OBJECTIVES: To assess 30-day mortality from bacteremia in relation to age and comorbidity and the association between age and mortality with increasing comorbidity. DESIGN: Population-based cohort study. SETTING: North Jutland County, Denmark. PARTICIPANTS: Adults in medical wards with community-acquired bacteremia, 1995 to 2004. MEASUREMENTS: Smoothed mortality curves and computed mortality rate ratios (MRRs) using Cox regression analysis. RESULTS: Two thousand eight hundred fifty-one patients, 851 aged 15 to 64, 1,092 aged 65 to 79, and 909 aged 80 and older were included. Mortality increased linearly with age. Compared with patients younger than 65, adjusted MRRs in patients aged 65 to 79 and 80 and older were 1.5 (95% confidence interval (CI)=1.2-2.0) and 1.8 (95% CI=1.4-2.3), respectively. Mortality also increased with level of comorbidity. Compared with patients with low comorbidity, adjusted MRRs in patients with medium and high comorbidity were 1.5 (95% CI=1.2-1.8) and 1.7 (95% CI=1.4-2.2), respectively. Regardless of the level of comorbidity, MRRs were consistently higher in older than in younger patients. CONCLUSION: Older age and greater comorbidity predicted mortality, and increasing age-related comorbidity did not explain the effect of age.
 
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To quantify the effect of hand-hygiene interventions on rates of gastrointestinal and respiratory illnesses and to identify interventions that provide the greatest efficacy, we searched 4 electronic databases for hand-hygiene trials published from January 1960 through May 2007 and conducted meta-analyses to generate pooled rate ratios across interventions (N=30 studies). Improvements in hand hygiene resulted in reductions in gastrointestinal illness of 31% (95% confidence intervals [CI]=19%, 42%) and reductions in respiratory illness of 21% (95% CI=5%, 34%). The most beneficial intervention was hand-hygiene education with use of nonantibacterial soap. Use of antibacterial soap showed little added benefit compared with use of nonantibacterial soap. Hand hygiene is clearly effective against gastrointestinal and, to a lesser extent, respiratory infections. Studies examining hygiene practices during respiratory illness and interventions targeting aerosol transmission are needed.
 
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OBJECTIVES: To estimate the effects of excess body weight on objective and subjective physical function and mortality risks in noninstitutionalized older adults. DESIGN: Population-based cohort study. SETTING: The English Longitudinal Study of Ageing (ELSA). PARTICIPANTS: Three thousand seven hundred ninety-three participants in the ELSA aged 65 and older followed up for 5 years. MEASUREMENTS: Analyses compared the risks of impaired physical function and mortality for subjects who were at the recommended weight (body mass index (BMI)=20.0-24.9) with those who were overweight (BMI=25.0-29.9), obese (BMI=30.0-34.9) or severely obese (BMI>/=35.0). Outcome measures were difficulties with activities of daily living (ADLs), score on the Short Physical Performance Battery, and mortality. RESULTS: Participants in higher BMI categories had greater risk of impaired physical function at follow-up but little or no greater risk of mortality. For example, compared with men of recommended weight, obese men (BMI=30.0-34.9) had relative risk ratios of difficulties with ADLs of 1.99 (95% confidence interval (CI)=1.42-2.78), of measured functional impairment of 1.51 (95% CI=1.05-2.16), and of mortality of 0.99 (95% CI=0.60-1.61). Findings were robust when excluding those who lost weight, smoked, or had poor self-rated health. CONCLUSION: Excess body weight in people aged 65 and older is associated with greater risk of impaired physical function but not with greater mortality risk. Societies with growing numbers of overweight and obese older people are likely to face increasing burdens of disability-associated health and social care costs.
 
