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Air quality (AQ) significantly impacts human health, influenced by both natural phenomena and human activities. In 2021, heightened awareness of AQ's health impacts prompted the revision of the World Health Organization (WHO) guidelines, advocating for stricter pollution standards. However, research on AQ has predominantly focused on high-income countries and densely populated cities, neglecting low- and middle-income countries, particularly Pacific Island Countries, Territories, and States (PICTS). This systematic review compiles existing peer-reviewed literature on AQ research in PICTS to assess the current state of knowledge and emphasize the need for further investigation. A systematic literature search yielded 40 papers from databases including Web of Science, Scopus, and Embase. Among the 26 PICTS, only 6 (Hawai'i, Fiji, Papua New Guinea, New Caledonia, Republic of Marshall Islands, and Pacific) have been subject to AQ-related research, with 4 considering the World Health Organization (WHO) parameters and 26 addressing non-WHO parameters. Analysis reveals AQ parameters often exceed 2021 WHO guidelines for PM2.5, PM10, SO2, and CO, raising concerns among regional governments. Studies primarily focused on urban, agricultural, rural, and open ocean areas, with 15 based on primary data and 14 on both primary and secondary sources. Research interests and funding sources dictated the methods used, with a predominant focus on environmental risks over social, economic, and technological impacts. Although some papers addressed health implications, further efforts are needed in this area. This review underscores the urgent need for ongoing AQ monitoring efforts in PICTS to generate spatially and temporally comparable data. By presenting the current state of AQ knowledge, this work lays the foundation for coordinated regional monitoring and informs national policy development.
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Contaminación del Aire , Humanos , Contaminantes Atmosféricos/análisis , Contaminación del Aire/estadística & datos numéricos , Exposición a Riesgos Ambientales/estadística & datos numéricos , Salud Ambiental , Monitoreo del Ambiente/métodos , Islas del Pacífico , Organización Mundial de la SaludRESUMEN
Patients treated for drug addiction have high asthma and COPD prevalence rates. The relative contributions of cigarette smoking, smoking intensity and possible smoking of other substances has not been described. We aimed to describe the prevalence and determinants of asthma and COPD in patients prescribed methadone as opioid substitution therapy (OST). In a cross-sectional study of an anonymised patient-level primary care dataset of UK inner-city general practices (n = 46), 321,395 patients aged ≥18 years were identified. A total of 676 (0.21%) had a record of a methadone ever issued in primary care. The association between respiratory disease and methadone prescribing was examined using logistic regression. Models were adjusted for potential effects of clustering by practice. A total of 97.3% of patients prescribed methadone were cigarette smokers, either current (81.2%) or ex-smokers (16.1%). The prevalences of asthma and COPD were higher in methadone patients (14.2% and 12.4%, respectively) compared to non-methadone patients (4.4% and 1.1%, respectively). Methadone was an independent determinant of asthma, adjusting for smoking status (OR 3.21; 95% CI: 2.52, 4.10) or for smoking intensity (3.08; 2.27, 4.19), and of COPD, adjusting for smoking status (6.00; 4.61, 7.80) or for smoking intensity (5.80; 4.12, 8.17). COPD and asthma prevalence were substantially higher in those prescribed methadone compared to those never prescribed methadone. Prescription of methadone was an independent predictor for both COPD and asthma, even after adjustment for smoking status and smoking intensity. Possible explanations include confounding by association with smoking of heroin or crack cocaine, both of which may have a causal association with COPD and asthma.
