An epidemiological study of acute carbon monoxide poisoning in the West Midlands

OBJECTIVES: To describe the epidemiology of carbon monoxide (CO) poisoning in a defined population, identifying those at greatest risk from acute poisoning resulting in admission to hospital or death. METHODS: A retrospective study with routinely collected information, set in the former West Midlands Regional Health Authority; population of 5.2 million. The data comprised 939 deaths and 701 hospital admissions due to CO poisoning between January 1988 to December 1994. The main outcome measures were age and sex standardised incidence rates (SIRs) for non-intentional, suicidal, and undetermined poisonings for health authorities and the linear relation with socioeconomic deprivation. RESULTS: Overall rate of non-intentional poisonings over the 7 year period was 7.6/100,000, an annual rate of 1.1/100,000. The 7 year rates were highest in people > or = 85; men 24.0/100,000 and women 19.7/100,000. For suicides the 7 year rate was 19.6/100,000, an annual rate of 2.8/100,000. The 7 year rates were highest for men of 35-39, 64.1/100,000, and for women aged 45-49, 15.3/100,000. None of the causes of poisoning were related to deprivation. Non-intentional poisonings showed a strong seasonal variation with the highest rates being recorded in the months October to March. Increased rates of poisoning were found in the rural districts of the West Midlands. There seems to have been a decline in suicides coinciding with the introduction of three way catalytic converters on cars. CONCLUSIONS: Elderly people and the very young are at the greatest risk from non-intentional CO poisoning and rates are highest in the winter months. Although deaths from non-intentional CO poisoning are declining nationally, in the West Midlands they have remained stable and hospital admissions are increasing. It is not solely an urban phenomenon with rates for non-intentional CO poisoning and suicides higher in the rural districts. Health authorities need to consider all populations in any prevention programme. Further work is needed to establish the extent of the burden of chronic CO poisoning and the impact of catalytic converters on suicides.     

Symposium "infections, recently worth noticing". Introductory address

All non-traffic child pedestrian deaths and injuries resulting in hospitalization in the Auckland region over a 5 year period were identified from coroner's and hospital records. There were eight deaths (0.77/100,000 children per year) and 91 hospital admissions (8.7/100,000 children per year). Close to half (48%) of the non-traffic pedestrian injury admissions had been misclassified as traffic pedestrian injuries. Eighty-seven per cent of the non-traffic pedestrian injury deaths and 93% of the injuries occurred in residential driveways, most often involving a child run over by a reversing vehicle. Further studies are required to determine the most effective strategies for the prevention of non-traffic child pedestrian injuries.     

The association of patellar ultrasound transmissions and forearm densitometry with vertebral fracture, number and severity: the Saunders County Bone Quality Study

A population survey was conducted to determine the incidence of injuries among preschoolers and their risk factors. A systematic sample (15%, n = 4540) of families with at least one child aged 0-5 years in 1991 living in the Canton of Vaud (Switzerland) received a mailed questionnaire in February 1992. There were 5827 eligible children in the sample. The response rate was 67.5% after two recall mailings. Injuries were defined as those from all causes with at least one physician contact in 1991. The overall incidence was 224 injuries per 1000 children (95% CI [= confidence intervall]: 211-237); 188 per 1000 children were injured over 1 year (95% CI: 176-200, n = 746), of whom 16.5% (n = 123) had 32 injuries. Falls represented 66% of all injuries, followed by burns (8%) and poisonings (5%). The proportion of hospitalized cases was 4.8% and the population incidence of hospitalization due to injury was 10.8/1000 children. Socioeconomic factors did not influence the occurrence of injuries. CONCLUSION: The measured incidence of injuries among preschoolers is among the highest in developed countries. Practitioners could contribute more effectively to injury prevention through routine information and counselling of parents from all social backgrounds.     

