The Australian general practice morbidity and prescribing survey, 1969 to 1974. 5. Aspects of morbidity: diseases of the circulatory system.
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Adult↗
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The Australian general practice morbidity and prescribing survey, 1969 to 1974. 5. Aspects of morbidity: respiratory infections.
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Adolescent↗
The Australian general practice morbidity and prescribing survey. 1969 to 1974. 5. Aspects of morbidity: asthma.
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Asthma↗
The Australian general practice morbidity and prescribing survey, 1969 to 1974. 5. Aspects of morbidity: diseases of the digestive system.
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Adult↗
The Australian general practice morbidity and prescribing survey, 1969 to 1974. 5. Aspects of morbidity: diseases of skin and subcutaneous tissue.
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Adolescent↗
The Australian general practice morbidity and prescribing survey, 1969 to 1974. 5. Aspects of morbidity: accidents, poisoning and violence.
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Adolescent↗
Morbidity profile and its relationship with disability and psychological distress among elderly people in Northern India.
BACKGROUND: Morbidity among elderly people has an important influence on their physical functioning and psychological well-being. Evaluation of the morbidity profile and its determinants, which have implications for elderly people, are not available. The objective of this study is to assess morbidity, co-morbidity, and patterns of treatment seeking, and to determine relationship of morbidity with disability, psychological distress, and socio-demographic variables among the elderly population in northern India. METHODS: A cross-sectional survey of 200 subjects over 60 years old (100 each from the urban population of Chandigarh City and the rural population of Haryana State of India) was carried out using a cluster sampling technique. The study period was July 1999-April 2000. Various socio-demographic characteristics were recorded at baseline. A clinical diagnosis was made by a physician based on reported illness, clinical examination, and cross-checking of medical records and medications held by the subjects. Psychological distress and disability was assessed using the PGI-Health Questionnaire-N-1 and the Rapid Disability Rating Scale-2, respectively. ANOVA, Kruskal-Wallis H test, correlation coefficient, and multivariate analysis were used to assess the relationship and association of morbidity with other variables. RESULTS: Of the total sample, 88.9% reported illness based on their perception, and of these 43.5% were seeking treatment and actually taking medicines, and 42.5% were diagnosed as having 4-6 morbidities. The mean number of morbidities among elderly people was 6.1 (SD 2.9). A total of 87.5% had minimal to severe disabilities and 66% of elderly people were distressed physically, psychologically, or both. The most prevalent morbidity was anaemia, followed by dental problems, hypertension, chronic obstructive airway disease (COAD), cataract, and osteoarthritis. Morbidities like asthma, COAD, hypertension, osteoarthritis, gastrointestinal disorders, anaemia, and eye and neurological problems were significantly associated with disability and distress. Higher number of morbidities was associated with greater disability and distress. In univariate analysis, socio-demographic variables like age, locality, caste, education, occupation, and income were important determinants of morbidity. Multivariate analysis was undertaken to find out the independent relationship of socio-demographic variables with morbidity. Morbidity was significantly associated with age (b value 0.06, 95% CI: 0.01, 0.12), sex (b value 1.03, 95% CI: 0.02, 2.05), and occupation (b value 0.20, 95% CI: 0.07, 0.33). CONCLUSIONS: A high mean number of morbidities (6.1, SD 2.9) was observed. Elderly subjects with higher morbidity had increasing disability and distress. Age, sex, and occupation were important determinants of morbidity. Assessment of the morbidity profile and its determinants will help in the application of interventions, both medical and social, to improve the health status and thus the quality of life of the elderly in Northern India.
Aged↗
Early and late radiotherapeutic morbidity in 442 consecutive patients with locally advanced carcinoma of the uterine cervix.