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Asma/epidemiología , Fumar Cigarrillos/epidemiología , Trastornos Relacionados con Opioides/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Adulto , Analgésicos Opioides/uso terapéutico , Estudios de Casos y Controles , Estudios Transversales , Femenino , Humanos , Modelos Logísticos , Masculino , Metadona/uso terapéutico , Persona de Mediana Edad , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Prevalencia , Atención Primaria de Salud , Riesgo , Reino Unido/epidemiologíaRESUMEN
OBJECTIVES: To determine the feasibility and tissue yield of a perinatal incisionless ultrasound-guided biopsy procedure, the INcisionless Targeted Core Tissue (INTACT) technique, in the context of minimally invasive autopsy. METHODS: Cases of perinatal death in which the parents consented for minimally invasive autopsy underwent postmortem magnetic resonance imaging and an INTACT biopsy procedure, defined as needle biopsy of organs via the umbilical cord, performed under ultrasound guidance. In each case, three cores of tissue were obtained from seven target organs (both lungs, both kidneys, heart, spleen and liver). Biopsy success was predefined as an adequate volume of the intended target organ for pathological analysis, as judged by a pathologist blinded to the case and biopsy procedure. RESULTS: Thirty fetuses underwent organ sampling. Mean gestational age was 30 weeks (range, 18-40 weeks) and mean delivery-to-biopsy interval was 12 days (range, 6-22 days). The overall biopsy success rate was 153/201 (76.1%) samples, with the success rates in individual organs being highest for the heart and lungs (93% and 91%, respectively) and lowest for the spleen (11%). Excluding splenic samples, the biopsy success rate was 150/173 (86.7%). Histological abnormalities were found in 4/201 (2%) samples, all of which occurred in the lungs and kidneys of a fetus with pulmonary hypoplasia and multicystic kidney disease. CONCLUSIONS: Incisionless ultrasound-guided organ biopsy using the INTACT procedure is feasible, with an overall biopsy success rate of over 75%. This novel technique offers the ideal combination of an imaging-led autopsy with organ sampling for parents who decline the conventional invasive approach. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Autopsia/métodos , Feto/diagnóstico por imagen , Biopsia Guiada por Imagen/métodos , Ultrasonografía Prenatal/métodos , Estudios de Factibilidad , Femenino , Feto/patología , Edad Gestacional , Humanos , Recién Nacido , Masculino , Muerte Perinatal/etiología , EmbarazoRESUMEN
OBJECTIVE: Less invasive autopsy techniques in cases of fetal or infant death have good acceptability among parents, but the published sampling adequacy in needle biopsy studies is generally poor. Minimally Invasive Autopsy with Laparoscopically assisted sampling (MinImAL) has the potential to increase the diagnostic yield of less invasive autopsy by improving the quality and quantity of tissue samples obtained, whilst permitting visualization, extraction and examination of internal organs through a small incision. The aim of this study was to present the findings of our experience with the MinImAL procedure in cases of fetal, neonatal and pediatric death. METHODS: This was a retrospective analysis of 103 prospectively recruited unselected cases of fetal, neonatal or pediatric death that underwent the MinImAL procedure at a tertiary referral center over a 5-year period. Following preprocedure 1.5-T whole-body postmortem magnetic resonance imaging, MinImAL autopsy was performed. Procedure duration, sampling adequacy and cause of death were assessed. Chi-square analysis was used to compare the 'unexplained' rate of intrauterine deaths in the cohort with that in a previously published cohort of > 1000 cases of intrauterine death examined by standard autopsy. RESULTS: MinImAL autopsy was performed successfully in 97.8% (91/93) of the cases undergoing a complete procedure. There was a satisfactory rate of adequate histological sampling in most major organs; heart (100%, 91 cases), lung (100%, 91 cases), kidney (100%, 91 cases), liver (96.7%, 88 cases), spleen (94.5%, 86 cases), adrenal glands (89.0%, 81 cases), pancreas (82.4%, 75 cases) and thymus (56.0%, 51 cases). Procedure duration was similar to that of standard autopsy in a previously published cohort of intrauterine deaths. The unexplained rate in stillbirths and intrauterine fetal deaths that underwent MinImAL autopsy was not significantly different from that following standard autopsy. CONCLUSIONS: The MinImAL procedure provides good histological yield from major organs with minimal cosmetic damage and can be learned by an autopsy practitioner. The MinImAL procedure is an appropriate minimally invasive alternative for the investigation of perinatal and pediatric deaths in which consent to full autopsy is withheld, and may have applications in both high- and low/middle-income settings. