BMJ medicine最新文献

Objective: To compare the risk of hospital admissions with infections and infections not in hospital in children born by caesarean section with children born by vaginal birth.

Data sources: Medline, Embase, and PubMed were searched with no restriction on start date up to 12 February 2024.

Study selection: Observational studies were included that reported the association between caesarean section and vaginal birth in relation to the risk of infections (both those that lead to hospital admission and those that do not) up to 18 years of age. Studies were excluded if they were not representative of a general population or if they focused on congenital, neonatal, or vertically acquired infections. No restrictions were made for language, publication date, or setting.

Review methods: Findings for hospital admissions with infection were synthesised by meta-analyses of specific infection outcomes and type of caesarean birth (emergency v elective) and findings for other infections (ie, infection episodes reported by parents and primary care visits) by direction of effect. Risk of bias was assessed using the ROBINS-E tool and the overall certainty of evidence through the GRADE framework.

Results: 31 eligible studies of over 10 million children were included. Findings were from population-based birth cohorts and registry data linkage studies in high income countries. Cohort sizes ranged from 288 to 7.2 million and follow up age was from one to 18 years. Outcomes included overall and specific clinical categories of infection. From studies of overall admission to hospital with infection, the proportion of children admitted ranged between 9-29% across exposure groups. In random-effects meta-analyses combining hazard ratios, children delivered by caesarean section had an increased rate of hospital admission with infections overall and in three common clinical infection categories: (1) overall admissions to hospital with infection (emergency caesarean section: n=6 study populations, hazard ratio 1.10 (95% confidence interval 1.06 to 1.14), $\tau$ ²=0.0009, I²=96%; elective caesarean section: n=7, 1.12 (1.09 to 1.15), $\tau$ ²=0.0006, I²=88%); (2) admission to hospital for upper respiratory infections (emergency caesarean section: n=7, 1.11 (1.09 to 1.13), $\tau$ ²=0.0003, I²=73%; elective caesarean section: n=7, 1.16 (1.12 to 1.20), $\tau$ ²=0.0012, I²=89%); (3) admission to hospital for lower respiratory infections (emergency caesarean section: n=8, 1.09 (1.06 to 1.12), $\tau$ ²=0.0010, I²=88%; elective caesarean section: n=8, 1.13 (1.10 to 1.16), $\tau$ ²=0.0009, I²=84%); (4) admission to hospital for gastrointesti

Abstract:

Objective: To estimate the effectiveness of vaccination with a monovalent covid-19 mRNA vaccine containing the omicron XBB.1.5 subvariant against severe covid-19 disease in Denmark, Finland, and Sweden.

Design: Target trial emulation based on registry data.

Setting: Denmark, Finland, and Sweden, 1 October 2023 to 21 April 2024.

Participants: Source population of 3 898 264 individuals eligible for vaccination with the XBB.1.5 containing covid-19 mRNA vaccine at the start of the study on 1 October 2023. Study cohort comprised 1 876 282 recipients of an XBB.1.5 containing vaccine during the study period matched with 1 876 282 non-recipients. Individuals were aged ≥65 years (mean age 75.4 years, standard deviation 7.4 years) and had received at least four doses of a previous covid-19 vaccine.

Main outcome measures: Cumulative incidences of hospital admissions and deaths related to covid-19 in a follow-up period of 24 weeks after immunisation (defined as one week after vaccination) in recipients of an XBB.1.5 containing covid-19 mRNA vaccine and matched non-recipients. Cumulative incidences were used to calculate comparative vaccine effectiveness (1-risk ratio) and risk differences.

Results: The associated comparative vaccine effectiveness was 57.9% (95% confidence interval (CI) 49.9% to 65.8%) against hospital admission for covid-19 (1085 v 2635 events) and 75.2% (70.6% to 79.9%) against deaths related to covid-19 disease (348 v 1458 events) after 24 weeks of follow-up. This result corresponded to 154.7 (95% CI 78.3 to 231.0) hospital admissions for covid-19 and 120.3 (110.5 to 130.2) deaths prevented per 100 000 individuals who were vaccinated with an XBB.1.5 containing vaccine. The associated comparative vaccine effectiveness was similar irrespective of sex, age group (65-74 v ≥75 years), number of doses of previous covid-19 vaccines, subgroup of co-administered seasonal influenza vaccines, and period of when either the omicron XBB or BA.2.86 sublineage was predominant. Although the observed reduction in risk was highest during the first weeks after vaccination, comparative vaccine effectiveness was well maintained after 24 weeks of follow-up.

Conclusions: In this study, in adults aged ≥65 years, vaccination with a monovalent XBB.1.5 containing covid-19 mRNA vaccine was associated with reduced rates of hospital admissions for covid-19 and deaths related to covid-19, during the autumn and winter of 2023-24 in Denmark, Finland, and Sweden.

Objective: To describe which combinations of long term conditions were associated with a higher risk of hospital admission or death during winter 2021-22 (the third wave of the covid-19 pandemic) in adults in England.

Design: Population based cohort study.

Setting: Linked primary and secondary care data from the General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR) database, Hospital Episode Statistics, and Office for National Statistics death registry, comprising pseudoanonymised routinely collected electronic medical records from the whole population of England registered at a general practice, 1 December 2021 to 31 March 2022.

Participants: 48 253 125 individuals, registered in GDPPR in England, aged ≥18 years, and alive on 1 December 2021.

Main outcomes measures: All cause hospital admissions and deaths associated with combinations of multiple long term conditions compared with those with no long term conditions, during the winter season (1 December 2021 to 31 March 2022). Overdispersed Poisson regression models were used to estimate the incidence rate ratios after adjusting for age, sex, ethnic group, and index of multiple deprivation.

Results: Complete data were available for 48 253 125 adults, of whom 15 million (31.2%) had multiple long term conditions. Rates of hospital admissions and deaths among individuals with no long term conditions were 96.3 and 0.8 per 1000 person years, respectively. Compared with those with no long term conditions, the adjusted incidence rate ratio of hospital admissions were 11.0 (95% confidence interval (CI) 9.4 to 12.7) for those with a combination of cancer, chronic kidney disease, cardiovascular disease, and type 2 diabetes mellitus; 9.8 (8.3 to 11.4) for those with cancer, chronic kidney disease, cardiovascular disease, and osteoarthritis; and 9.6 (8.6 to 10.7) for those with cancer, chronic kidney disease, and cardiovascular disease. Compared with those with no long term conditions, the adjusted rate ratio of death was 21.4 (17.5 to 26.0) for those with chronic kidney disease, cardiovascular disease, and dementia; 23.2 (17.5 to 30.3) for those with cancer, chronic kidney disease, cardiovascular disease, and dementia; and 24.3 (19.1 to 30.4) for those with chronic kidney disease, cardiovascular disease, dementia, and osteoarthritis. Cardiovascular disease with dementia appeared in all of the top five combinations of multiple long term conditions for mortality, and this two disease combination was associated with a substantially higher rate of death than many three, four, and five disease combinations.

Conclusions: In this study, rates of hospital admission and death varied by combinations of multiple long term conditions and were substantially higher in those with than in those without any long term conditions. High risk