Sarcoidosis in children. Epidemiology in Danes, clinical features, diagnosis, treatment and prognosis

This paper reviews current knowledge of childhood sarcoidosis with regard to the epidemiology in Danes, clinical presentation, diagnostic procedures, treatment and prognosis. Sarcoidosis is a granulomatous disease of unknown aetiology, with multiorgan involvement. The diagnosis is confirmed by the demonstration of epitheloid cell granulomas in tissue biopsy specimens. During the period 1980-92, three cases of childhood sarcoidosis were recorded in Copenhagen County, which has a total population of 610,000. The approximate incidence of clinically recognized sarcoidosis in Danish children younger than 15 y of age was 0.22-0.27/100,000 children per year, corresponding to approximately three new cases in Denmark each year. The true incidence is unknown, since the disease is often asymptomatic and resolves without a clinical diagnosis being made. In children younger than 5 y of age, the disease is characterized by involvement of skin, eyes and joints, whereas in older children involvement of lungs, lymph nodes and eyes predominate. The mainstay of treatment consists of oral corticosteroids. The risk/benefit ratio of using long-term corticosteroids needs to be evaluated in each individual patient. Some patients may benefit from additional therapy with methotrexate. The long-term prognosis is not well established, but it seems to be poorer in children younger than 5 y. Older children appear to have as favourable a prognosis as young adults.     

Unusual large cystic acoustic neurinomas: report of two cases

OBJECTIVE: Examine the current magnitude of the injury problem to children and adolescents on farms, and to compare these data to that from 1978-83. DATA SOURCES: US National Center for Health Statistics Mortality Multiple Cause of Death Tapes for the years 1991-3, and the US Consumer Product Safety Commission National Electronic Injury Surveillance System for data on emergency department visits for 1990-3. SUBJECTS: Children and adolescents 19 years and younger injured on farms. RESULTS: There were an average of 104 deaths per year due to injuries occurring on farms. The rate of 8.0 deaths per 100,000 child farm residents is 39% lower than in 1979-81. More of the deaths occurred in hospital than previously. There were an average of 22,288 emergency department treated injuries per year. The rate of 1717 injuries per 100,000 child farm residents is 10.7% higher than 1979-83. Males were injured more frequently than females. Tractors accounted for 20.9% of all injuries, followed by horses (8.4%), all terrain vehicles and minibikes (8.0%), and farm wagons (7.7%). CONCLUSIONS: Farm injuries continue to be a major problem to children living on farms. While improved medical care may have contributed to the reduction in mortality, the continued high rate of injuries warrants study of a variety of intervention strategies to reduce the injury toll. There is also a need for ongoing injury surveillance to provide accurate data on the farm injury problem.     

Trends in hospitalizations and mortality due to medicinal or non-medicinal poisonings in Hong Kong

Previous epidemiologic studies of poisonings in Hong Kong are regional hospital-or poison information center-based and have focused on either adults or children. This paper reports on the territory-wide hospitalization and mortality rates, comparing medicinal and non-medicinal poisonings in the general population. Between 1980 and 1995, the figures for hospitalizations and mortality due to medicinal (ICD codes 960-977) or non-medicinal (ICD codes 980-989) poisonings were obtained from the Annual Reports of the Department of Health, Hong Kong Government. Rates of medicinal poisonings increased between 1980/81 (57.3/100,000) and 1987/88 (80.9/100,000), but then declined (59.1/100,000) in 1993/94. Rates of non-medicinal poisonings were rather static (49-53/100,000) between 1980/81 and 1988/89, but then declined (22.0/100,000) in 1994/95. Between 1980/81 and 1988/89, rates of fatal medicinal poisonings (0.73-1.31/100,000) were similar to those of fatal non-medicinal poisonings (0.98-1.70/100,000). However, from 1989/90, there was an increase in the rates of fatal medicinal poisonings (1.94-2.80/100,000), although rates for non-medicinal poisonings remained much the same (0.80-1.38/100,000). Hospitalizations due to poisonings are now less common in Hong Kong than before, due largely to a greater decline in non-medicinal poisonings.     

