BMJ

Single dose vitamin A treatment in acute shigellosis in Bangladesh children: randomised double blind controlled trial.

Year 1998
Hossain S. Biswas R. Kabir I. Sarker S. Dibley M. Fuchs G. Mahalanabis D.
Clinical Sciences Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka. shossain@icddrb.org
OBJECTIVE: To evaluate the efficacy of a single large oral dose of vitamin A in treating acute shigellosis in children in Bangladesh. DESIGN: Randomised double blind controlled clinical trial. SETTING: Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh. SUBJECTS: 83 children aged 1-7 years with bacteriologically proved shigellosis but no clinical signs of vitamin A deficiency; 42 were randomised to treatment with vitamin A and 41 formed a control group. INTERVENTION: Children were given a single oral dose of 200,000 IU of vitamin A plus 25 IU vitamin E or a control preparation of 25 IU vitamin E. MAIN OUTCOME MEASURES: Clinical cure on study day 5 and bacteriological cure. RESULTS: Baseline characteristics of the subjects in the two treatment groups were similar. Significantly more children in the vitamin A group than in the control group achieved clinical cure (19/42 (45%) v 8/14 (20%); chi 2 = 5.14, 1 df, P = 0.02; risk ratio = 0.68 (95% confidence interval; 0.50 to 0.93)). When cure was determined bacteriologically, the groups had similar rates (16/42 (38%) v 16/41 (39%); chi 2 = 0.02, 1 df, P = 0.89; risk ratio = 0.98 (0.70 to 1.39)). CONCLUSIONS: Vitamin A reduces the severity of acute shigellosis in children living in areas where vitamin A deficiency is a major public health problem.

Why do children have chronic abdominal pain, and what happens to them when they grow up? Population based cohort study.

Year 1998
Hotopf M. Carr S. Mayou R. Wadsworth M. Wessely S.
Department of Psychological Medicine, King's College School of Medicine and Dentistry and Institute of Psychiatry, London SE5 8AZ, UK. m.hotopf@iop.bpmf.ac.uk
OBJECTIVE: To test the hypotheses that children with abdominal pain have anxious parents and come from families with high rates of physical illness and that they grow up to suffer from high rates of medically unexplained symptoms and psychiatric disorders. DESIGN: Population based birth cohort study.SETTING: General population. SUBJECTS: Participants in the Medical Research Council (MRC) national survey of health and development, a population based birth cohort study established in 1946.MAIN OUTCOME MEASURES: Abdominal pain present throughout childhood in the absence of defined organic disease, and measures of physical symptoms and psychiatric disorder at age 36 years. RESULTS: There were high rates of complaints about physical health among the parents of children with persistent abdominal pain, and the mothers had higher neuroticism scores. Children with persistent abdominal pain were more likely to suffer from psychiatric disorders in adulthood (odds ratio 2.72 (95% confidence interval 1.65 to 4.49)) but were not especially prone to physical symptoms once psychiatric disorder was controlled for (odds ratio 1. 39 (0.83 to 2.36)). CONCLUSIONS: Persistent abdominal pain is associated with poor health and emotional disorder in the parents. Children with abdominal pain do not necessarily continue to experience physical symptoms into adulthood but are at increased risk of adult psychiatric disorders.

Effectiveness of treatments for infantile colic: systematic review.

Year 1998
Lucassen PL. Assendelft WJ. Gubbels JW. van Eijk JT. van Geldrop WJ. Neven AK.
Institute for Research in Extramural Medicine, Free University, Amsterdam, The Netherlands.
OBJECTIVE: To evaluate the effectiveness of diets, drug treatment, and behavioural interventions on infantile colic in trials with crying or the presence of colic as the primary outcome measure. DATA SOURCES: Controlled clinical trials identified by a highly sensitive search strategy in Medline (1966-96), Embase (1986-95), and the Cochrane Controlled Trials Register, in combination with reference checking for further relevant publications. Keywords were crying and colic. STUDY SELECTION: Two independent assessors selected controlled trials with interventions lasting at least 3 days that included infants younger than 6 months who cried excessively. DATA SYNTHESIS: Methodological quality was assessed by two assessors independently with a quality assessment scale (range 0-5). Effect sizes were calculated as percentage success. Effect sizes of trials using identical interventions were pooled using a random effects model. RESULTS: 27 controlled trials were identified. Elimination of cows' milk protein was effective when substituted by hypoallergenic formula milks (effect size 0.22 (95% confidence interval 0.09 to 0.34)). The effectiveness of substitution by soy formula milks was unclear when only trials of good methodological quality were considered. The benefit of eliminating cows' milk protein was not restricted to highly selected populations. Dicyclomine was effective (effect size 0.46 (0.33 to 0.60)), but serious side effects have been reported. The advice to reduce stimulation was beneficial (effect size 0.48 (0.23 to 0.74)), whereas the advice to increase carrying and holding seemed not to reduce crying. No benefit was shown for simethicone. Uncertainty remained about the effectiveness of low lactose formula milks. CONCLUSIONS: Infantile colic should preferably be treated by advising carers to reduce stimulation and with a one week trial of a hypoallergenic formula milk.