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Autopsia/métodos , Laparoscopía/métodos , Adolescente , Causas de Muerte , Niño , Preescolar , Estudios de Factibilidad , Muerte Fetal/etiología , Humanos , Lactante , Muerte del Lactante/etiología , Recién Nacido , Estudios Retrospectivos , Imagen de Cuerpo EnteroRESUMEN
PURPOSE: We present a prospective case series of patients undergoing an arthroscopic, extra-articular psoas tenotomy. METHODS: From February 2009 to February 2017, 13 consecutive patients underwent day case, arthroscopic tenotomy. Patients were selected following clinical evidence of impingement and a diagnostic ultra-sound-guided steroid injection of the psoas bursa. The patient's mean age was 52.8 years ± 13.7 (29.1-82.7), mean ASA 1.8 and mean BMI 30.6 ± 8.5 kg/m2. We detail the technique employed and patient outcomes to include FABER testing, manual hip flexion strength assessment and pain improvements. RESULTS: The typical onset of impingement symptoms following THA was 4 months (2-24 months). 9 patients tested FABER negative and 62% (n = 8) were pain-free within 6-12 weeks. An average 20% (5-30%) reduction in hip flexion strength was seen post-arthroscopy. The mean follow-up was 2 years, (0.5-7 years). Regarding complications, one patient required revision surgery due to recurrence prompting a technique adaptation. CONCLUSION: For psoas impingement following THA where non-operative measures are ineffective, we recommend extra-articular arthroscopic psoas tenotomy as a feasible operative strategy. This minimally invasive, day case, low-risk treatment option is beneficial in relieving impingement symptoms.
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Artroplastia de Reemplazo de Cadera , Artroscopía/métodos , Pinzamiento Femoroacetabular , Músculos Psoas , Tenotomía/métodos , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Femenino , Pinzamiento Femoroacetabular/diagnóstico , Pinzamiento Femoroacetabular/etiología , Pinzamiento Femoroacetabular/cirugía , Articulación de la Cadera/cirugía , Humanos , Masculino , Persona de Mediana Edad , Dolor/etiología , Dolor/fisiopatología , Manejo del Dolor/métodos , Estudios Prospectivos , Músculos Psoas/diagnóstico por imagen , Músculos Psoas/fisiopatología , Músculos Psoas/cirugía , Rango del Movimiento Articular , Reoperación/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Globally the incidence of fragility hip fractures is rising with increasingly elderly and co-morbid patients. These injuries are associated with a high morbidity and mortality. AIMS: This clinical study's primary outcome is to establish the rate of operative inadvertent hypothermia (<36⯰C) in elderly hip fracture patients (>65â¯years old). We also aimed to identify risk factors and outcomes in patients with inadvertent hypothermia. PATIENTS AND METHODS: A single centre, retrospective study of 929 hip fracture patients managed operatively between June 2015 and July 2017 was conducted. Patients' demographic, anaesthetic and surgical variables were analysed together with outcomes for length of stay (LoS), 30-day re-admissions, and 30-day mortality. RESULTS: Overall rates of inadvertent hypothermia in elderly hip fracture patients undergoing surgery were 10%, with increasing age (pâ¯=â¯0.006) and pre-operative hypothermia (pâ¯<â¯0.0001) as risk factors. Patient's hypothermic pre-operatively compared with normothermic patients were 1.9 times more likely to be <36⯰C on leaving theatre. There was a trend towards a higher 30-day mortality (χ2(1)â¯=â¯2.818, pâ¯=â¯0.093), and a significantly higher mortality in patients undergoing SHS (pâ¯=â¯0.03). No survival differences for LoS were observed between hypothermic and ≥36⯰C patients (χ2(1)â¯=â¯0.069, pâ¯=â¯0.79). 30-day re-admissions were higher in hypothermic patients (χ2(1)â¯=â¯16.301, pâ¯<â¯0.0001). CONCLUSION: Rates of inadvertent hypothermia are high in operatively managed hip fracture patients and are significantly associated with a higher 30-day readmission rate with a trend towards higher 30-day mortality.
