Perforated Peptic Ulcer

Because no large series of perforated peptic ulcers has been reported from Canada, 402 cases from the Ottawa Civic Hospital were reviewed to study this dramatic disorder.The incidence was 15 per 100,000 population annually, or one in every 1000 hospital admissions.The incidence in females and the elderly in this series was higher than reported elsewhere. The risk of perforation increased with age, being greatest after 55; this was not due to an excess of chronic ulcers in older patients, indicating that ageing is an etiological factor.As the mortality of perforated peptic ulcer—20%—had remained unchanged over the years, fatal cases were studied to see if changes should be made in the management of this condition. The mortality for patients undergoing operation was 7.5%. Patients treated conservatively because their general condition was poor, died. Fifteen patients, in whom an incorrect diagnosis was made, died. More aggressive therapy and greater efforts at diagnosis might have saved some of these patients.     

Surgical Procedures in Nonagenarians

During the hospital course of 225 nonagenarian patients who underwent 285 major operations—80% on the general, vascular, orthopedic and urologic services—overall morbidity was 37% and mortality 7.5%. The 100 emergency operations were associated with a higher morbidity and mortality rate. Nonsurvivors were more likely to have associated cardiac or cerebral medical conditions, higher utilization of intraoperative invasive hemodynamic monitoring and greater use of surgical intensive care units. Compared with all surgical patients, the nonagenarians were admitted twice as often to the surgical intensive care unit, required twice the number of hospital days, underwent intraoperative hemodynamic monitoring twice as frequently and incurred 200% greater hospital charges. We conclude that with careful evaluation and management, a nonagenarian patient presenting with a surgical condition can safely undergo necessary operative procedures.     

TRIC Agent as a Cause of Neonatal Eye Sepsis

Among 2,700 babies born in a maternity hospital there were 71 (2.6%) cases of eye sepsis, mostly mild. Forty-four of these cases were screened for inclusions of TRIC agent. Four certain positives and a further four very suggestive cases were found—an incidence of 18% of the cases of eye sepsis investigated. The true incidence is probably somewhat higher.Follow-up showed that even minimal and transitory eye sepsis from TRIC infection in the neonate can lead to permanent scarring of the conjunctiva and cornea, with or without pannus.     

Patterns of Cervical Spine Injury and Their Associated Lesions

Motorcycle riding and diving into shallow water continue to present a high risk of cervical spine injury, often complicated by spinal cord damage. In patients with high cervical cord trauma, differentiation of arterial hypotension due to losing vasomotor control from the effects of internal hemorrhage can cause difficulty. In a series of 123 consecutive cases of cervical spine injury, no evidence was found that either early surgical treatment or steroid administration exert a favorable influence on recovery from traumatic myelopathy. When compared with other series, differences were found in the nature, frequency and severity of both spinal and associated injuries, resulting from the relative frequency among the population studied of trauma due to a particular mechanism—traffic accident, diving, industrial injury—and the special functions and location of the hospital from which information is gathered.     

Consultant Surgeons and Vasectomy

In late 1971 410 consultant general surgeons and urologists—74% of a national random sample—responded to a postal survey about vasectomy. Probably about 50,000 vasectomies were performed by surgeons in England and Wales in 1970. The service was largely a private one: 60% of consultants'' hospital vasectomies were not done under the National Health Service, and, in addition, 26% of the consultants who worked in relevant specialties performed vasectomies elsewhere than in hospital (usually in private nursing homes). Based again on consultants'' estimates, probably 6,000 men in 1970 had their requests for vasectomy turned down by surgeons, or more than one turned down for every 10 done. The most common reason was that patients were “too young.”About 90% of the consultants thought vasectomy could normally be performed safely and adequately as an outpatient procedure, yet only 64% said that 90% or more of their hospital vasectomies were done on this basis. While 69% regarded services in their areas as adequate, most were in favour of more special vasectomy clinics.     

Epidemics of Tuberculosis in Canada in the Sixties

Data on 24 localized tuberculosis epidemics occurring in Canada from January 1960 to March 1965 have been analyzed. In a population of about 13,000 at some degree of risk 308 new cases of active tuberculosis occurred—an incidence of 2.3%. In individual outbreaks, however, the incidence was as high as 31%. Epidemics occurred under a wide variety of circumstances—in schools, homes, communities, an army camp and a hockey team. Detected source cases included parents, school teachers, a cook, a hired man and a “den mother”.Because of the involvement of children, about four out of 10 new active cases were primary tuberculosis. Approximately two out of 10 were moderately or far advanced pulmonary cases. The findings suggest the need to reconsider BCG vaccination of the younger age group as a means of raising the level of herd immunity.     

