Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19

CONTEXT

The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19.

OBJECTIVES

Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19.

METHODS

This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death.

RESULTS

We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR.

CONCLUSION

In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.

Association of Renin Angiotensin Aldosterone System Inhibitors and Outcomes of Hospitalized Patients With COVID-19

OBJECTIVES

To determine the association of prior use of renin-angiotensin-aldosterone system inhibitors (RAASIs) with mortality and outcomes in hospitalized patients with COVID-19.

DESIGN

Retrospective observational study.

SETTING

Multicenter, international COVID-19 registry.

SUBJECTS

Adult hospitalized COVID-19 patients on antihypertensive agents (AHAs) prior to admission, admitted from March 31, 2020, to March 10, 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data were compared between three groups: patients on RAASIs only, other AHAs only, and those on both medications. Multivariable logistic and linear regressions were performed after controlling for prehospitalization characteristics to estimate the effect of RAASIs on mortality and other outcomes during hospitalization. Of 26,652 patients, 7,975 patients were on AHAs prior to hospitalization. Of these, 1,542 patients (19.3%) were on RAASIs only, 3,765 patients (47.2%) were on other AHAs only, and 2,668 (33.5%) patients were on both medications. Compared with those taking other AHAs only, patients on RAASIs only were younger (mean age 63.3 vs 66.9 yr; p < 0.0001), more often male (58.2% vs 52.4%; p = 0.0001) and more often White (55.1% vs 47.2%; p < 0.0001). After adjusting for age, gender, race, location, and comorbidities, patients on combination of RAASIs and other AHAs had higher in-hospital mortality than those on RAASIs only (odds ratio [OR] = 1.28; 95% CI [1.19-1.38]; p < 0.0001) and higher mortality than those on other AHAs only (OR = 1.09; 95% CI [1.03-1.15]; p = 0.0017). Patients on RAASIs only had lower mortality than those on other AHAs only (OR = 0.87; 95% CI [0.81-0.94]; p = 0.0003). Patients on ACEIs only had higher mortality compared with those on ARBs only (OR = 1.37; 95% CI [1.20-1.56]; p < 0.0001).

CONCLUSIONS

Among patients hospitalized for COVID-19 who were taking AHAs, prior use of a combination of RAASIs and other AHAs was associated with higher in-hospital mortality than the use of RAASIs alone. When compared with ARBs, ACEIs were associated with significantly higher mortality in hospitalized COVID-19 patients.

The Association of Latitude and Altitude with COVID-19 Symptoms: A VIRUS: COVID-19 Registry Analysis

Background:

Better delineation of COVID-19 presentations in different climatological conditions might assist with prompt diagnosis and isolation of patients.

Objectives:

To study the association of latitude and altitude with COVID-19 symptomatology.

Methods:

This observational cohort study included 12267 adult COVID-19 patients hospitalized between 03/2020 and 01/2021 at 181 hospitals in 24 countries within the SCCM Discovery VIRUS: COVID-19 Registry. The outcome was symptoms at admission, categorized as respiratory, gastrointestinal, neurological, mucocutaneous, cardiovascular, and constitutional. Other symptoms were grouped as atypical. Multivariable regression modeling was performed, adjusting for baseline characteristics. Models were fitted using generalized estimating equations to account for the clustering.

Results:

The median age was 62 years, with 57% males. The median age and percentage of patients with comorbidities increased with higher latitude. Conversely, patients with comorbidities decreased with elevated altitudes. The most common symptoms were respiratory (80%), followed by constitutional (75%). Presentation with respiratory symptoms was not associated with the location. After adjustment, at lower latitudes (<30º), patients presented less commonly with gastrointestinal symptoms (p<.001, odds ratios for 15º, 25º, and 30º: 0.32, 0.81, and 0.98, respectively). Atypical symptoms were present in 21% of the patients and showed an association with altitude (p=.026, odds ratios for 75, 125, 400, and 600 meters above sea level: 0.44, 0.60, 0.84, and 0.77, respectively).

Conclusions:

We observed geographic variability in symptoms of COVID-19 patients. Respiratory symptoms were most common but were not associated with the location. Gastrointestinal symptoms were less frequent in lower latitudes. Atypical symptoms were associated with higher altitude.

Neurologic Manifestations of Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Hospitalized Patients During the First Year of the COVID-19 Pandemic

To describe the prevalence, associated risk factors, and outcomes of serious neurologic manifestations (encephalopathy, stroke, seizure, and meningitis/encephalitis) among patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

DESIGN

Prospective observational study.