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PURPOSE: This study aimed to estimate trends in antithrombotic prescriptions from 2001 to 2015 among people aged 80 years and over within clinical indications. METHODS: A prospective cohort study with 215,559 participants registered with the UK Clinical Practice Research Datalink from 2001 to 2015 was included in the analyses. The prevalence and incidence of antiplatelet and anticoagulant drugs were estimated for each year and by five clinical indications. RESULTS: The prevalence rate of antithrombotic prescriptions among patients aged over 80 years and diagnosed with atrial fibrillation increased from 53% in 2001 to 77% in 2015 (Ptrend <.001). Anticoagulant prescriptions rates also increased five-fold in older adults with atrial fibrillation from around 10% in 2001 to 46% in 2015 (Ptrend <.001). Clopidogrel-prescribing rates in patients aged over 80 years and with venous thrombosis increased from 0.4% in 2001 to 10% in 2015 (Ptrend <.001). Warfarin-prescribing rates in older patients with venous thrombosis increased from 13% in 2001 to 21% in 2015 (Ptrend <.001). CONCLUSIONS: The use of antithrombotic drugs increased from 2001 to 2015 in people aged 80 years and over across multiple clinical indications. Assessing the benefits and harms of antithrombotic drugs across different clinical indications in older people is a priority.
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Fibrilación Atrial/tratamiento farmacológico , Prescripciones de Medicamentos/estadística & datos numéricos , Fibrinolíticos/uso terapéutico , Pautas de la Práctica en Medicina/tendencias , Accidente Cerebrovascular/prevención & control , Anciano de 80 o más Años , Anticoagulantes/administración & dosificación , Registros Electrónicos de Salud , Femenino , Humanos , Masculino , Atención Primaria de Salud , Estudios ProspectivosAsunto(s)
Aire , Artrografía/métodos , Medios de Contraste/administración & dosificación , Articulación de la Cadera/diagnóstico por imagen , Artropatías/diagnóstico por imagen , Artrografía/economía , Artrografía/instrumentación , Medios de Contraste/economía , Fluoroscopía/instrumentación , Fluoroscopía/métodos , Humanos , Agujas , JeringasRESUMEN
AIMS: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. METHODS: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. RESULTS: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. CONCLUSIONS: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.
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Diabetes Mellitus Tipo 2/complicaciones , Trastornos Mentales/complicaciones , Adolescente , Adulto , Factores de Edad , Anciano , Bangladesh/etnología , Estudios Transversales , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/etnología , Diabetes Mellitus Tipo 2/psicología , Registros Electrónicos de Salud , Femenino , Medicina General , Disparidades en el Estado de Salud , Humanos , India/etnología , Londres/epidemiología , Masculino , Trastornos Mentales/etnología , Trastornos Mentales/fisiopatología , Trastornos Mentales/psicología , Persona de Mediana Edad , Pakistán/etnología , Prevalencia , Riesgo , Índice de Severidad de la Enfermedad , Medicina Estatal , Adulto JovenRESUMEN
OBJECTIVES: Guidelines for the investigation of intrauterine death and sudden unexpected death in infancy (SUDI) recommend, based on expert opinion, autopsy procedures and tissue sampling strategies for histological analysis. Although stillbirth is much more common than SUDI, there have been no large-scale studies published which evaluate the usefulness of histological evaluation of specific organs in stillbirth for determining cause of death. Our aim was to evaluate the use of macroscopic and microscopic assessment of internal organs to determine cause of intrauterine death. METHODS: As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for cases of intrauterine death examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for all organs were examined in relation to the final cause of death, as determined by objective criteria. RESULTS: Among 1064 intrauterine deaths, the majority (> 80%) of cases had internal organs that were normal on both macroscopic and microscopic examination. There was no case in which histological cardiac examination provided the cause of death when the macroscopic appearance of the heart was normal. Microscopic examination of lung tissue revealed 13 (1%) cases with histological abnormalities that provided the cause of death when the macroscopic appearance was normal, but there was only one (0.1%) case in which the diagnosis would not have been apparent on placental examination: a case of congenital cytomegalovirus infection. There