A. Rosano

DI TANNA, GIAN LUCA

P. Mastroiacovo

English

Archivio della ricerca- Università di Roma La Sapienza

We attempted to control for the effects of time byhaving patients re-evaluated 24 hours after admission,as change in symptoms and signs can be an importantadjunct in diagnosis. This was arguably both a strengthand a weakness. One weakness was the possibility forconfounding factors—seven patients receiving earlycomputed tomography underwent other radiologicalinvestigations and 13 patients receiving standard prac-tice underwent off-study or delayed computed tomo-graphy. No differences emerged in the results betweenthe intention to treat and as treated analyses. Limitingthe study to weekends may have influenced referralpatterns, timeliness of investigations, and clinicaldecision making.The most likely reason for the non-significance ofthe results of our main outcome measures is that ourstudy was underpowered, being based on a differencein length of hospital stay of 1.5 days.We thank the radiographic staff, surgical teams, and juniorradiologists who participated.Contributors: See bmj.comFunding: This study was funded by Addenbrooke’s NHS TrustEndowment Fund. The NHS Executive Eastern supported theCentre for Applied Medical Statistics.Competing interests: None declared.1 Taourel P, Baron MP, Pradel J, Fabre JM, Seneterre E, Bruel JM. Acuteabdomen of unknown origin: impact of CT on diagnosis andmanagement. Gastrointest Radiol 1992;17:287-91.2 Siewert B, Raptopoulos V, Mueller MF, Rosen MP, Steer M. Impact of CTon diagnosis and management of acute abdomen in patients initiallytreated without surgery. Am J Roentgenol 1997;168:173-8.3 Rosen MP, Sands DZ, Longmaid III HE, Reynolds KF, Wagner M,Raptopoulos V. Impact of abdominal CT on the management of patientspresenting to the emergency department with acute abdominal pain. AmJ Roentgenol 2000;174:1391-6.4 Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominalCT vs upright chest film. J Comput Assist Tomogr 1992;16:713-6.5 Puylaert JBCM, van der Zant FM, Rijke AM. Sonography and the acuteabdomen. Am J Roentgenol 1997;168:179-86.6 Mindelzun RE, Jeffrey RB. Unenhanced helical CT for evaluating acuteabdominal pain: a little more cost, a lot more information. Radiology1997;205:43-7.7 Birnbaum BA, Jeffrey RB Jr. CT and sonographic evaluation of acuteright lower quadrant abdominal pain. Am J Roentgenol 1998;170:361-71.8 Rao PM, Rhea JT, Novelline RA, Mostafavi AA, Lawrason JN, McCabe CJ.Helical CT combined with contrast material administered only throughthe colon for imaging of suspected appendicitis. Am J Roentgenol1997;169:1275-80.9 Malone AJ. Unenhanced CT in the evaluation of the acute abdomen: thecommunity hospital experience. Semin Ultrasound CT MRI 1999;20:68-76.10 Urban BA, Fishman EK. Targeted helical CT of the acute abdomen:appendicitis, diverticulitis, and small bowel obstruction. Semin UltrasoundCT MRI 2000;21:20-39.11 Urban BA, Fishman EK. Tailored helical CT evaluation of acuteabdomen. Radiographics 2000;20:725-49.12 Safran DB, Pilati D, Folz E, Oller D. Is appendiceal CT scan overused forevaluating patients with right lower quadrant pain? Am J Emerg Med2001;19:199-203.Prevalence of gastroschisis at birth: retrospective studyGian Luca Di Tanna, Aldo Rosano, Pierpaolo MastroiacovoGastroschisis is a congenital defect of the abdominalwall, characterised by herniation of abdominal visceraoutside the abdominal cavity through a defect in theabdominal wall to the side of the umbilicus.1 Recentstudies showed an increase in the prevalence of gastro-schisis at birth but gave no convincing explanation.2 3We describe the temporal and geographical variationin this prevalence, using data from the InternationalClearinghouse For Birth Defects Monitoring Systems,founded in 1974, which fosters sharing informationand collaboration among the programmes that moni-tor birth defects worldwide. Currently, 36 programmesfrom Europe, the Americas, Asia, Australia, and SouthAfrica participate in the clearinghouse and cumula-tively monitor 3.3 million