PURPOSE: to evaluate the early and late radiotherapeutic morbidity after combined external and intracavitary radiotherapy to the uterine cervix. METHODS AND MATERIALS: The morbidity in 442 consecutive cervical cancer patients FIGO Stage IIB (139), IIIA (10), IIIB (221) and IVA (72) treated from 1974 to 1984 were recorded retrospectively according to our own previously described system (18). This system is based on the assumption that radiotherapeutic morbidity progresses in severity with time wherefore successive morbidity scoring rather than recording the maximal damage alone is required to estimate the burden of complications for a group of patients. The early and late morbidity (within or beyond 3 months after the end of radiotherapy) was graded into mild, moderate, severe, and causing death depending on the symptoms and signs, and the requirement and type of therapy. The late morbidity was characterized by both the frequency and the actuarially corrected estimate. Also, the combined morbidity in two, three, four and five organs and the probability of surviving without tumor recurrence and/or significant late morbidity were evaluated. RESULTS: Early morbidity was most frequently seen in the rectosigmoideum (61%) and urinary bladder (27%). Medication for early morbidity was required in 68% and hospitalization in 10% of the patients. The frequencies of each late morbidity grade did not differ in relation to FIGO Stage while the actuarial estimates increased significantly with increasing stage. This reflects the poor prognosis in the more advanced stages, where few patients survived to develop late morbidity, and also points to the importance of latency in reporting late radiotherapeutic morbidity. In Stage IVA patients, the ratios between the actuarial estimate and the frequency of late severe rectosigmoid and urinary bladder morbidity were as high as 2.5 and 3, respectively. The highest 5-year risks (+/- 1 SE of the estimate) of late severe morbidity were found for the rectosigmoideum (28% +/- 3), small intestine (13% +/- 2) and urinary bladder (10% +/- 2). Rectosigmoid and urinary bladder complications constituted the most important part of the combined organ morbidity. Almost half of the patients developing late moderate rectosigmoid and one-third of those developing late moderate bladder complications, did so within one year after radiotherapy. Almost all complications were developed within 3 to 4 years after radiotherapy. The probability of surviving without recurrence and/or severe combined rectosigmoid and urinary bladder morbidity was low (23% +/- 2). CONCLUSION: Actuarial estimates rather than frequencies should be reported to avoid underestimation of the risk of late radiotherapeutic morbidity in long-term survivors.
Adult↗
Urinary morbidity with a modified peripheral loading technique of transperineal (125)i prostate implantation.
PURPOSE: Analysis of urinary morbidity within the first 12 months following a modified peripheral loading technique for permanent transperineal transrectal ultrasound (TRUS) guided (125)I prostate implantation and comparison of urinary morbidity with various clinical and implant parameters. MATERIALS AND METHODS: Between October 1, 1996, and March 11, 1998, 87 patients with favorable, early stage prostate cancer were treated with permanent transperineal TRUS guided (125)I prostate implantation. A peripheral loading technique was utilized for source placement with 75-80% source distribution in the periphery and 20-25% source distribution centrally. A mean total activity of 38 mCi of (125)I was implanted (range, 19-66 mCi). The mean source activity was 0.43 mCi/source (range, 0.26-0.61 mCi/source) and the mean number of sources implanted was 88 (range, 56-134). The minimum prescribed dose to the prostate was 145 Gy. The median D(90), V(100), and V(150) were 152 Gy (range, 104-211 Gy), 92% (range, 71-99%), and 61% (range, 11-89%), respectively. The median follow-up time was 19 months (range, 12-29 months). Urinary morbidity was scored at 3 weeks and then at 3-month intervals for the first 2 years using a modified Radiation Therapy Oncology Group (RTOG) grading system (scale 0-5). RESULTS: Most patients developed at least minor urinary symptoms with frequency or nocturia being the most common. Overall, 79% (69/87) of patients experienced urinary morbidity with 21% (18/87) reporting no symptoms. The incidence of overall Grade 1 urinary morbidity was 37% (32/87); Grade 2 morbidity was 37% (32/87); and Grade 3 morbidity was 6% (5/87). There was no Grade 4 or 5 