was no case in which microscopic examination of macroscopically normal liver, kidneys, adrenals, spleen, thymus, intestines, pancreas, brain or thyroid provided the cause of death. CONCLUSION: In this large series of autopsies in cases of intrauterine death, only around 1% of cases demonstrated histological abnormalities which provided the cause of death when the internal organs appeared normal macroscopically. There was no case in which routine histological examination of most tissues provided diagnostically useful information that was not apparent from other examinations, such as placental pathology. There is little benefit, purely in terms of determining cause of death, in obtaining tissue from most macroscopically normal organs for routine histological examination. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Autopsia , Causas de Muerte , Muerte Fetal/etiología , Microscopía , Manejo de Especímenes , Mortinato , Encéfalo/patología , Femenino , Humanos , Riñón/patología , Hígado/patología , Pulmón/patología , Miocardio/patología , Tamaño de los Órganos , Placenta/patología , Valor Predictivo de las Pruebas , Embarazo , Mortinato/epidemiología , Reino Unido/epidemiologíaRESUMEN
OBJECTIVES: There have been several attempts to classify cause of death (CoD) in stillbirth; however, all such systems are subjective, allowing for observer bias and making comparisons between systems challenging. This study aimed to examine factors relating to determination of CoD using a large dataset from two specialist centers in which observer bias had been reduced by classifying findings objectively and assigning CoD based on predetermined criteria. METHODS: Detailed autopsy reports from intrauterine deaths in the second and third trimesters during 2005-2013 were reviewed and findings entered into a specially designed database, in which CoD was assigned using predefined objective criteria. Data regarding CoD categories and factors affecting determination of CoD were examined. RESULTS: There were 1064 intrauterine deaths, including 246 early intrauterine fetal deaths (IUFD) (< 20 weeks), 179 late IUFDs (20-23 weeks) and 639 stillbirths (≥ 24 weeks' gestation). Overall, around 40% (n = 412) had a clear CoD identified, whilst around 60% (n = 652) were classified as 'unexplained', including around half with identified risk factors or lesions of uncertain significance, with the remaining half (n = 292 (45%)) being entirely unexplained. A stepwise increase in the proportion of unexplained deaths was observed with increasing maceration. Black and Asian women had significantly greater proportions of deaths due to ascending infection, whilst women aged over 40 years had significantly increased placenta-related CoDs. There was no significant difference in CoD distribution according to maternal body mass index or with increasing postmortem interval. Around half of those with an identifiable CoD could be identified from clinical review and external fetal examination or imaging, with most of the remainder being determined following placental examination. CONCLUSIONS: Based on objective criteria, many intrauterine deaths throughout gestation remain unexplained despite autopsy examination. The rate of unexplained death varies from around 30% to 60% depending on interpretation of the significance of features. CoD determination is dependent on both the classification system used and subjective interpretation, such that variation in the proportion of 'unexplained' cases is based largely on speculation regarding mechanisms of death. Novel methods to determine objectively the mechanism of death at postmortem examination are required. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Autopsia , Causas de Muerte , Muerte Fetal/etiología , Feto/patología , Enfermedades Placentarias/patología , Mortinato , Adulto , Consejo , Femenino , Edad Gestacional , Humanos , Padres , Enfermedades Placentarias/mortalidad , Embarazo , Mortinato/epidemiología , Mortinato/psicologíaRESUMEN