The epidemiology of urban pediatric neurological trauma: evaluation of, and implications for, injury prevention programs

OBJECTIVE: To describe the incidence and causes of pediatric head, spinal cord, and peripheral nerve injuries in an urban setting and to assess the implications of these data for injury prevention programs. METHODS: Pediatric deaths and hospital admissions secondary to neurological trauma included in the Northern Manhattan Injury Surveillance System from 1983 to 1992 were linked to census counts to compute incidence rates. Rates before the implementation of a nonspecific injury prevention program were compared with rates after the implementation, and rates for the target population were compared to rates for the control population. Rates were analyzed on the basis of the cause of injury as well as the age, gender, and neighborhood income level of the injured. RESULTS: The incidence of neurological injuries resulting in hospitalization or death was 155 incidents per 100,000 population per year; the mortality rate was 6 people per 100,000 population per year. Neurological injuries represented 18% of all pediatric injuries and accounted for 23% of all traumatic deaths. Spinal cord and peripheral nerve injuries were relatively rare (5%) compared to head injuries (95%). Minor head injuries, including isolated cranial fractures, minor concussions (<1 h loss of consciousness), and unspecified minor head injuries, accounted for the majority of neurological injuries (76%), whereas severe head injuries, including severe concussion (>1 h loss of consciousness), cerebral laceration/contusion, intracerebral hemorrhage, and unspecified major injuries, were less common (18% of all neurological injuries). Boys were more often affected than girls at every age, and this preference increased with age. Children younger than 1 year showed the highest incidence of both major and minor injuries. One- to 4-year olds showed the lowest rates, with steady increases thereafter. Traffic accidents and falls were the leading causes (38 and 34%, respectively), and assaults were the next leading causes (12%). Among children admitted to surveillance system hospitals, falls were most common in children younger than 4 years, pedestrian motor vehicle accidents were most common in late childhood, and assaults were most common in early adolescence. Case:fatality rates were 5 to 7% for all age groups except 5- to 12-year-olds, for whom the case:fatality rate was 1.9%. Residence in a low-income neighborhood was associated with an increased risk of injury (rate ratio, 1.71; confidence interval, 95%, 1.54, 1.89). The average hospitalization cost per injury was $8502. Medicaid (54%) and other government sources (5%) covered the majority of expenses, including indirect reimbursement of usually uncollected self-pay billing (19%). Although injury incidence rates fell in both the control and intervention cohorts during implementation of a nonspecific injury prevention program, targeted age and population groups demonstrated greater relative reductions in injuries than nontargeted ones, suggesting a positive effect. CONCLUSIONS: Deaths and hospital admissions secondary to pediatric neurological trauma represent a significant public health problem, with the majority of the direct cost being born by government agencies. Future efforts to prevent neurological trauma in children who live in inner cities should focus on families with low incomes and provide novel education programs regarding infant abuse, infant neglect, and infant injury avoidance. Age-appropriate school-based programs should also be developed to address traffic safety and conflict resolution.     

The incidence of pediatric rheumatic diseases: results from the Canadian Pediatric Rheumatology Association Disease Registry

OBJECTIVE: To determine the incidence of rheumatic diseases in children, and the frequency of musculoskeletal disorders seen by pediatric rheumatology specialists in Canada. METHODS: Applying standardized disease definitions and disease codes modified from ICD-9, members of the Canadian Pediatric Rheumatology Association from 13 centers in all 10 provinces of Canada registered all new patients seen between May 1, 1991 and April 30, 1993. Patient data included age, sex, ethnicity, date of birth, date of disease onset, date of diagnosis, and diagnostic codes (more than one diagnosis could be entered). To minimize the bias of right censoring, only data from patients with disease onset between May 1, 1991 and October 31, 1992 were used to estimate disease incidence. RESULTS: 3362 records totalling 3683 diagnoses (92 separate diagnoses) were registered. Median referral rate per year to a pediatric rheumatology center was 26 per 100,000 children at risk. The frequency of diseases seen was 23.3% for all forms of chronic arthritis, 6.5% for connective tissue diseases, and 6.1% for all forms of vasculitis. The minimum incidence rates per 100,000 children at risk per year calculated from the whole registry were: all forms of chronic arthritis 4.08 (95% CI: 3.62, 4.60), systemic lupus erythematosus 0.28 (0.18, 0.45), and dermatomyositis 0.15 (0.09, 0.29). Substantially higher figures were obtained if the figures were calculated excluding the 2 provinces (Alberta and Quebec) that had disproportionately low referral rates. CONCLUSION: Pediatric rheumatologists see children with a wide variety of diseases. It is important that pediatric rheumatology training reflects this and does not focus exclusively on the classical inflammatory arthropathies. The minimum incidence data show there are substantial numbers of children developing potentially lifelong chronic rheumatic diseases each year in Canada. These data should be helpful in planning the delivery of pediatric rheumatology services not only in Canada, but also in other developed countries.     