Adverse socioeconomic conditions in childhood and cause specific adult mortality: prospective observational study.

Year 1998
Smith GD. Hart C. Blane D. Hole D.
Department of Social Medicine, University of Bristol, Canynge Hall, Bristol BS8 2PR. zetkin@bristol.ac.uk
OBJECTIVE: To investigate the association between social circumstances in childhood and mortality from various causes of death in adulthood. DESIGN: Prospective observational study. SETTING: 27 workplaces in the west of Scotland. SUBJECTS: 5645 men aged 35-64 years at the time of examination. MAIN OUTCOME MEASURES: Death from various causes. RESULTS: Men whose fathers had manual occupations when they were children were more likely as adults to have manual jobs and be living in deprived areas. Gradients in mortality from coronary heart disease, stroke, lung cancer, stomach cancer, and respiratory disease were seen (all P

Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies. EU Working Group on Socioeconomic Inequalities in Health.

Year 1998
Kunst AE. Groenhof F. Mackenbach JP. Health EW.
Department of Public Health, Erasmus University, PO Box 1738, NL-3000 DR Rotterdam, Netherlands. kunst@mgz.fgg.eur.nl
OBJECTIVES: To compare countries in western Europe with respect to class differences in mortality from specific causes of death and to assess the contributions these causes make to class differences in total mortality. DESIGN: Comparison of cause of death in manual and non-manual classes, using data on mortality from national studies. SETTING: Eleven western European countries in the period 1980-9. SUBJECTS: Men aged 45-59 years at death. RESULTS: A north-south gradient was observed: mortality from ischaemic heart disease was strongly related to occupational class in England and Wales, Ireland, Finland, Sweden, Norway, and Denmark, but not in France, Switzerland, and Mediterranean countries. In the latter countries, cancers other than lung cancer and gastrointestinal diseases made a large contribution to class differences in total mortality. Inequalities in lung cancer, cerebrovascular disease, and external causes of death also varied greatly between countries. CONCLUSIONS: These variations in cause specific mortality indicate large differences between countries in the contribution that disease specific risk factors like smoking and alcohol consumption make to socioeconomic inequalities in mortality. The mortality advantage of people in higher occupational classes is independent of the precise diseases and risk factors involved.

Varying efficacy of Helicobacter pylori eradication regimens: cost effectiveness study using a decision analysis model.