OBJECTIVES: Placental abnormalities are a common cause of death in stillbirth, ranking second only to unexplained deaths, though there is wide variation in the proportion attributed to placental disease. In clinical practice, interpretation of the significance of placental findings is difficult, since many placental features in stillbirths overlap with those in live births. Our aim was to examine objectively classified placental findings from a series of > 1000 autopsies following intrauterine death in order to evaluate the role of placental histological examination in determining the cause of death. METHODS: As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for all cases examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for placentas were evaluated in relation to the final cause of death. RESULTS: Among 1064 intrauterine deaths, 946 (89%) cases had the placenta submitted for examination as part of the autopsy. Of these, 307 (32%) cases had the cause of death assigned to abnormalities of the placenta, cord or membranes. Around one third of stillbirths (≥ 24 weeks) had some isolated placental histological abnormality identified, many of uncertain significance, a significantly greater proportion than in cases of second-trimester intrauterine fetal demise (P < 0.0001). The cause of death was ascending infection in 176/946 (19%) cases, peaking at 22 weeks' gestation, with significantly more black mothers having ascending infection compared with other ethnicities (P < 0.0001). Maternal vascular malperfusion was the largest category of placental abnormalities in stillbirth, with peak prevalence in the early third trimester. There were 18 (2%) cases with specific histological abnormalities, including chronic histiocytic intervillositis and massive perivillous fibrin deposition. CONCLUSIONS: Placental pathologies represent the largest category of cause of intrauterine death. Placental histological examination is the single most useful component of the autopsy process in this clinical setting. A minority of cases are associated with specific placental pathologies, often with high recurrence rates, that can be diagnosed only on microscopic examination of the placenta. Many deaths remain unexplained, although placental histological lesions may be present which are of uncertain significance. A rigorous, systematic approach to placental pathology research and classification may yield better understanding of the significance of placental findings and reduce the rate of unexplained intrauterine deaths. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Autopsia , Causas de Muerte , Muerte Fetal/etiología , Enfermedades Placentarias/patología , Placenta/patología , Mortinato , Adolescente , Adulto , Femenino , Edad Gestacional , Humanos , Placenta/anomalías , Placenta/irrigación sanguínea , Enfermedades Placentarias/mortalidad , Embarazo , Adulto JovenRESUMEN
OBJECTIVE: According to the classification system used, 15-60% of stillbirths remain unexplained, despite undergoing recommended autopsy examination, with variable attribution of fetal growth restriction (FGR) as a cause of death. Distinguishing small-for-gestational age (SGA) from pathological FGR is a challenge at postmortem examination. This study uses data from a large, well-characterized series of intrauterine death autopsies to investigate the effects of secondary changes such as fetal maceration, intrauterine retention and postmortem interval on body weight. METHODS: Autopsy findings from intrauterine death investigations (2005-2013 inclusive, from Great Ormond Street Hospital and St George's Hospital, London) were collated into a research database. Growth charts published by the World Health Organization were used to determine normal expected weight centiles for fetuses born ≥ 24 weeks' gestation, and the effects of intrauterine retention (maceration) and postmortem interval were calculated. RESULTS: There were 1064 intrauterine deaths, including 533 stillbirths ≥ 24 weeks' gestation with a recorded birth weight. Of these, 192 (36%) had an unadjusted birth weight below the 10th centile and were defined as SGA. The majority (86%) of stillborn SGA fetuses demonstrated some degree of maceration, indicating a significant period of intrauterine retention after death. A significantly greater proportion of macerated fetuses were present in the SGA population compared with the non-SGA population (P = 0.01). There was a significant relationship between increasing intrauterine retention interval and both more severe maceration and reduction in birth weight (P < 0.0001 for both), with an average artifactual reduction in birth weight of around -0.8 SD of expected weight. There was an average 12% reduction in fetal weight between delivery and autopsy and, as postmortem interval increased, fetal weight loss increased (P = 0.0001). CONCLUSION: Based on birth weight alone, 36% of stillbirths are classified as SGA. However, fetuses lose weight in utero with increasing intrauterine retention and continue to lose weight between delivery and autopsy, resulting in erroneous overestimation of FGR. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Autopsia , Muerte Fetal , Retardo del Crecimiento Fetal/patología , Mortinato , Causas de Muerte , Femenino , Muerte Fetal/etiología , Muerte Fetal/prevención & control , Peso Fetal , Humanos , Recién Nacido Pequeño para la Edad Gestacional , EmbarazoRESUMEN