Descriptive epidemiology of IDDM in Hokkaido, Japan: the Childhood IDDM Hokkaido Registry

OBJECTIVE: To identify the incidence of IDDM with regard to sex, age, family history of diabetes, season, and 5-year period of childhood IDDM among children ages 0-14 years from a population-based epidemiological study in Hokkaido, Japan, from 1973 to 1992. RESEARCH DESIGN AND METHODS: Registration of all new IDDM cases in Hokkaido was conducted by the Childhood IDDM Hokkaido Registry Study Group from 1973 to 1992. The cases were selected from among 1) patients who were admitted to the member hospitals of the study group, 2) patients who answered a questionnaire distributed to hospitals and diabetic clinics throughout Hokkaido, and 3) patients whose cases were recorded in free-treatment medical records of urban and rural districts. The case ascertainment rate was estimated to be 100%. Differences in incidence with regard to sex, age, family history of diabetes, season, and year period were analyzed by the Poisson regression analysis by GENMOD. RESULTS: During the 20-year period studied, 396 cases (181 boys, 215 girls) of abrupt-onset IDDM were registered. Statistically significant differences in annual incidence were found according to sex (female), age (8-14 years), history (having no diabetes in family), season (spring), and 5-year period. CONCLUSIONS: This is the first population-based, long-term epidemiological study of childhood IDDM from Japan. We observed a significantly higher annual incidence (per 100,000/year) of IDDM in female subjects (1.81), older age-groups (2.25 for 8-14 years), subjects with no family history of diabetes (1.26), diabetes onset in the spring (2.20), and an increased trend over the 20 years. In addition, the heterogeneity of IDDM among Japanese children needs to be elucidated.     

Children referred for specialist care: a nationwide study in Dutch general practice

BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.     

Meningococcal disease in childhood--a regional study in Ireland

A retrospective study of microbiology laboratory records of culture-confirmed cases of meningococcal disease in children under 14 years of age, admitted to four Dublin hospitals, was conducted for the period 1981-1991 inclusive. The study aimed to describe the epidemiology of meningococcal disease in childhood and to assess the potential of meningococcal group A and C vaccine in preventing disease. There were 406 cases of meningococcal disease of which 319 (78.6%) were in children under 5 years of age. The meningitis to septicaemia ratio was almost 4:1 (320 vs. 86 cases). Of the 406 cases, 216 (53.2%) cases occurred during the period November to March. The age-specific annual incidence rates for the Eastern Health Board region served was 64.2 per 100,000 under 1 year of age and 24.6 per 100,000 under 5 years of age. A relative increase in disease caused by meningococcal serogroup C was observed during the period of the study. Only 15% all cases could have been prevented by a policy of universal meningococcal group A and C immunisation at 2 years of age. Such a policy, therefore, is not recommended. A vaccine for preventing disease caused by meningococcal group B is urgently required.     

Pertussis in Massachusetts, 1981-1991: incidence, serologic diagnosis, and vaccine effectiveness

Massachusetts provides diphtheria-tetanus toxoid-pertussis (DTP) vaccine, and since 1980 has monitored pertussis with a statewide diagnostic service. The incidence of bacteriologically confirmed pertussis was 104.5 per 100,000 person-years in 1-month-old infants and declined progressively thereafter. Infants < 6 months old experienced disproportionate morbidity: 44% of bacteriologically confirmed pertussis, 64% of hospitalizations, and 71% of hospital days. Most children with pertussis had received < 3 DTP doses during childhood, whereas 87% of adolescents with pertussis had received > or = 4 doses. Serodiagnosis by single serum anti-pertussis toxin antibody ELISA increased the incidence of confirmed pertussis in persons 11-19 years old from 3.0 to 12.9 per 100,000 and in persons > or = 20 years old from 0.16 to 0.56 per 100,000. Bacteriologic methods underestimate pertussis incidence, but a single serum anti-pertussis toxin antibody ELISA is a practical method for population-based diagnosis in adolescents and adults.     