SETTING

One hundred seventy-nine hospitals in 24 countries within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 Registry.

PATIENTS

Hospitalized adults with laboratory-confirmed SARS-CoV-2 infection.

INTERVENTIONS

None.

RESULTS

Of 16,225 patients enrolled in the registry with hospital discharge status available, 2,092 (12.9%) developed serious neurologic manifestations including 1,656 (10.2%) with encephalopathy at admission, 331 (2.0%) with stroke, 243 (1.5%) with seizure, and 73 (0.5%) with meningitis/encephalitis at admission or during hospitalization. Patients with serious neurologic manifestations of COVID-19 were older with median (interquartile range) age 72 years (61.0-81.0 yr) versus 61 years (48.0-72.0 yr) and had higher prevalence of chronic medical conditions, including vascular risk factors. Adjusting for age, sex, and time since the onset of the pandemic, serious neurologic manifestations were associated with more severe disease (odds ratio [OR], 1.49; p < 0.001) as defined by the World Health Organization ordinal disease severity scale for COVID-19 infection. Patients with neurologic manifestations were more likely to be admitted to the ICU (OR, 1.45; p < 0.001) and require critical care interventions (extracorporeal membrane oxygenation: OR, 1.78; p = 0.009 and renal replacement therapy: OR, 1.99; p < 0.001). Hospital, ICU, and 28-day mortality for patients with neurologic manifestations was higher (OR, 1.51, 1.37, and 1.58; p < 0.001), and patients had fewer ICU-free, hospital-free, and ventilator-free days (estimated difference in days, -0.84, -1.34, and -0.84; p < 0.001).

CONCLUSIONS

Encephalopathy at admission is common in hospitalized patients with SARS-CoV-2 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.

Association of latitude and altitude with adverse outcomes in patients with COVID-19: The VIRUS registry

BACKGROUND

The coronavirus disease 2019 (COVID-19) course may be affected by environmental factors. Ecological studies previously suggested a link between climatological factors and COVID-19 fatality rates. However, individual-level impact of these factors has not been thoroughly evaluated yet.

AIM

To study the association of climatological factors related to patient location with unfavorable outcomes in patients.

METHODS

In this observational analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: COVID-19 Registry cohort, the latitudes and altitudes of hospitals were examined as a covariate for mortality within 28 d of admission and the length of hospital stay. Adjusting for baseline parameters and admission date, multivariable regression modeling was utilized. Generalized estimating equations were used to fit the models.

RESULTS

Twenty-two thousand one hundred eight patients from over 20 countries were evaluated. The median age was 62 (interquartile range: 49-74) years, and 54% of the included patients were males. The median age increased with increasing latitude as well as the frequency of comorbidities. Contrarily, the percentage of comorbidities was lower in elevated altitudes. Mortality within 28 d of hospital admission was found to be 25%. The median hospital-free days among all included patients was 20 d. Despite the significant linear relationship between mortality and hospital-free days (adjusted odds ratio (aOR) = 1.39 (1.04, 1.86), P = 0.025 for mortality within 28 d of admission; aOR = -1.47 (-2.60, -0.33), P = 0.011 for hospital-free days), suggesting that adverse patient outcomes were more common in locations further away from the Equator; the results were no longer significant when adjusted for baseline differences (aOR = 1.32 (1.00, 1.74), P = 0.051 for 28-day mortality; aOR = -1.07 (-2.13, -0.01), P = 0.050 for hospital-free days). When we looked at the altitude’s effect, we discovered that it demonstrated a non-linear association with mortality within 28 d of hospital admission (aOR = 0.96 (0.62, 1.47), 1.04 (0.92, 1.19), 0.49 (0.22, 0.90), and 0.51 (0.27, 0.98), for the altitude points of 75 MASL, 125 MASL, 400 MASL, and 600 MASL, in comparison to the reference altitude of 148 m.a.s.l, respectively. P = 0.001). We detected an association between latitude and 28-day mortality as well as hospital-free days in this worldwide study. When the baseline features were taken into account, however, this did not stay significant.

CONCLUSION

Our findings suggest that differences observed in previous epidemiological studies may be due to ecological fallacy rather than implying a causal relationship at the patient level.