OBJECTIVES: Of 780 000 births annually in the UK, around 3300 are stillborn, a rate of approximately 4 per 1000 births. Traditional epidemiological associations are based on historic data. The aim of this study was to document contemporary demographic findings in a large series of > 1000 deaths in utero in London and compare these with national datasets. METHODS: From a dedicated database, including > 400 data fields per case, of fetal, infant and pediatric autopsies performed at Great Ormond Street Hospital and St George's Hospital, London, we extracted information on all intrauterine deaths, excluding terminations of pregnancy, from 2005 to 2013, inclusive. Demographic data were analyzed according to the gestational age at which fetal death occurred (second-trimester intrauterine fetal death (IUFD), subdivided into early (< 20 weeks) and late (20-23 weeks) IUFD, and third-trimester stillbirth (≥ 24 weeks)) and compared with national datasets when available, using Mann-Whitney U-test and comparison of proportions testing as appropriate. RESULTS: Data were available from 1064 individual postmortem reports examining intrauterine deaths delivered between 12 and 43 weeks' gestation, including 425 IUFDs (246 early and 179 late) and 639 stillbirths. Compared with the overall UK pregnant population, women in whom an intrauterine death occurred were significantly older and more obese. White mothers had a higher proportion of stillbirths (as opposed to IUFDs) than did non-white mothers, whereas black mothers had a higher proportion of IUFDs relative to stillbirths. Increased body mass index was associated with increased risk across all groups. Women who had uterine fibroids, those who had a history of vaginal bleeding in early pregnancy and those who had undergone assisted conception had a relatively higher proportion of IUFDs than stillbirths. CONCLUSIONS: Based on a large series of >1000 autopsies in cases of intrauterine death, these data highlight the increased risk for fetal loss associated with maternal demographic factors in contemporary clinical practice, particularly associations with increased maternal age and body mass index. Among women in whom an intrauterine death occurs, maternal ethnicity, mode of conception and gynecological history are associated with differing timing of fetal loss. Further research is required to understand the mechanisms involved in such maternal factors in order to develop preventative strategies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Muerte Fetal/etiología , Mujeres Embarazadas , Mortinato/epidemiología , Población Urbana , Adolescente , Adulto , Demografía , Femenino , Edad Gestacional , Humanos , Londres/epidemiología , Edad Materna , Persona de Mediana Edad , Embarazo , Mujeres Embarazadas/etnología , Mortinato/etnología , Adulto JovenRESUMEN
OBJECTIVES: The postmortem fetal brain:liver weight ratio is commonly used as a marker of nutrition for diagnosis of fetal growth restriction (FGR). However, there are limited data regarding the effects of intrauterine retention, fetal maceration and postmortem interval on organ weights and their ratios at autopsy. Our aims were to examine the relationships between gestational-age-adjusted and sex-adjusted fetal organ weights at autopsy, cause of intrauterine death and effects of intrauterine retention, and to determine whether the brain:liver weight ratio is a reliable marker of FGR in intrauterine death. METHODS: As part of a larger study examining autopsy findings in intrauterine death, data from two specialist centers in London were collated in a specially designed database. Autopsy and clinical information for > 1000 intrauterine deaths between 2005 and 2013 were extracted. Adjusted (delta) organ weights were calculated by plotting against gestational age female and male brain, liver, thymus, heart, combined kidney, combined lung, spleen and combined adrenal gland weights. Polynomial regression was used to determine best fit and to calculate expected (50th centile) organ weights and deviations from expected. We compared adjusted organ weights and body:organ weight ratios in fetuses which were small-for-gestational age (SGA) at autopsy (birth weight < 10th centile for normal live births) vs those in fetuses which were not, and in macerated vs non-macerated fetuses. RESULTS: The majority of fetal organs (brain, liver, heart, thymus, lungs, kidneys and thyroid) in SGA fetuses were significantly lighter than those in non-SGA fetuses. Body:organ weight ratios for thymus, liver and spleen were significantly greater in SGA fetuses, indicating these organs to be disproportionately small. The majority of organs were significantly lighter in macerated