Prevention and control of hepatitis B virus infection in Singapore

Hepatitis B virus (HBV) accounted for 24% to 54% of the reported acute viral hepatitis cases in Singapore from 1982 to 1996. The prevalence of HBV infection, as indicated by the presence of markers of HBV, increased from 9.3% in children below 5 years of age to 54.6% in adults above 55 years. The overall hepatitis B surface antigen (HBsAg) prevalence was 5.7% for males and 3.4% for females, with the highest rate among the Chinese. About 39% of the HBsAg carriers were hepatitis B 'e' antigen positive. The main mode of transmission during the first year of life was perinatal, with 43% of the babies born to HBsAg-positive mothers developing the carrier state. Horizontal transmission within the infected household was significantly associated with sharing of personal and household articles. Based on the findings of seroprevalence surveys in various population groups and clinical trials on the safety, immunogenicity and efficacy of various doses and schedules with the plasma-based and yeast-derived hepatitis B vaccines in newborn babies, a national childhood hepatitis B vaccination programme was formulated and implemented in phases, starting with babies born to carrier mothers on 1 October 1985 and finally extending to all newborns on 1 September 1987. The hepatitis B prevention and control programme has been successful. During the period 1994 to 1996, more than 90% of children completed the full schedule of immunisation by below one year of age, and 85% had evidence of vaccination at school entry at age six. Follow-up of 2 cohorts of vaccinated children showed that perinatal transmission has been reduced by 80% to 100%. Horizontal transmission has also declined through other public health measures. The efficacy of the hepatitis B vaccine and the adequacy of reduced doses in the long-term protection of chronic carrier state have been shown in children and adults. The incidence of acute hepatitis B has declined from 10.4 per 100,000 in 1985 to 4.8 per 100,000 in 1996. There is a noticeable reduction in HBsAg prevalence in selected population (school children, national servicemen and antenatal women). The age-standardised incidence rate of primary liver cancer among males had also dropped from 27.8 per 100,000 per year during 1978 to 1982 to 19.0 per 100,000 per year during 1988 to 1992.     

Poisoning mortality, 1985-1995

Poisoning was reported as the underlying cause of death for 18,549 people in the United States in 1995 and was ranked as the third leading cause of injury mortality, following deaths from motor vehicle traffic injuries and firearm injuries. Poisoning was the leading cause of injury death for people ages 35 to 44 years. Poisoning death rates were higher in 1995 than in any previous year since at least 1979. From 1990 to 1995, the age-adjusted rate of death from poisoning increased 25%; all of the increase was associated with drugs. About three-fourths of poisoning deaths (77%) in 1995 were caused by drugs. The age-adjusted rate of drug-related poisoning deaths for males (7.2 per 100,000) in 1995 was more than twice that for females (3.0 per 100,000). From 1985 to 1995, poisoning death rates for males ages 35-54 years nearly doubled to 20.4 per 100,000, and the drug-related poisoning death rate for males ages 35-54 years nearly tripled, reaching 16.1 per 100,000. From 1990 to 1995, death rates associated with opiates and cocaine more than doubled among males ages 35-54 years. The numbers of opiate and cocaine poisoning deaths for 1995 more than doubled when all multiple cause of death codes were examined instead of only the underlying cause of death codes.     

A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989

BACKGROUND: Virtually all natural history studies of Wolff-Parkinson-White (WPW) syndrome have been case series and, as such, have been constrained by referral biases, skewed age and sex distributions, or brief follow-up periods. The purpose of our study was to examine the natural history, the development of arrhythmias, and the incidence of sudden death in an entire cohort of pediatric and adult WPW patients from a community-based local population. METHODS AND RESULTS: We identified 113 residents of Olmsted County, Minnesota, during the period 1953-1989 using the centralized records-linkage system provided by the Mayo Clinic and the Rochester Epidemiology Program Project. Medical records and ECGs were reviewed to confirm the diagnosis and to establish pathway location by ECG criteria. Follow-up, via record review and telephone interview, was complete in 95% of subjects through 1990. The incidence of newly diagnosed cases was approximately four per 100,000 per year. Preexcitation was not present on the initial ECG of 22% of the cohort. Approximately 50% of the population was asymptomatic at diagnosis, with 30% subsequently having symptoms related to arrhythmia at follow-up. Two sudden cardiac deaths (SCD) occurred over 1,338 patient-years of follow-up, yielding an overall SCD rate of 0.0015 (95% confidence interval, 0.0002-0.0054) per patient-year. No SCD occurred in patients asymptomatic at diagnosis. CONCLUSIONS: The incidence of sudden death in a local community-based population is low and suggests that electrophysiological testing should not be performed routinely in asymptomatic patients with WPW syndrome. Nevertheless, young, asymptomatic patients, particularly those < 40 years old, should return for medical follow-up should symptoms develop.     