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OBJECTIVES: We investigated whether nonstandard work schedules by mothers were associated with adolescent overweight. METHODS: We conducted multiple regression analyses using a sample of mother-child pairs (n=2353) from the National Longitudinal Survey of Youth to examine the association between the number of years mothers worked at nonstandard schedules and adolescent overweight at age 13 or 14 years. Separate analyses were also conducted by family income and family type. RESULTS: Child`s body mass index increased significantly if mothers worked either a few years or many years at nonstandard schedules. Risk of overweight was also significantly associated with 1 to 4 and 10 or more years of maternal nonstandard work schedules. In both cases, results were driven by those families with predicted incomes in the 2nd quartile ("near-poor"), with a few or many years of nonstandard work schedules also associated with increased risk of adolescent overweight in 2-parent families. CONCLUSIONS: Results indicate the importance of the overlooked association between maternal nonstandard work schedules and adolescent overweight at age 13 or 14 years. Nonstandard work schedules among near-poor families and in 2-parent families may disrupt the work-family balance, affecting adolescent overweight.
 
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BACKGROUND: Indonesia has had the most human cases of highly pathogenic avian influenza A (H5N1) and one of the highest case-fatality rates worldwide. We described the factors associated with H5N1 case-fatality in Indonesia. METHODS: Between June, 2005, and February, 2008, there were 127 confirmed H5N1 infections. Investigation teams were deployed to investigate and manage each confirmed case; they obtained epidemiological and clinical data from case-investigation reports when possible and through interviews with patients, family members, and key individuals. FINDINGS: Of the 127 patients with confirmed H5N1 infections, 103 (81%) died. Median time to hospitalisation was 6 days (range 1-16). Of the 122 hospitalised patients for whom data were available, 121 (99%) had fever, 107 (88%) cough, and 103 (84%) dyspnoea on reaching hospital. However, for the first 2 days after onset, most had non-specific symptoms; only 31 had both fever and cough, and nine had fever and dyspnoea. Median time from onset to oseltamivir treatment was 7 days (range 0-21 days); treatment started within 2 days for one patient who survived, four (36.4%) of 11 receiving treatment within 2-4 days survived, six (37.5%) of 16 receiving treatment within 5-6 days survived, and ten (18.5%) of 44 receiving treatment at 7 days or later survived (p=0.03). Initiation of treatment within 2 days was associated with significantly lower mortality than was initiation at 5-6 days or later than 7 days (p<0.0001). Mortality was lower in clustered than unclustered cases (odds ratio 33.3, 95% CI 3.13-273). Treatment started at a median of 5 days (range 0-13 days) from onset in secondary cases in clusters compared with 8 days (range 4-16) for primary cases (p=0.04). INTERPRETATION: Development of better diagnostic methods and improved case management might improve identification of patients with H5N1 influenza, which could decrease mortality by allowing for earlier treatment with oseltamivir. FUNDING: None.
 
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Background: Quantitative evidence on the strength of the association between abdominal obesity and the incidence of type 2 diabetes was assessed. Methods: Systematic review of longitudinal studies assessing the relationship between measures reflecting abdominal obesity and the incidence of type 2 diabetes. Results: There was a strong association between measures reflecting abdominal obesity and the incidence of type 2 diabetes, the pooled odds ratio was 2.14 (95% CI: 1.70-2.71; p < 0.0001). Waist circumference (WC) was at least as good as other measures in predicting outcome. Conclusions: There is a strong association between measures reflecting abdominal obesity and the development of type 2 diabetes. Reducing WC may reduce the risk of developing type 2 diabetes.
 
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OBJECTIVES: To assess whether a pragmatic multidisciplinary fall-prevention program was more effective than usual care in preventing new falls and functional decline in elderly people. DESIGN: A two-group, randomized, controlled trial with 12 months of follow-up. SETTING: University hospital and home-based intervention, the Netherlands. PARTICIPANTS: Three hundred thirty-three community-dwelling Dutch people aged 65 and over who were seen in an emergency department after a fall. INTERVENTION: Participants in the intervention group underwent a detailed medical and occupational-therapy assessment to evaluate and address risk factors for recurrent falls, followed by recommendations and referral if indicated. People in the control group received usual care. MEASUREMENTS: Number of people sustaining a fall (fall calendar) and daily functioning (Frenchay Activity Index). RESULTS: Results showed no statistically significantly favorable effects on falls (odds ratio=0.86, 95% confidence interval (CI)=0.50-1.49) or daily functioning (regression coefficient=0.37, CI=-0.90 to 1.63) after 12 months of follow-up. CONCLUSION: The multidisciplinary fall-prevention program was not effective in preventing falls and functional decline in this Dutch healthcare setting. Implementing the program in its present form in the Netherlands is not recommended. This trial shows that there can be considerable discrepancy between the ``ideal`` (experimental) version of a program and the implemented version of the same program. The importance of implementation research in assessing feasibility and effectiveness of such a program in a specific healthcare setting is therefore stressed.
 