compared with non-macerated fetuses and body:organ weight ratios for most organs (liver, thymus, lung, pancreas, adrenal gland, kidney, heart) were significantly greater in macerated compared with non-macerated fetuses. When SGA cases with demonstrable placental histological abnormalities were compared with other SGA cases, there was a significant difference in the brain:liver weight ratio (median, 6 vs 3.5). CONCLUSION: Changes after intrauterine death lead to loss of fetal weight, with preferential weight loss of visceral organs such as the liver. Maceration therefore affects the brain:liver weight ratio and adjustment should be made for such changes during interpretation of ratios. Fetal organ weights may be affected significantly by mechanism of death and postmortem changes. The fetal brain:liver weight ratio may provide useful information regarding intrauterine growth status at time of death, provided that adjustment is made for effects of intrauterine retention and that appropriate cut-off values are used. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Asunto(s)
Autopsia , Muerte Fetal , Retardo del Crecimiento Fetal/diagnóstico , Retardo del Crecimiento Fetal/patología , Mortinato , Encéfalo/patología , Factores de Confusión Epidemiológicos , Femenino , Feto/patología , Edad Gestacional , Humanos , Hígado/patología , Pulmón/patología , Tamaño de los Órganos , Embarazo , Bazo/patología , Timo/patologíaRESUMEN
OBJECTIVE: To compare differences in cardiovascular (CV) risk factors assessment and management among patients with rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) with that of matched controls. METHODS: A matched cohort study was conducted using primary care electronic health records for one London borough. All patients diagnosed with RA or IBD, and matched controls registered with local general practices on 12th of January 2014 were identified. The study compared assessment and treatment of CV risk factors (blood pressure, body mass index, cholesterol and smoking) in the year before, the year after, and 5 years after RA and IBD diagnosis. RESULTS: A total of 1121 patients with RA and 1875 patients with IBD were identified and matched with 4282 and, respectively, 7803 controls. Patients with RA were 25% (incidence rate ratio, 1.25, 95% CI 1.12 to 1.35) more likely to have a CV risk factor measured compared with matched controls. The difference declined to 8% (1.08, 1.04 to 1.14) over 5â years of follow-up. The corresponding figures for IBD were 26% (1.26, 1.16 to 1.38) and 10% (1.10, 1.05 to 1.15). Patients with RA showed higher antihypertensive prescription rates during 5â years of follow-up (OR, 1.37, 95% CI 1.14 to 1.65) and patients with IBD showed higher statin prescription rates in the year preceding diagnosis (2.30, 1.20 to 4.42). Incomplete CV risk assessment meant that QRISK scores could be calculated for less than a fifth (17%) and clinical recording of CV disease (CVD) risk scores among patients with RA and IBD was 11% and 6%, respectively. CONCLUSIONS: The assessment and treatment of vascular risk in patients with RA and IBD in primary care is suboptimal, particularly with reference to CVD risk score calculation.
Asunto(s)
Artritis Reumatoide/epidemiología , Artritis Reumatoide/terapia , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/terapia , Enfermedades Inflamatorias del Intestino/epidemiología , Enfermedades Inflamatorias del Intestino/terapia , Pautas de la Práctica en Medicina/tendencias , Atención Primaria de Salud/tendencias , Adulto , Anciano , Antihipertensivos/uso terapéutico , Artritis Reumatoide/diagnóstico , Biomarcadores/sangre , Presión Sanguínea , Índice de Masa Corporal , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/fisiopatología , Estudios de Casos y Controles , Colesterol/sangre , Enfermedad Crónica , Dislipidemias/sangre , Dislipidemias/tratamiento farmacológico , Dislipidemias/epidemiología , Registros Electrónicos de Salud , Femenino , Adhesión a Directriz/tendencias , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Hipertensión/fisiopatología , Incidencia , Enfermedades Inflamatorias del Intestino/diagnóstico , Londres/epidemiología , Masculino , Persona de Mediana Edad , Obesidad/epidemiología , Obesidad/terapia , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Fumar/efectos adversos , Cese del Hábito de Fumar , Prevención del Hábito de Fumar , Factores de Tiempo , Salud Urbana/tendenciasRESUMEN
PURPOSE: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK. METHODS: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers. RESULTS: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)). CONCLUSIONS: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.