morbidity. The incidence of Grade 0 frequency/nocturia was 36% (31/87); Grade 1 was 33% (29/87); Grade 2 was 30% (26/87); and Grade 3 was 1% (1/87). Grade 0 dysuria was seen in 56% (49/87) of patients; 32% (28/87) had Grade 1; 10% (9/87) Grade 2; and 1% (1/87) Grade 3 dysuria. Most urinary symptoms started a few weeks after implantation and began to subside by 6 months. At 12 months, 22% (19/87) of patients had persistent urinary symptoms (78% Grade 0, 15% Grade 1, 3% Grade 2, and 3% Grade 3). The mean urethral point dose was 174 Gy (range, 99-315 Gy). The mean number of sources implanted correlated significantly with the likelihood of developing acute urinary morbidity (p = 0.03). The total activity implanted also correlated with the morbidity outcome dysuria (p = 0.01) with a threshold seen at 37 mCi. Urethral point dose, source activity, intraoperative TRUS prostate volume, D(90), V(100), V(150), patient age, pretreatment PSA, Gleason score, and T stage did not correlate with morbidity. CONCLUSIONS: Permanent transperineal TRUS guided (125)I prostate implantation using a modified peripheral loading technique is associated with mild urinary morbidity that resolves in 78% of patients by 12 months. Grade 3 urinary morbidity was encountered in only 6% (5/87) of patients. Urinary morbidity may be related to the total number of sources implanted and/or the total activity implanted. Overall urinary morbidity was not correlated with urethral point dose, source activity, intraoperative TRUS prostate volume, D(90), V(100), V(150), patient age, pretreatment PSA, Gleason score, and T stage. The low incidence of urinary morbidity may be a consequence of our modified peripheral loading technique and/or the selection of patients with good-to-excellent preimplant urological parameters. Longer follow-up is necessary to assess biochemical control rates and long-term morbidity.
Aged↗
Evaluation of morbidity after external radiotherapy and intracavitary brachytherapy in 771 patients with carcinoma of the uterine cervix or endometrium.
PURPOSE: The aim of the present study was to evaluate early and late radiation morbidity and to assess the factors influencing morbidity in patients with cervical or endometrial cancer treated by a combination of external radiotherapy (ERT) and intracavitary brachytherapy (IBRT). MATERIALS AND METHODS: Early and late radiation morbidity were evaluated retrospectively using RTOG/EORTC criteria and Franco-Italian glossary in 771 patients treated between November 1992 and December 1999. RESULTS: Four hundred and seven patients (52.8%) had endometrial carcinoma and 364 (47.2%) had carcinoma of the cervix. One hundred and fifty-four patients with cervical carcinoma were inoperable. In patients with endometrial carcinoma total doses at the vagina, bladder and rectum were 60.36 Gy, 56.2 Gy and 55.6 Gy respectively. Biologically equivalent doses (BED) for the same points were 79.35, 68.63 and 67.37, respectively for early effects and 123.67, 97.65 and 94.85, respectively for late effects. One hundred and sixty-nine patients (41.5%) developed acute morbidity, grade I and II bladder morbidity being the most common type and 85 patients (20.9%) developed late morbidity, grade I and II vaginal morbidity being the most common type. No grade IV morbidity was recorded. Total doses at the vagina, bladder and rectum in operated cervix cancer patients were 60.51 Gy, 56.53 Gy and 55.67 Gy, respectively. BED for the same points were 79.77, 69.36 and 67.52, respectively for early effects and 124.74, 99.3 and 95.17, respectively for late effects. Eighty patients (38.1%) developed early morbidity. Grade I and II bladder morbidity was the most common type. Sixty-five patients (30.9%) developed late morbidity, vaginal morbidity being the most common type. Total doses at the vagina, bladder and rectum in inoperable patients were 70.92 Gy, 66.71 Gy and 62.38 Gy, respectively. BED for the same points were 97.43, 89.64 and 81.63, respectively for early effects and 159.3, 143.16 and 126.56, respectively for late effects. Sixty patients (39%) developed acute morbidity which was grade I or II bladder morbidity in 95%. Ninety-five patients (61.7%) developed late morbidity which was grade I-III vaginal morbidity in 94%. CONCLUSION: Patients with cervical or endometrial cancer can be treated safely by a combination of ERT and IBRT. However the patients should be assessed before, during and after treatment and at every period of follow-up using a standard and well-defined system in order to define and predict the morbidity rate.