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BACKGROUND: Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed. RESEARCH DESIGN AND METHODS: We searched the Cochrane Collaboration`s Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics. RESULTS: Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6-13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17-117 prescriptions per 1000 person-years. Study methodologic quality was fair. CONCLUSIONS: QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.
 
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OBJECTIVE: Obesity and underweight in young adulthood are associated with greater risk of future disability pension. Neither underlying causes of disability pension nor whether overweight confers excess risk is established in this age group. The aim of this study was to investigate risk of future disability pension according to body mass index (BMI) in young adulthood. DESIGN: BMI was measured at military conscription (1969-1994; n=1 191 027; mean age 18.3+/-0.5 years). Date and cause of disability pension, death and emigration dates were collected from national registers (1971-2006). Muscular strength, age, municipality, socioeconomic position, testing center and year were adjusted for in Cox regressions. RESULTS: During 28.4 million person-years, 60 024 subjects were granted disability pension. The hazard ratios (HRs) for underweight (1.14, CI 95% 1.11-1.17), overweight (1.36, 1.32-1.40), moderate (BMI 30-34.9; 1.87, 1.76 to 1.99) and morbid obesity (BMI>or=35; 3.04, 2.72-3.40) were elevated compared to normal weight. Not adjusting for muscular strength led to overestimation of the risk in underweight (1.27, 1.24-1.31), but underestimation in overweight (1.29, 1.25-1.33), moderately (1.72, 1.62-1.82) and morbidly obese subjects (2.77, 2.48-3.09). For circulatory and musculoskeletal causes, respectively, HRs were elevated only for overweight (2.06; 1.82-2.34; 1.47; 1.39-1.55) and obesity (3.51; 2.79-4.40; 2.15; 1.94-2.38). The same applied for tumors and nervous system, but not psychiatric causes, for which underweight (1.20; 1.16-1.24) displayed similar HR as overweight (1.21; 1.16-1.27), whereas the risk in obese subjects was higher (1.60; 1.46-1.75). CONCLUSION: The risks in overweight and obese, but not underweight, subjects were significantly elevated for each cause investigated. Although causality cannot be inferred, productivity losses associated with adverse BMI in young adulthood appear to be large.
 
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Objective: Daughters of teenage mothers have increased risk for teenage childbearing, perpetuating intergenerational cycles. Using Ecological Systems Theory, this study prospectively examined risk factors for teenage childbearing among a national sample of adolescent girls. Design: Data came from the National Longitudinal Survey of Youth 1997. Participants (N = 1,430) were recruited in early adolescence and interviewed yearly for 6 years. Survival analysis was used to examine the rate of childbirth across the teenage years by maternal age at first birth. Hierarchical Cox regression was used to identify multivariate predictors of teenage childbearing and to test whether risk factors differed between daughters of teenage versus older mothers. Primary Outcome Measure: Age at first childbirth was based on cumulative information collected at yearly interviews. Results: Daughters of teenage mothers were 66% more likely to become teenage mothers, after accounting for other risks. Individual (school performance), family (maternal education, marital status, number of children), peer (dating history), and environmental (race, enrichment) factors predicted teenage childbearing. Risks unique to daughters of teenage mothers were deviant peer norms, low parental monitoring, Hispanic race, and poverty. Conclusion: Results support multidimensional approaches to pregnancy prevention, and targeted interventions addressing unique risk factors among daughters of teenage mothers. (PsycINFO Database Record (c) 2008 APA, all rights reserved).
 
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