Association of hypothyroidism with outcomes in hospitalized adults with COVID-19: Results from the International SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry

INTRODUCTION

Coronavirus disease 2019 (COVID-19) is associated with high rates of morbidity and mortality. Primary hypothyroidism is a common comorbid condition, but little is known about its association with COVID-19 severity and outcomes. This study aims to identify the frequency of hypothyroidism in hospitalized patients with COVID-19 as well as describe the differences in outcomes between patients with and without pre-existing hypothyroidism using an observational, multinational registry.

METHODS

In an observational cohort study we enrolled patients 18 years or older, with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection between March 2020 and February 2021. The primary outcomes were (1) the disease severity defined as per the World Health Organization Scale for Clinical Improvement, which is an ordinal outcome corresponding with the highest severity level recorded during a patient's index COVID-19 hospitalization, (2) in-hospital mortality and (3) hospital-free days. Secondary outcomes were the rate of intensive care unit (ICU) admission and ICU mortality.

RESULTS

Among the 20,366 adult patients included in the study, pre-existing hypothyroidism was identified in 1616 (7.9%). The median age for the Hypothyroidism group was 70 (interquartile range: 59-80) years, and 65% were female and 67% were White. The most common comorbidities were hypertension (68%), diabetes (42%), dyslipidemia (37%) and obesity (28%). After adjusting for age, body mass index, sex, admission date in the quarter year since March 2020, race, smoking history and other comorbid conditions (coronary artery disease, hypertension, diabetes and dyslipidemia), pre-existing hypothyroidism was not associated with higher odds of severe disease using the World Health Organization disease severity index (odds ratio [OR]: 1.02; 95% confidence interval [CI]: 0.92, 1.13; p = .69), in-hospital mortality (OR: 1.03; 95% CI: 0.92, 1.15; p = .58) or differences in hospital-free days (estimated difference 0.01 days; 95% CI: -0.45, 0.47; p = .97). Pre-existing hypothyroidism was not associated with ICU admission or ICU mortality in unadjusted as well as in adjusted analysis.

CONCLUSIONS

In an international registry, hypothyroidism was identified in around 1 of every 12 adult hospitalized patients with COVID-19. Pre-existing hypothyroidism in hospitalized patients with COVID-19 was not associated with higher disease severity or increased risk of mortality or ICU admissions. However, more research on the possible effects of COVID-19 on the thyroid gland and its function is needed in the future.

SARS-CoV-2 infection increases risk of acute kidney injury in a bimodal age distribution

BACKGROUND

Hospitalized patients with SARS-CoV2 develop acute kidney injury (AKI) frequently, yet gaps remain in understanding why adults seem to have higher rates compared to children. Our objectives were to evaluate the epidemiology of SARS-CoV2-related AKI across the age spectrum and determine if known risk factors such as illness severity contribute to its pattern.

METHODS

Secondary analysis of ongoing prospective international cohort registry. AKI was defined by KDIGO-creatinine only criteria. Log-linear, logistic and generalized estimating equations assessed odds ratios (OR), risk differences (RD), and 95% confidence intervals (CIs) for AKI and mortality adjusting for sex, pre-existing comorbidities, race/ethnicity, illness severity, and clustering within centers. Sensitivity analyses assessed different baseline creatinine estimators.

RESULTS

Overall, among 6874 hospitalized patients, 39.6% (n = 2719) developed AKI. There was a bimodal distribution of AKI by age with peaks in older age (≥60 years) and middle childhood (5-15 years), which persisted despite controlling for illness severity, pre-existing comorbidities, or different baseline creatinine estimators. For example, the adjusted OR of developing AKI among hospitalized patients with SARS-CoV2 was 2.74 (95% CI 1.66-4.56) for 10-15-year-olds compared to 30-35-year-olds and similarly was 2.31 (95% CI 1.71-3.12) for 70-75-year-olds, while adjusted OR dropped to 1.39 (95% CI 0.97-2.00) for 40-45-year-olds compared to 30-35-year-olds.

CONCLUSIONS

SARS-CoV2-related AKI is common with a bimodal age distribution that is not fully explained by known risk factors or confounders. As the pandemic turns to disproportionately impacting younger individuals, this deserves further investigation as the presence of AKI and SARS-CoV2 infection increases hospital mortality risk.

Palliative care consultation and end-of-life outcomes in hospitalized COVID-19 patients

Rationale

The impact of palliative care consultation on end-of-life care has not previously been evaluated in a multi-center study.

Objectives

To evaluate the impact of palliative care consultation on the incidence of cardiopulmonary resuscitation (CPR) performed and comfort care received at the end-of-life in hospitalized patients with COVID-19.

