A J Swerdlow, C D Higgins, M C Pike

Abstract

Design: Cohort study.

Setting: Hospital for Sick Children, Great Ormond Street, London.

Subjects: 1075 boys with cryptorchidism treated by orchidopexy or hormones at the hospital during 1951-64.

Main outcome measures: Relative risk of testicular cancer in the cohort compared with men in the general population.

Results: 12 testicular cancers occurred in 11 of the patients during follow up to mid-1990 (relative risk of cancer in males with cryptorchidism=7.5 (95% confidence interval 3.9 to 12.8)). The relative risk fell significantly beyond 15 years after orchidopexy but did not decrease with younger age at orchidopexy. Risk was significantly raised in testes that had had biopsy samples removed during orchidopexy (relative risk=66.7 (23.9 to 143.3) compared with a testis in a man in the general population) and was significantly greater in these testes than in undescended testes that had not had biopsy samples taken at orchidopexy (6.7 (2.7 to 13.5)). No reasons for biopsy or distinguishing clinical aspects of the testes that had had biopsy samples taken and later developed malignancies were evident in the case notes. No histological abnormalities were evident at initial biopsy except in one testis that had features of dysgenesis.

Conclusions: Biopsy seems to be a stronger risk factor for testicular cancer than any factor previously identified. The trauma of open biopsy may contribute substantially to risk of malignancy or the testes may have been selected for biopsy on the basis of clinical factors predictive of malignancy but not mentioned in the case notes.

Epidemiological Monitoring Unit,
Department of Epidemiology and Population Sciences,
London School of Hygiene and Tropical Medicine,
Keppel Street,
London WC1E 7HT
A J Swerdlow, professor of epidemiology
C D Higgins, lecturer in medical statistics

University of Southern California School of Medicine,
Department of Preventive Medicine,
Norris Cancer Center,
1441 Eastlake Avenue,
Los Angeles,
CA 90033-0800,
USA
M C Pike, professor of preventive medicine

Correspondence to: Professor Swerdlow.

Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus

Klas Malmberg for the DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group

Abstract

Design: Patients with diabetes mellitus and acute myocardial infarction were randomly allocated standard treatment plus insulin-glucose infusion for at least 24 hours followed by multidose insulin treatment or standard treatment (controls).

Subjects: 620 patients were recruited, of whom 306 received intensive insulin treatment and 314 served as controls.

Main outcome measure: Long term all cause mortality.

Results: The mean (range) follow up was 3.4 (1.6-5.6) years. There were 102 (33%) deaths in the treatment group compared with 138 (44%) deaths in the control group (relative risk (95% confidence interval) 0.72 (0.55 to 0.92); P=0.011).The effect was most pronounced among the predefined group that included 272 patients without previous insulin treatment and at a low cardiovascular risk (0.49 (0.30 to 0.80); P=0.004).

Conclusion: Insulin-glucose infusion followed by intensive subcutaneous insulin in diabetic patients with acute myocardial infarction improves long term survival, and the effect seen at one year continues for at least 3.5 years, with an absolute reduction in mortality of 11%. This means that one life was saved for nine treated patients. The effect was most apparent in patients who had not previously received insulin treatment and who were at a low cardiovascular risk.

Department of Cardiology,
Karolinska Hospital,
S-171 76 Stockholm,
Sweden
Klas Malmberg, cardiologist

Case-control study of sudden infant death syndrome in Scotland, 1992-5

Hazel Brooke, Angus Gibson, David Tappin, Helen Brown

Abstract

Methods: National study of 201 infants dying of the sudden infant death syndrome (cases) and 276 controls by means of home interviews comparing methods of infant care and socioeconomic factors.

Results: Sleeping prone (odds ratio 6.96 (95% confidence interval 1.51 to 31.97)) and drug treatment in the previous week (odds ratio 2.33 (1.10 to 4.94)) were more common in the cases than controls on multivariate analysis. Smoking was confirmed as a significant risk factor (odds ratio for mother and father both smoking 5.19 (2.26 to 11.91)). The risk increased with the number of parents smoking (P<0.0001), with the number of cigarettes smoked by mother or father (P=0.0001), and with bed sharing (P<0.005). A new finding was an increased risk of dying of the syndrome for infants who slept at night on a mattress previously used by another infant or adult (odds ratio 2.51 (1.39 to 4.52)). However, this increased risk was not established for mattresses totally covered by polyvinyl chloride.