Thyroid hormone resistance. Clinical, biochemical and genetic study of a family

OBJECTIVE: To investigate the incidence rate of IDDM in China. RESEARCH DESIGN AND METHODS: The Chinese IDDM registry was established in 1991 as part of the World Health Organization's Multinational Project for Childhood Diabetes (DiaMond) project. Twenty-two centers were developed to monitor the incidence of IDDM in children < 15 years of age. The population under investigation includes > 20 million individuals, representing approximately 7% of the children in China. Capture-recapture methods were used to estimate the ascertainment. RESULTS: The overall ascertainment-corrected IDDM incidence rate in China was 0.51 per 100,000, the lowest rate ever reported. There was a 12-fold geographic variation (0.13-1.61 per 100,000). In general, the incidence rate was higher in the north and the east. There was a sixfold difference among ethnic groups (highest: Mongol group, 1.82 per 100,000; lowest: Zhuang group, 0.32 per 100,000). CONCLUSIONS: China has an extremely low overall IDDM incidence rate. China also has the greatest geographic and ethnic variation seen for any country.     

Intestinal invagination in children in the county of Hordaland 1983-92]

The incidence of intussusception was examined with respect to whether children lived in the city of Bergen, where pediatricians were the primary contacts in 45% of the cases, or in the remaining municipalities where pediatricians were the primary contacts in 18%. Diagnosis and course of illness were compared for children admitted by pediatricians and general practitioners. Information was retrieved from hospital medical records. During 1983-92, 142 children 0 to 14 years were given the diagnosis on basis of barium enema (139 children) or surgery (three children). The incidence was 1.8 per 1,000 children per year for Bergen vs. 1.4 in the rest of the county (p = 0.3). Children admitted by pediatricians more often had the correct referral diagnosis (70% vs. 42%, p = 0.003), but they did not differ with respect to median age (8 months for both), median duration of symptoms (12 vs. 24 hours), percent in need of surgery (58% vs. 59%) or in symptoms. The lack of difference in incidence between Bergen and the more distant municipalities suggests that spontanous resolution of intussusception is uncommon. Although pediatricians more often admitted the children with the correct diagnosis, duration of symptoms and outcome did not differ from those admitted by general practitioners. This suggests that the general practitioners also appreciated the urgency of the symptoms.     

Folate supplementation and neural tube defects: a review of a public health issue

OBJECTIVE: To examine the causes and mortality of poisoning in Tehran. METHODS: The 7000 poisoning cases referred to Loghman-Hakim Hospital in Tehran over six months in 1994 were evaluated retrospectively. RESULTS: The overall female to male ratio was 1.8:1. Most poisonings occurred in the age range 2-6 y for children and 21-40 y for adults. Oral ingestion was the most common route of intoxication. In children, boys had a higher frequency of poisonings than girls. Most cases of children were referred to the hospital between 8 am and 8 pm. In adults referred to the hospital, there was little diurnal variation in poisoning presentations. In adults, drugs were the most common cause of intoxication (60.2%). Of these, benzodiazepines (24.5%) were the most frequent, followed by antidepressants (20.5%) and analgesics (18%). Pesticide and opiate intoxications were also commonly observed. In children, after drugs (32.1%), hydrocarbons were the most frequent cause of poisoning (19.2%). Pesticide poisonings were most often fatal (19.2%), followed by barbiturates (18.6%) and opiates (16.2%). Organophosphate insecticides were responsible for 57% of total pesticide poisoning cases. Of the deaths, 87.5% were attributed to suicide. CONCLUSION: The majority of poisoning cases in adults occur intentionally and in children accidentally.