Methods

We used the Society of Critical Care Medicine’s COVID-19 registry to extract clinical data on patients hospitalized with COVID-19 between March 31st, 2020 to March 17th, 2021 and died during their hospitalization. The proportion of patients who received palliative care consultation was assessed in patients who did and did not receive CPR (primary outcome) and comfort care (secondary outcome). Propensity matching was used to account for potential confounding variables.

Measurements and Main Results

3,227 patients were included in the analysis. There was no significant difference in the incidence of palliative care consultation between the CPR and no-CPR groups (19.9% vs. 19.4%, p = 0.8334). Patients who received comfort care at the end-of-life were significantly more likely to have received palliative care consultation (43.3% vs. 7.7%, p < 0.0001). After propensity matching for comfort care on demographic characteristics and comorbidities, this relationship was still significant (43.2% vs. 8.5%; p < 0.0001).

Conclusion

Palliative care consultation was not associated with CPR performed at the end-of-life but was associated with increased incidence of comfort care being utilized. These results suggest that utilizing palliative care consultation at the end-of-life may better align the needs and values of patients with the care they receive.

Strategies for General Surgery Training Programs During the COVID-19 Pandemic

The COVID-19 pandemic presented a unique challenge for Medical systems worldwide. Initial response to the crisis situation for the pandemic closely mirrored plans for a mass casualty event. By leveraging resources including human and physical, and by dividing our surgeon workforce into micro teams we were able to create a flexible and responsive infrastructure to address the crisis as it unfolded. By adoption of virtual platforms and equal division of labor, surgical resident education was continued. Specific adjustments to the schedule and curriculum for medical students allowed them to continue their studies safely and on schedule. Our model serves as an example by which hospital systems of similar size may utilize principles of mass casualty preparedness to craft their own plan for a future contagion response strategy.

Geriatric Trauma Screening Tool: Preinjury Functional Status Dictates Intensive Care Unit Discharge Disposition

Older adults account for an increasing percentage of trauma patients and have worse outcomes when compared with younger populations. Simple prediction tools are needed to designate risk categories among these patients. The Geriatric Trauma Screening Tool (GTST) was developed to risk stratify older adults admitted to the ICU at a Level 1 trauma center. One hundred fifty patients aged ≥ 65 years were prospectively screened for high-risk (HR) injuries, comorbidities, and pre-hospital function using the GTST. Patients who screened for HR were more likely to have an unfavorable disposition than non-HR patients. HR patients had significantly longer ICU and hospital length of stays when compared with non-HR patients. In addition, patients with prior functional impairment were at higher risk for an unfavorable discharge disposition than their counterparts. Implementation of the GTST predicted discharge disposition in geriatric trauma patients admitted to the ICU. Pre-injury functional status was a better predictor of discharge disposition than either the types of HR injuries or the presence of comorbidities. Risk stratification of geriatric trauma patients allows for early engagement of patients and caregivers regarding transitions of care as well as more efficient utilization of hospital resources.

Geriatric Trauma Screening Tool: Preinjury Functional Status Dictates Intensive Care Unit Discharge Disposition

Older adults account for an increasing percentage of trauma patients and have worse outcomes when compared with younger populations. Simple prediction tools are needed to designate risk categories among these patients. The Geriatric Trauma Screening Tool (GTST) was developed to risk stratify older adults admitted to the ICU at a Level 1 trauma center. One hundred fifty patients aged ≥ 65 years were prospectively screened for high-risk (HR) injuries, comorbidities, and prehospital function using the GTST. Patients who screened for HR were more likely to have an unfavorable disposition than non-HR patients. HR patients had significantly longer ICU and hospital length of stays when compared with non-HR patients. In addition, patients with prior functional impairment were at higher risk for an unfavorable discharge disposition than their counterparts. Implementation of the GTST predicted discharge disposition in geriatric trauma patients admitted to the ICU. Pre-injury functional status was a better predictor of discharge disposition than either the types of HR injuries or the presence of comorbidities. Risk stratification of geriatric trauma patients allows for early engagement of patients and caregivers regarding transitions of care as well as more efficient utilization of hospital resources.