Adult↗
Familial aggregation of morbid obesity.
Recent studies have shown major gene effects for obesity in randomly ascertained families. To investigate the familial aggregation of a specific subset of obesity, which is particularly prone to medical complications, families with morbid obesity were studied. This condition occurs in 1%-2% of the population and is defined as 45.5 kg (100 pounds) or more over ideal weight. First-degree relatives of 221 morbidly obese probands (1560 adults) were identified, and height and weight (current and greatest) were obtained from each family member. Morbid obesity occurred in the family members of the probands 8 times more often than in the general population. Of the morbidly obese probands, 48% had one or more first-degree relatives who were also morbidly obese compared to a 6% population estimate. By the ages of 20-24, 12% of the morbidly obese probands were already 45.5 kg or more overweight, and 45% were 22.7 kg (50 pounds) or more overweight. There was little difference in the prevalence of familial morbid obesity by the gender of the probands: 47% of the male probands and 48% of the female probands had another morbidly obese relative, while 67% and 53% of the early onset (before age 25) male and female probands, respectively, had one or more first-degree relatives who were also morbidly obese. In addition to the extreme degree of familial aggregation, the prevalence of morbid obesity in parent-offspring sets was calculated within the morbidly obese families. Morbidly obese families who have one or two morbidly obese parents have a 2.6 times increased risk (p<0.002) of having one or more morbidly obese adult offspring, compared to families who have neither parent morbidly obese. Evidence for trimodality of the body mass index distribution was found for each gender (p = 0.0006 for male relatives and p = 0.075 for female relatives). The strong familial aggregation of morbid obesity indicates the need for further understanding of the genetic determinants of this extreme clinical disorder and how environmental factors affect the genetic expression of the trait.
Adult↗
Co-morbidities and survival of men with localized prostate cancer treated with surgery or radiation therapy.
PURPOSE: We determined the impact of preexisting co-morbidities on survival of men with clinical stages T1b and T2NXM0 prostate cancer treated with surgery or radiation therapy. MATERIALS AND METHODS: A weighted co-morbidity score was determined for 276 consecutive men treated with surgery (138) or radiation therapy (138) at a Veterans Affairs medical center and was correlated with actuarial freedom from death due to co-morbid disease. RESULTS: After a median potential followup of 7.0 years 91 patients (33%) died of co-morbid disease and 20 (7%) died of cancer related causes. There were highly significant correlations between actuarial survival and weighted co-morbidity (p < 0.000001), and the 10-year actuarial survivals in men with no or severe co-morbidities were 66 and 9%, respectively. Associations between patient age and co-morbidity score were highly significant (p < 0.0001). The age adjusted risk of co-morbid death was 5.7 times greater in men with severe compared to no co-morbidities. There were also significant correlations between actuarial survival and weighted co-morbidity among patients treated with surgery (p = 0.02) and radiation therapy (p = 0.0002). Patient age and severity of co-morbidities were significantly greater among men treated with radiation therapy compared to surgery, and age adjusted risk of co-morbid death among men with a co-morbidity score of 1 was 3.8 times greater among men treated with radiation therapy (p = 0.025). CONCLUSIONS: Cancer related deaths are unusual within 5 to 10 years after surgery or radiation therapy in men with stages T1b and 2 prostate cancer. The risk of death during this interval is directly related to the severity of co-morbid conditions, which should be factored in an individual when assessing the advisability of therapeutic intervention. Since patient co-morbidities impact all cause survival, quantitative assessment of co-morbidities using validated instruments offers a method to control partially for the variabilities of health status among men receiving different treatments for localized prostate cancer.
Aged↗
The incidence of morbidities in a cohort of neonates in rural Gadchiroli, India: seasonal and temporal variation and a hypothesis about prevention.