Year 1998
Duggan AE. Tolley K. Hawkey CJ. Logan RF.
Department of Public Health and Epidemiology, University of Nottingham, Nottingham NG7 2UH. anne.duggan@nottingham.ac.uk
OBJECTIVE: To determine how small differences in the efficacy and cost of two antibiotic regimens to eradicate Helicobacter pylori can affect the overall cost effectiveness of H pylori eradication in duodenal ulcer disease. DESIGN: A decision analysis to examine the cost effectiveness of eight H pylori eradication strategies for duodenal ulcer disease with and without 13C-urea breath testing to confirm eradication. MAIN OUTCOME MEASURES: Cumulative direct treatment costs per 100 patients with duodenal ulcer disease who were positive for H pylori. RESULTS: In model 1 the strategy of omeprazole, clarithromycin, and metronidazole alone was the most cost effective of the four strategies assessed. The addition of the 13C-urea breath test and a second course of omeprazole, clarithromycin, and metronidazole achieved the highest eradication rate (97%) but was the most expensive (62.63 pounds per patient). The cost of each additional effective eradication was 589.00 pounds (incremental cost per case) when compared with the cost of treating once only with omeprazole, clarithromycin, and metronidazole; equivalent to the cost of a patient receiving ranitidine for duodenal ulcer relapse for more than 15 years. Eradication strategies of omeprazole, amoxycillin, and metronidazole were less cost effective than omeprazole, clarithromycin, and metronidazole alone. In model 2 the addition of the 13C-urea breath test after treatment, and maintenance treatment, increased the cost of all the strategies and reduced the cost advantage of omeprazole, clarithromycin, and metronidazole alone. CONCLUSION: Small differences in efficacy can influence the comparative cost effectiveness of strategies for eradicating H pylori. Of the strategies tested the most cost effective (omeprazole, clarithromycin, and metronidazole alone) was neither the least expensive (omeprazole, amoxycillin, and metronidazole alone) nor the most effective (omeprazole, clarithromycin, and metronidazole with further treatment for patients found positive for H pylori on 13C-urea breath testing). Cost effectiveness should be an important part of choosing an eradication strategy for H pylori.

Clinical outcome in relation to care in centres specialising in cystic fibrosis: cross sectional study.

Year 1998
Mahadeva R. Webb K. Westerbeek RC. Carroll NR. Dodd ME. Bilton D. Lomas DA.
Department of Haematology, University of Cambridge, Medical Research Council Centre, Cambridge CB2 2QH.
OBJECTIVES: To assess the effect on clinical outcome of managing paediatric and adult patients with cystic fibrosis at specialised cystic fibrosis centres. DESIGN: Cross sectional study. SETTING: Two adult cystic fibrosis centres in the United Kingdom. SUBJECTS: Patients from an adult cystic fibrosis centre in Manchester were subdivided into those who had received continuous care from paediatric and adult cystic fibrosis centres (group A), and those who had received paediatric care in a centre not specialising in cystic fibrosis followed by adult care in a cystic fibrosis centre (group B). Group C were referrals to the new adult cystic fibrosis centre in Cambridge who had received neither paediatric nor adult centre care for their cystic fibrosis. MAIN OUTCOME MEASURES: Body mass index (weight (kg)/height (m2)), lung function (forced expiratory volume in one second (FEV1 percentage of predicted)), the Northern chest x ray film score, and age at colonisation with Pseudomonas aeruginosa. RESULTS: A prominent stepwise increase in body mass index was associated with increasing amounts of care at a cystic fibrosis centre; 18.3, 20.2, and 21.3 for groups C, B, and A respectively (P

Incidence of seroconversion to positivity for hepatitis C antibody in repeat blood donors in England, 1993-5.

Year 1998
Soldan K. Barbara JA. Heptonstall J.
Public Health Laboratory Service Communicable Disease Surveillance Centre, London NW9 5EQ.
OBJECTIVE: To estimate the rate of seroconversion to positivity for hepatitis C antibody in repeat blood donors in England and to describe the probable routes of infection in these donors. DESIGN: Retrospective survey of blood donors becoming positive for hepatitis C antibody and of the results of donation testing. SETTING: The 14 blood centres in England. SUBJECTS: All repeat donors giving blood between January 1993 and December 1995. MAIN OUTCOME MEASURES: Number of donors developing hepatitis C between donations during the three years of testing for hepatitis C antibody at English blood centres and the rate of seroconversion among repeat blood donors. Probable routes of infection. RESULTS: 14 donors during 1993-5 fulfilled the case definition for seroconversion to positivity for hepatitis C antibody. The estimated seroconversion rate for infection with hepatitis C in repeat donors was 0.26 per 100 000 person years (95% confidence interval 0.15 to 0.43). Counselling after diagnosis found that four of these donors had risk factors specified in the criteria excluding people from giving blood but these factors had not come to light before donation. Another of the donors who seroconverted had a risk factor that has since been included in the exclusion criteria. Heterosexual intercourse was considered to be the most likely route of infection for five of the 14 donors. CONCLUSIONS: The rate of seroconversion for positivity to hepatitis C antibody in repeat blood donors in England was extremely low. During 1993-5 fewer than 1 in 450 000 donations were estimated to have come from repeat donors who had become positive for hepatitis C antibody since the previous donation.