Hepatic Artery Aneurysms: Evolution from Open to Endovascular Repair Techniques

With the development of endovascular therapy, treatment for hepatic artery aneurysm (HAA) has evolved from open excision and repair to include endovascular approaches. We reviewed our recent experience with HAA to help define the treatment of HAA. From 2002 to 2010, five patients underwent treatment of HAA, all men with a median age of 63.2 years (range, 41-75). The median diameter of HAA was 5.8 cm (range, 2.4 cm-11 cm). Four lesions involved the extrahepatic portion of the hepatic artery, and one was an intrahepatic HAA that involved the right hepatic artery. Three were true aneurysms and two were pseudoaneurysms associated with trauma. Four of the five HAA patients were symptomatic, three with nonspecific abdominal pain, and one with free hemorrhage from a ruptured intrahepatic pseudoaneurysm. All five underwent computed tomography and selective arteriography. Two patients underwent open surgical aneurysmectomy and revascularization because of aneurysm location and concerns of the potential lack of collateral flow. Three patients underwent an endovascular coil embolization because obliteration of a saccular aneurysm could be achieved without compromising arterial flow of the native hepatic vessel. Re-embolization was necessary in the intrahepatic aneurysm because of recanalization of a feeding vessel. Endovascular embolization is an important minimally invasive approach in the treatment of HAA. Depending on HAA location and the adequacy of collateral arterial flow around the lesion, open aneurysmectomy and revascularization may be required.

Hepatic artery aneurysms: evolution from open to endovascular repair techniques

With the development of endovascular therapy, treatment for hepatic artery aneurysm (HAA) has evolved from open excision and repair to include endovascular approaches. We reviewed our recent experience with HAA to help define the treatment of HAA. From 2002 to 2010, five patients underwent treatment of HAA, all men with a median age of 63.2 years (range, 41-75). The median diameter of HAA was 5.8 cm (range, 2.4 cm-11 cm). Four lesions involved the extrahepatic portion of the hepatic artery, and one was an intrahepatic HAA that involved the right hepatic artery. Three were true aneurysms and two were pseudoaneurysms associated with trauma. Four of the five HAA patients were symptomatic, three with nonspecific abdominal pain, and one with free hemorrhage from a ruptured intrahepatic pseudoaneurysm. All five underwent computed tomography and selective arteriography. Two patients underwent open surgical aneurysmectomy and revascularization because of aneurysm location and concerns of the potential lack of collateral flow. Three patients underwent an endovascular coil embolization because obliteration of a saccular aneurysm could be achieved without compromising arterial flow of the native hepatic vessel. Re-embolization was necessary in the intrahepatic aneurysm because of recanalization of a feeding vessel. Endovascular embolization is an important minimally invasive approach in the treatment of HAA. Depending on HAA location and the adequacy of collateral arterial flow around the lesion, open aneurysmectomy and revascularization may be required.

A recurring question--how many beds for dementia?

Experience at Crichton Royal in dealing with dementia over a thirty year period has been used to develop two models of bed requirements for dementia sufferers. The first based on results from the periods 1957 to 1959 and 1974 to 1976 and the second on experience in the years 1974-75 and 1984-85. The variables considered were demographic change, admission of a constant proportion of the at risk group and changes in individual patient survival between groups of patients admitted. Projections based on the earlier model suggested that the SHAPE provision of 10 beds per 1000 of the over 64 population would be insufficient to maintain established standards of care. The later model, however, finds SHAPE numbers appropriate. The reasons for the change of view--inaccuracy in estimate of increasing male survival and significant under-estimates of population growth--nullify each other. The conclusion is that SHAPE is a useful model provided the demographic changes and patient survival change are carefully monitored.

Further change in the pattern of mental illness in the elderly

The methods of Roth's 1948-49 Graylingwell study, previously applied to a Crichton cohort of elderly patients of the years 1974-76, were repeated in 1984-86. The results support the continuing validity of Roth's classification of mental illness in the elderly, but changes in the diagnostic distribution of the cohort, previously observed in the 1970s study, are further in evidence in the 1980s one. Admissions of dementia cases continued to increase both relatively and absolutely, while the trend of increasing survival in dementia also continued.

Psychogeriatrics 1974 to 1984. Expanding problems and fixed resources

The impact of a 16% increase between censuses in the population aged 65 and over, on a psychogeriatric department whose bed complement remained static between 1974 and 1984, has been studied. Demand for service, as measured by new referrals, rose by 150%, while admissions fell by 14%. The increase in new referrals was uniform across the diagnostic spectrum, but the fall in admissions was not. Functional admissions fell in all age-groups except that of women of 85 and over, while organic-case admissions other than for cases of dementia virtually collapsed. Overall admissions for dementia rose to the predicted level, but the distribution of the increase was irregular and unexpected. Admissions of males and females aged 65-74 and females of 85 and over fell relatively and absolutely, while those of women aged 75-84 and men of 85 and over were little changed. Only admissions of men aged 75-84 alone increased in real terms.