births each year. The headoffice of the clearinghouse, the International Centrefor Birth Defects, registers and evaluates these data.Participants, methods, and resultsWe selected registries that provided information on atleast 10 consecutive years including 1998 and analysedbirths occurring between 1974 and 1998 from 19registries (see bmj.com). The numerators of the pre-valences (see table) include liveborn and stillbornbabies with gastroschisis (isolated or associated withother defects); denominators are the total numbers ofbirths. Registries used their own diagnostic criteria anddefinitions of gastroschisis and omphalocele, but wefound no substantial differences.We estimated annual prevalence at birth and 95%confidence intervals from the data and analysedtemporal trends using Poisson regression. We used ÷2tests to test for heterogeneity of birth prevalenceamong registries. We compared the time distributionsof gastroschisis and omphalocele by using theSpearman non-parametric correlation test to excludenegative correlations that might suggest shifts in classi-fication of defects from omphalocele to gastroschisis.The 19 registries recorded 3073 cases of gastroschis.The overall prevalence at birth was 0.29 (95%confidence interval 0.21 to 0.40) per 10 000 births in1974 and 1.66 (1.51 to 1.85) per 10 000 births in 1998.Prevalences varied among programmes. Nine areas hadsignificant increases in the prevalence of gastroschisis atbirth (table 1) from Europe (five registries), Australia,Japan, and the Americas (two registries).What is already known on this topicComputed tomography improves the accuracy of diagnosis of severalacute abdominal conditionsUncontrolled studies have shown improvements in accuracy of diagnosisafter computed tomography; none have described an effect on mortalityWhat this study addsEarly abdominopelvic computed tomography for acute abdominalpain can identify unforeseen serious abdominal conditionsIt may also reduce length of hospital stay and may reduce inpatientmortalityDetails ofcontributors are onbmj.comPapersInternationalCentre for BirthDefects, 00195Rome, ItalyGian Luca Di Tannasenior statisticianPierpaoloMastroiacovodirectorItalian Institute ofSocial Medicine,00196 RomeAldo Rosanosenior researcherCorrespondence to:P Mastroiacovoicbd@icbd.orgBMJ 2002;325:1389–901389BMJ VOLUME 325 14 DECEMBER 2002 bmj.comTo assess whether such an increase might beexplained by a diagnostic shift of the abdominal walldefects, we analysed the time trends of omphalocele inthese registries. One registry (Australia) had a milddecrease of omphalocele, three registries had signifi-cant increases, and the remaining six registries had notemporal trend. The distributions of gastroschisis andomphalocele over time were not negatively correlated.CommentPrevalence of gastroschisis at birth increased in nearlyhalf of the registries studied, beginning at the end ofthe 1980s in several areas. Such an increase may beeven greater than shown here, because of possibleunder-reporting of cases among selective pregnancyterminations,4 particularly in areas such as France andthe Netherlands, where the proportion of selective ter-minations is high. The increased prevalence of gastro-schisis is unlikely to be explained by a systematic shiftin the classification of abdominal wall defects. Thespeed at which the increase has occurred suggestsenvironmental rather than genetic risk factors.Selective termination and systematic shift in classi-fication should be assessed in a multicentre case-control study. Because children of young mothers aremore susceptible to gastroschisis,5 shifts in maternalage distribution should also be investigated. Geo-graphical spread and magnitude show that increasedprevalence of gastroschisis at birth is “epidemic.”Contributors: GLDT designed the study, managed and analysedthe data, and participated in drafting the paper. AR projectedand designed the study, interpreted the data, and participated indrafting the paper. PM revised the paper. PM is guarantor.Funding: No additional funding.Competing