BACKGROUND: The incidence of morbidities among home-cared neonates in rural areas has not been studied. OBJECTIVES: To estimate the incidence of various neonatal morbidities and the associated risk of death in home-cared neonates in rural setting. To estimate the variation in the incidence of neonatal morbidities by season and by day of life. To identify the scope for prevention of morbidities and suggest a hypothesis. STUDY DESIGN: A prospective observational study nested in the first year of the field trial in rural Gadchiroli, India. Trained village health workers in 39 villages observed neonates at the time of birth and in subsequent eight home visits up to 28 days. We diagnosed 20 neonatal morbidities by using clinical definitions. The data were analyzed for the incidence, case fatality, and relative risk of death and for the seasonal and day-wise variation in the incidence of morbidities. RESULTS: We observed total 763 neonates in 1 year. The incidence of morbidities was a mean of 2.2 morbidities per neonate. The case fatality in 13 morbidities was >10%. Only 2.6% neonates were seen or treated by a physician, and 0.4% were hospitalized. Hypothermia, fever, upper respiratory symptoms, umbilical and skin infections, and conjunctivitis showed statistically significant seasonal variation. Although the morbidities were concentrated in the first week of life, new cases continued to appear throughout the neonatal period. Various morbidities showed different distribution of incidence during 1 to 28 days. CONCLUSIONS: A large burden of disease occurs in rural home-cared neonates, and many morbidities are associated with high case fatality. Some morbidities show strong seasonal and day-wise variation in incidence, indicating poor care at home. We hypothesize that changes in practices and better home-based care will prevent the seasonal and temporal increase in morbidities. Some morbidities may not be preventable and will need early detection and treatment. Therefore, frequent home visits by a health worker are necessary to identify sick neonates.
Age Distribution↗
Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery.
OBJECTIVE: Assess effects of body mass index (BMI) on trial of labor after previous cesarean delivery and determine whether morbidly obese women have greater maternal and perinatal morbidity with trial of labor compared with elective repeat cesarean delivery. METHODS: Secondary analysis from a prospective observational study included all term singletons undergoing trial of labor after previous cesarean delivery. Body mass index groups were as follows: normal 18.5-24.9, overweight 25.0-29.9, obese 30.0-39.9, morbidly obese 40.0 kg/m2 or greater, and were compared for failure and maternal and neonatal morbidities. The morbidly obese trial of labor and elective repeat cesarean delivery were compared for maternal and neonatal morbidities. Multivariable logistic regression analysis controlled for confounding variables. RESULTS: There were 14,142 trial of labor participants and 14,304 elective repeat cesarean delivery participants. Increasing BMI was directly associated with failed trial of labor after previous cesarean delivery: from 15.2% in normal weight (1,344) to 39.3% in morbidly obese (1,638), with combined risk of rupture/dehiscence increasing from 0.9% to 2.1% in morbidly obese women. Among morbidly obese women, trial of labor carried greater than five-fold risk of uterine rupture/dehiscence (2.1% versus 0.4%), almost a two-fold increase in composite maternal morbidity (7.2% versus 3.8%) and five-fold risk of neonatal injury (1.1% versus 0.2%) (fractures, brachial plexus injuries, and lacerations), but no neonatal encephalopathy. Morbidly obese women failing a trial of labor had six-fold greater composite maternal morbidity than those undergoing a successful trial of labor (14.2% versus 2.6%). CONCLUSION: Body mass index correlates with outcomes in trial of labor after previous cesarean delivery. Morbidly obese women undergoing a trial of labor were at increased risk for failure. Increased BMI was associated with greater composite morbidity and neonatal injury compared with elective repeat cesarean delivery, but absolute morbidities were small. Increased risks should be considered before trial of labor after previous cesarean delivery. LEVEL OF EVIDENCE: II-2.
Adult↗
Co-morbidities in trauma patients: common and significant.