Conclusions: Sleeping prone and parental smoking are confirmed as modifiable risk factors for the sudden infant death syndrome. Sleeping on an old mattress may be important but needs confirmation before recommendations can be made.

Scottish Cot Death Trust,
Royal Hospital for Sick Children,
Glasgow G3 8SJ
Hazel Brooke, executive director
Angus Gibson, chairman
David Tappin, senior lecturer in community paediatrics, University of Glasgow

Medical Statistics Unit,
University of Edinburgh Medical School,
Edinburgh EH8 9AG
Helen Brown, research associate

Correspondence to: Mrs Brooke.

Reproductive pattern, perinatal mortality, and sex preference in rural Tamil Nadu, South India: community based, cross sectional study

Birgitte Bruun Nielsen, Jerker Liljestrand, Morten Hedegaard, Shakuntala Haraksingh Thilsted, Abraham Joseph

Abstract

Design: Community based, cross sectional questionnaire study of 30 randomly selected areas served by health subcentres.

Setting: Rural parts of Salem District, Tamil Nadu, South India.

Subjects: 1321 women and their offspring delivered in the 6 months before the interview.

Main outcome measures: Number of pregnancies, pregnancy outcome, spacing of pregnancies, sex of offspring, perinatal and neonatal mortality rates.

Results: 41% of the women (535) were primiparous; 7 women (0.5%) were grand multiparous (g6 births). The women had a mean age of 22 years and a mean of 2.3 pregnancies and 1.8 live children. The sex ratio at birth of the index children was 107 boys per 100 girls. The stillbirth rate was 13.5/1000 births, the neonatal mortality rate was 35.3/1000, and the perinatal mortality rate was 42.0/1000. Girls had an excess neonatal mortality (rate ratio 3.42; 95% confidence interval 1.68 to 6.98; this was most pronounced among girls born to multiparous women with no living sons (rate ratio 15.48 (2.04 to 177.73) v 1.87 (0.63 to 5.58) in multiparous women with at least one son alive).

Conclusions: In this rural part of Tamil Nadu, women had a controlled reproductive pattern. The excess neonatal mortality among girls constitutes about one third of the perinatal mortality rate. It seems to be linked to a preference for sons and should therefore be addressed through a holistic societal approach rather than through specific healthcare measures.

Perinatal Epidemiological Research Unit,
Department of Obstetrics and Gynaecology,
Aarhus University Hospital,
8200 Aarhus N,
Denmark
Birgitte Bruun Nielsen, research fellow
Morten Hedegaard, registrar

Baltic International School of Health,
37185 Karlskrona,
Sweden
Jerker Liljestrand, senior lecturer

Research Department of Human Nutrition,
The Royal Veterinary and Agricultural University,
Rolighedsvej 30,
1958 Frederiksberg C,
Denmark
Shakuntala Haraksingh Thilsted, associate professor

Community Health Department,
Christian Medical College,
Vellore 632 002,
Tamil Nadu,
South India
Abraham Joseph, professor

Correspondence to: Dr Nielsen.

Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis

Christopher Del Mar, Paul Glasziou, Mauricio Hayem

Abstract

Design: Systematic search of the medical literature to identify studies that used antibiotics in randomised controlled trials to treat acute otitis media. Studies were examined blind, and the results of those of satisfactory quality of methodology were pooled.

Subjects: Six studies of children aged 7 months to 15 years.

Main outcome measures: Pain, deafness, and other symptoms related to acute otitis media or antibiotic treatment.

Results: 60% of placebo treated children were pain free within 24 hours of presentation, and antibiotics did not influence this. However, at 2-7 days after presentation, by which time only 14% of children in control groups still had pain, early use of antibiotics reduced the risk of pain by 41% (95% confidence interval 14% to 60%). Antibiotics reduced contralateral acute otitis media by 43% (9% to 64%). They seemed to have no influence on subsequent attacks of otitis media or deafness at one month, although there was a trend for improvement of deafness at three months. Antibiotics were associated with a near doubling of the risk of vomiting, diarrhoea, or rashes (odds ratio 1.97 (1.19 to 3.25)).

Conclusions: Early use of antibiotics provides only modest benefit for acute otitis media: to prevent one child from experiencing pain by 2-7 days after presentation, 17 children must be treated with antibiotics early.

Centre for General Practice,
University of Queensland Graduate School of Medicine,
Brisbane,
Australia 4006
Christopher B Del Mar, professor of general practice
Paul P Glasziou, reader
Mauricio Hayem, postgraduate student

Correspondence to: Professor Del Mar.