interests: None declared.1 Torfs CP, Velie EM, Oechsli FW, Bateson TF, Curry CJ. Apopulation-based study of gastroschisis: demographic, pregnancy, andlifestyle risk factors. Teratology 1994;50:44-53.2 Tan KH, Kilby MD, Whittle MJ, Beattie BR, Booth IW, Botting BJ.Congenital anterior abdominal wall defects in England and Wales 1987-93: retrospective analysis of OPCS data. BMJ 1996;313:903-6.3 Rankin J, Dillon E, Wright C. Congenital anterior abdominal wall defectsin the north of England, 1986-1996: occurrence and outcome. PrenatDiagn 1999;19:662-8.4 Barisic I, Clementi M, Hausler M, Gjergja R, Kern J, Stoll C. Evaluation ofprenatal ultrasound diagnosis of fetal abdominal wall defects by 19 Euro-pean registries. Ultrasound Obstet Gynecol 2001;18:309-16.5 Nichols CR, Dickinson JE, Pemberton PJ. Rising incidence ofgastroschisis in teenage pregnancies. J Matern Fetal Med 1997;6:225-9.(Accepted 25 June 2002)Mortality from methicillin resistant Staphylococcus aureus inEngland and Wales: analysis of death certificatesN S Crowcroft, M CatchpoleThe number of infections caused by methicillin resist-ant Staphylococcus aureus (MRSA) is increasing everyyear in England and Wales.1 2 These infections aremore difficult to treat than others because of the resist-ance of the bacterium to first line antibiotics. Theimpact of these infections on mortality has beenunknown; data on the mortality caused by MRSAinfections is not routinely available because theinternational classification of diseases (ICD) has nocode for these infections. The evidence that theinfections are associated with a higher mortality thanmethicillin sensitive S aureus infections is equivocal.1We used death certificates to examine the evidence thatmortality due to MRSA and staphylococcal infectionsin England and Wales is increasing.Methods and resultsIn 1993 redevelopment of the processing systems fordeath registrations in England and Wales enableddeath registration data to be analysed by all conditionsmentioned on death certificates (rather than by thefinal underlying cause alone).3 ICD-9 (ICD, 9threvision) was in use during the period of this study.We examined all death registrations in the Officefor National Statistics database with ICD-9 codes 05.0,08.4, 038.1, 041.1, 320.3, and 482.4, indicatingstaphylococcal infection, on any part of the death cer-tificate for deaths that occurred between 1 January1993 and 31 December 1998. We manually identifiedthe inclusion of MRSA by noting the text entered onPrevalence and 95% confidence intervals of gastroschisis at birth in registries that showed significant increases. Rates are per10 000 birthsRegistry No of cases No of birthsEarliest LatestPRR (95% CI)Rate (95% CI) Year Rate (95% CI) YearAustralia 593 4 140 849 0.88 (0.42 to 1.62) 1981 2.65 (2.06 to 3.35) 1997 1.08 (1.06 to 1.10)Finland 97 947 072 0.92 (0.33 to 2.00) 1984 1.92 (0.96 to 3.44) 1998 1.11 (1.05 to 1.16)France (central east) 180 1 932 649 0.15 (0.00 to 0.82) 1978 1.46 (0.82 to 2.42) 1998 1.04 (1.01 to 1.06)France (Paris) 92 659 523 0.00 (0.00 to 1.04) 1981 2.69 (1.29 to 4.95) 1998 1.11 (1.07 to 1.16)Ireland (Dublin) 30 395 528 0.00 (0.00 to 1.47) 1980 1.56 (0.30 to 4.58) 1998 1.15 (1.07 to 1.23)Japan 361 2 931 758 1.01 (0.43 to 2.00) 1974 2.28 (1.43 to 3.46) 1998 1.03 (1.02 to 1.05)Mexico 161 820 987 1.20 (0.38 to 2.81) 1980 4.93 (2.87 to 7.90) 1998 1.06 (1.03 to 1.10)Norway 265 1 403 783 0.99 (0.36 to 2.17) 1974 3.07 (1.82 to 4.86) 1998 1.04 (1.02 to 1.06)South America 353 3 565 511 0.12 (0.00 to 0.67) 1974 2.88 (2.07 to 3.90) 1998 1.16 (1.13 to 1.18)PRR=Prevalence rate ratio per annual change according to Poisson regression model.PapersDemography andHealth, Office forNational Statistics,LondonSW1V 2QQN S Crowcroftconsultantepidemiologistcontinued overBMJ 2002;325:1390–11390 BMJ VOLUME 325 14 DECEMBER 2002 bmj.com

Prevalence of gastroschisis at birth: Retrospective study

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Prevalence of gastroschisis at birth: Retrospective study

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