Strategies for control of infectious diseases common to developed and developing countries

The problems are the same in the developed and the developing world although conditions differ sharply from place to place. The way of life, habits, custom of a people affect the incidence and severity of infectious disease. Economics affect the way infectious disease is tackled. Examples are given of common diseases in different countries.

Change in the pattern of care for the demented

The experience of 82 demented female patients, admitted to Crichton Royal in the period 1957-59, is compared with 107 similar female patients from 1974-76. All finally died in the hospital, or at the closure of the study in November 1981 were long-stay patients there. Results show that on average, each patient in the more recent group spent 24 per cent longer in hospital; the results, however, were only statistically significant in the very elderly--over 85. Further study of the 1970s failed to demonstrate that day care and intermittent holiday admissions had any effect on the length of time the patient spent in hospital on final admission. Using the study data, models of future needs are worked out on the basis of bed requirements for patients admitted without prospect of discharge.

Viral hepatitis in children: a study in Libya

Serum surveys in Gharian and Derna, Libya, assessed by radioimmunoassay, indicated that 100% of children of seven years and older, were HAV immune, as were 60-70% of three-year old children revealing that infection occurs below the latter age. HBV infection occurs erratically in time and appears to be uncommon in young children, affects school children somewhat more frequently and adults more so. Non-A non-B hepatitis also occurs but in the absence of specific tests it is impossible to assess its incidence.

Changing patterns in mental illness in the elderly

The study of Graylingwell Hospital conducted by Roth (1955) has in part been replicated in order to study the changing patterns of mental illness in the elderly over a 25-year period. Important changes in the diagnostic distribution and outcome of cases admitted have occurred. Functional illness has given way to dementia, not as a proportion of patients admitted but in the number of beds employed for their care 6 and 24 months after their index admission. Discharge rates for all diagnostic groups except acute confusional states, have undergone considerable change and death rates have fallen. The study has concentrated on the residual in-patient population, paying particular attention to increasing demand for beds for the dementing group. These changes have been quantified and reflect a four-year increase in bed requirements for cases of dementia at two years. Despite a striking reduction in requirement for functional cases, there is an overall increase in bed requirement of 38 per cent at the two-year mark.

Plague in camels and goats: their role in human epidemics

In 1976, in a small, remote Libyan village, one apparently sick camel was slaughtered and skinned, and the camel meat was distributed for human comsumption. A few days later, 15 villagers suffered a severe febrile illness. Of the five individuals who had participated in the killing and dispensation of the camel, all were dead within four days. When samples of serum from nine of the remaining patients were examined, seven were found to be positive for plague as determined by the passive hemagglutination test. Another six persons became ill after killing two goats, and the serum of one goat contained antibodies to Yersinia pestis. Because all of the remaining patients except one were treated early enough, they recovered. These incidents confirm previous reports that the camel and the goat are susceptible to naturally occurring plague infection and have a significant role in the dissemination of human plague.

Pregnancy hepatitis in Libya

The death-rate from hepatitis in pregnant women in Libya is high. Of 922 hepatitis patients treated during 1975, 377 were males and 545 were females. The case fatality-rate was 0.53% for males and 7-67% for females. In 293 pregnant women it was 12-97% compared with 1-6% in 252 non-pregnant women. In pregnant women deaths occurred mainly in the last trimester. Although 18-4% of the male patients and 15-2% of the women were hepatitis B surface antigen (HBsAg) positive, no patient shown to be antigen-positive died. The frequency of hepatitis in the second half of the year fell both in pregnant women and in the general population, suggesting a warning hepatitis-A epidemic. The exact cause of the high mortality in pregnant women is not clear, but it may have a nutritional basis.

The clinical aspects of anthrax

Cutaneous anthrax is usually easy to diagnose provided the doctor thinks of anthrax. The lesion most likely to be confused with anthrax is accidental vaccinia. Orf lacks the characteristic central eschar. Cutaneous anthrax responds to antibiotic therapy: rare complications are meningitis and hypoxic hypertension. Pulmonary anthrax is highly fatal: its incidence is related to the number and size of anthrax-containing particles which are inhaled. Artificial mists containing lethal doses of anthrax bacilli can be manufactured. Intestinal anthrax may present as gastroenteritis or as ulceration of the intestine with obstruction and perforation.

Smallpox

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Penicillin Treatment of Malignant Diphtheria

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