INTRODUCTION: Trauma is a heterogeneous 'disease' that affects all age groups with varying degrees of severity. While injury severity, time to definitive care, and the quality of care in trauma patients have been quantified, it has been much more difficult to quantify pre-existing health status or 'host factors' in trauma patients and relate them to trauma outcome. Numerous studies have attempted this task, but none have succeeded in producing a simple system to quantify co-morbidities. As a prelude to developing a simple Abbreviated injury scale (AIS)-like score, the incidence of major and minor co-morbidities (and outcomes) in a cohort of admitted trauma patients > or =40 years of age were evaluated. METHODS: A prospective review of the Auckland Trauma Registry of trauma patients age > or =40 years that were admitted to Auckland Hospital between 1 January 2003 and 3 March 2003 was performed. Among the data collected were the patient's co-morbidities. The co-morbidities were divided into major and minor co-morbidities: major co-morbidities were defined by criteria found in the APACHE 2 PIC system, whereas minor co-morbidities were all the other co-morbidities not included in the APACHE 2 PIC system. RESULTS: A total of 105 patients were included. There were 57 males and 48 females in this study. Overall, 71% of the population had pre-existing co-morbid conditions, with 23% having a major co-morbid condition. Major trauma [injury severity score (ISS) of 15] was seen to decrease as age increases. The mortality rate in this group of patients was 4.7%. DISCUSSION: Co-morbidities were surprisingly common in trauma patients. Trauma outcome in patients with co-morbidities is difficult to predict and is not well addressed by any of the existing injury scales. The possibility of developing single 'AIS-like' co-morbidity score merits ongoing evaluation. The prevalence of co-morbidities in trauma patients > or =40 years of age suggests that the influence of co-morbidity on outcome should be considered in a much greater cohort than is currently the case.
APACHE↗
Morbidity in early childhood: family patterns in relation to sex, birth order, and social class.
BACKGROUND AND OBJECTIVES: This study investigated family patterns of morbidity in early childhood related to different degrees of severity of morbidity, sex, birth-order position, and social class. METHODS: The study was performed using data collected by the Continuous Morbidity Registration Project of the Department of Family Practice of the Nÿmegen University in the Netherlands. All recorded morbidity and a number of sociodemographic data (sex, birth order, and social class) were available. The study population included children (783 boys, 730 girls) born in the four practices from 1971 to 1985 and their parents. The children were followed until age five. Morbidity of children during the first five years of life and their parents during the same five years was categorized into three levels of seriousness and 10 morbidity groups. RESULTS: Correlations between morbidity of children and their mothers were high, particularly for nonserious morbidity (0.45-0.49). Correlations between morbidity of fathers and their children were similar for moderate and nonserious morbidity (0.30). Logistic regression analysis showed that the morbidity of the mother was the most important factor in predicting childhood morbidity. CONCLUSIONS: Although morbidity in early childhood was associated with sex, birth order, and social class, the morbidity of the parents, in particular the mother, was by far the most important factor.
Adult↗
Radiation therapy morbidity in carcinoma of the uterine cervix: dosimetric and clinical correlation.
PURPOSE: To quantitate the impact of total doses of irradiation, dose rate, and ratio of doses to bladder or rectum and point A on sequelae in patients treated with irradiation alone for cervical cancer. METHODS AND MATERIALS: Records were reviewed of 1456 patients (Stages IB-IVA) treated with external-beam irradiation plus two low-dose rate intracavitary insertions to deliver 70 to 90 Gy to point A. Follow-up was obtained in 98% of patients (median, 11 years; minimum, 3 years; maximum, 30 years). The relationships among various dosimetry parameters and Grade 2 or 3 sequelae were analyzed. RESULTS: In Stage IB, the frequency of patients developing Grade 2 morbidity was 9%, and Grade 3 morbidity, 5%; in Stages IIA, IIB, III, and IVA, Grade 2 morbidity was 10% to 12% and Grade 3 was 10%. The most frequent Grade 2 sequelae were cystitis and proctitis (0.7% to 3%). The most common Grade 3 sequelae were vesicovaginal fistula (0.6% to 2% in patients with Stage I-III