospital mortality was 26% (8/31). With univariate analysis, factors associated with death were: age > or =55 years (Ss p= 0,006, OR: 17.2 IC95%: 2.3-134), albuminorachie > or = 7 g/l (p = 0.002, OR: 22; IC95%: 1.9-2.51), shock (p = 0.031, OR: 6.7; IC95%: 1.05-42) and Glasgow Coma Score (GCS) < or =8 (p = 0.001, OR: 20; IC95%: 2.68-149). CONCLUSION: No susceptibility to penicillin G is not associated with a worse outcome in patients with pneumococcal meningitis. An age > or =55 years, albuminorachie > or =7 g/l shock and Glasgow Coma Score < or =8 at admission were determinant of the prognosis in our study.     

Predictors of institution admission in the year following acute hospitalisation of elderly people

Objectives

The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED).

Design

Prospective multicentre cohort.

Setting

Nine French university teaching hospitals.

Participants

One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub group analysis was performed on the 894 subjects with a caregiver.

Measurements

Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year.

Results

Within one year after hospital admission, 210 (20.1%) subjects were institutionalised For the overall study population, age >85 years (HR 1.6; 95% CI 1.1–2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1–2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1–2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4–2.6; p<0.001) proved to be independent predictors of institutionalisation; while a greater number of children was inversely linked to institutionalisation (HR 0.8; 95%CI 0.7–0.9; p<:0.001). Bathing was of borderline significance (p=.09). For subjects with a caregiver, initial caregiver burden was significantly linked to institutionalisation within one year, in addition to the predictors observed in the overall study population.

Conclusions

CGA performed at the beginning of hospitalisation in acute medical wards is useful to predict institutionalisation. Most of the predictors identified can lead to targeted therapeutic options with a view to preventing or delaying institution admission.