tumors), rectovaginal fistula (0.8% to 3%), and intestinal obstruction (0.8% to 4%). In the bladder, doses below 80 Gy correlated with less than 3% incidence of morbidity and 5% with higher doses (p = 0.31). In the rectosigmoid, the incidence of significant morbidity was less than 4% with doses below 75 Gy and increased to 9% with higher doses. For the small intestine, the incidence of morbidity was less than 1% with 50 Gy or less, 2% with 50 to 60 Gy, and 5% with higher doses to the lateral pelvic wall (p = 0.04). When the ratio of dose to the bladder or rectum in relation to point A was 0.8 or less, the incidence of rectal morbidity was 2.5% (8 of 320) vs. 7.3% (80 of 1095) with higher ratios (p < or = 0.01); bladder morbidity was 2.3% (7 of 305) and 5.8% (64 of 1110), respectively (p = 0.02). The incidence of Grade 2 and 3 bladder morbidity was 2.9% (10 of 336) when the dose rate was less than 0.80 Gy/h, in contrast to 6.1% (62 of 1010) with higher dose rates (p = 0.07). Rectal morbidity was 2% to 5% in Stage IB, regardless of dose rate to the rectum; in Stages IIA-B and III, morbidity was 5.2% (28 of 539) with a dose rate of 0.80 Gy or less and 10.7% (37 of 347) with higher dose rates (p < 0.01). Multivariate analysis showed that dose to the rectal point was the only factor influencing rectosigmoid sequelae, and dose to the bladder point affected bladder morbidity. CONCLUSIONS: Various dosimetric parameters correlate closely with the incidence of significant morbidity in patients treated with definitive irradiation for carcinoma of the uterine cervix. Careful dosimetry and special attention to related factors will reduce morbidity to the lowest possible level without compromising pelvic tumor control.
Brachytherapy↗
Why do neonates die in rural Gadchiroli, India? (Part II): estimating population attributable risks and contribution of multiple morbidities for identifying a strategy to prevent deaths.
OBJECTIVES: The understanding about why neonates die in rural areas in developing countries is limited. In the first year (1995 to 1996) of the field trial of home-based neonatal care in rural Gadchiroli, India, we prospectively observed a cohort of neonates in 39 villages. In Part I of this article, we presented the primary causes of death. The data were further analyzed: To estimate the population attributable risk (PAR) of death for the main causes of neonatal mortality. To evaluate the effect of a multiplicity of morbidities and to identify which morbidity combinations cause neonatal deaths. To develop a hypothesis about how best to reduce neonatal mortality. STUDY DESIGN: We analyzed the observational data by logistic regression to estimate the PAR of death for six major morbidities. The effect of the number of morbidities per neonate on case fatality (CF) was estimated. Then we identified the main combinations of morbidities as the component causes leading to death. We estimated the excess deaths attributable to sepsis. RESULTS: This cohort included 763 neonates among whom 40 neonatal deaths occurred. Six major morbidities were associated with the following proportion of deaths: preterm, 62.5%; sepsis, 60%; intrauterine growth restriction (IUGR), 27.5%; asphyxia, 25%; hypothermia, 22.5%, and feeding problems, 15%. The estimated PARs were: preterm, 0.74; IUGR, 0.55; sepsis, 0.55; asphyxia, 0.35; hypothermia, 0.08, and feeding problems, 0.04. The CF associated with the number of morbidities per neonate was: with no morbidity, 0.3%; one morbidity, 2.1%; two morbidities, 15.3%; three or more morbidities, 41.4% (p<0.001). In all, 82.5% of all deaths occurred in neonates with two or more morbidities. The proportion of total deaths associated with only preterm was 7.5%, and with only IUGR was 2.5%; however, with the main morbidity combinations it was preterm+sepsis, 35%; IUGR+sepsis, 22.5%; preterm+asphyxia, 20%; preterm+hypothermia, 15%; and preterm+feeding problem, 12.5%. The % CF with low birth weight (LBW) <2500 g alone was 5.2% and with infection alone was 1.9%, but with LBW+infection it was 31.9%. The estimated excess deaths caused by sepsis over and above LBW was 44% of the total deaths. CONCLUSIONS: Preterm and IUGR are ubiquitous components, but usually not sufficient to cause death. Most deaths occur due to a combination of preterm or IUGR with other comorbidities. If preterm birth or IUGR cannot be prevented, the strategy should be to ensure neonatal survival by addressing comorbidities, that is, infections, asphyxia, hypothermia, and feeding problems in that order of priority. We hypothesize that the prevention and/or management of neonatal infections will reduce neonatal mortality by 40 to 50%.
Cause of Death↗