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women''s clinical diagnoses.

Methods and Findings

Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status.The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.

Conclusions

Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors'' Summary     

Towards a National AIDS-Control Program in Uganda

A national AIDS-control program was developed in Uganda to deal with a potentially serious epidemic of the acquired immunodeficiency syndrome (AIDS). A cumulative total of 1,138 cases of AIDS has been reported in Uganda between 1983—since AIDS was introduced into the country—and March 1987. More than 80% of the victims are sexually active persons whereas less than 10% are infants and children younger than 5 years. Virtually no cases or seropositivity is reported in persons between the ages of 5 and 14 years or after the age of 60 years. Most transmission has been through the heterosexual route, and, unlike in the United States, the male-female ratio is 1:1. Heterosexual high-risk behavior is cited as an important mode of transmission. A survey of household contacts showed that despite the closeness, only the sexual partners were seropositive.A five-year plan of action has been developed, and health education is the main thrust. It also includes blood screening, improved sterile procedures, improved surveillance and notification, research and terminal patient care. The plan stresses integration based on primary health care. There are unresolved moral issues of whether or not to tell the truth to an AIDS victim or any healthy seropositive person in developing countries, especially unstable persons. The best approach is to sensitize everyone so that they become guardians of their lives because sexual behavior is an issue of individual responsibility.     

A comparison of risk factors for cryptosporidiosis and non-cryptosporidiosis diarrhoea: A case-case-control study in Ethiopian children

BackgroundCryptosporidiosis is a major cause of diarrhoea in young children in low-and-middle-income countries. New interventions should be informed by evidence pertaining to risk factors and their relative importance. Inconsistencies in the literature may to some extent be explained by choice of methodology, furthermore, most previous risk factor studies compared cryptosporidiosis cases to diarrhoea cases of other aetiologies rather than with controls without diarrhoea.Methodology/Principal findingsWe investigated a broad set of factors in under-2-year-olds presenting with diarrhoea to a hospital and a health center in southwestern Ethiopia. We applied quantitative cut-offs to distinguish between cryptosporidiosis and incidental Cryptosporidium infection or carriage, a hierarchical causal framework to minimize confounding and overadjustment, and a case-case-control design, to describe risk factors for both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Moderate and severe acute malnutrition were strongly associated with both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Previous healthcare attendance and low maternal education were only associated with cryptosporidiosis, whereas unsafe child stool disposal, prematurity and early cessation of exclusive breastfeeding were significantly associated with non-cryptosporidiosis diarrhoea only. By estimation of population attributable fractions, socioeconomic factors—specifically low maternal education—and public tap water use, were apparently more important risk factors for cryptosporidiosis than for non-cryptosporidiosis diarrhoea.Conclusions/SignificanceNutritional management of moderate acute malnutrition may be an effective intervention against cryptosporidiosis, particularly if combined with targeted therapy for cryptosporidiosis which, again, may mitigate nutritional insult. Focused caregiver education in healthcare settings and follow-up of children with acute malnutrition may prevent or improve outcomes of future episodes of cryptosporidiosis.     

Occupational Skin Diseases in the San Francisco Bay Area

From answers by one-third of the practicing dermatologists in the San Francisco Bay Area to a questionnaire on occupational skin diseases, contact dermatitis due to irritants and sensitizers was found to rank first. Poison oak, which is the leading reported cause on “Doctor''s First Report of Work Injury” received by the California Department of Industrial Relations, was sixth on the list of the survey, trailing solvents, cleansing agents, petroleum products and epoxy resins. A history of atopic dermatitis was often noted in current cases of occupational diseases of the skin.Avoidance of exposure or limiting the contact with pathogenic substances—through engineering changes, observation of working conditions by physicians, education of workers—appeared to be the best preventive measures.     

Outcomes of Regionalized Perinatal Care in Washington State

We evaluated the extent to which the regionalization of perinatal care in Washington State has succeeded in concentrating high-risk pregnancies in technologically appropriate referral centers and in reducing differences in neonatal outcome among hospitals. Of all infants weighing less than 1,500 grams born between 1980 and 1983, nearly 68% were delivered in level III hospitals, although only 24% of all babies are born in these hospitals, indicating that the state is highly regionalized. Neonatal outcomes—as measured by standardized mortality ratios—are similar in level I, II and III hospitals and are not greatly influenced by the rural or urban location of the hospital. The most promising strategy for further reducing neonatal mortality is to decrease the number and proportion of very-low-birth-weight births.     

Determinants of Venous Thromboembolism among Hospitalizations of US Adults: A Multilevel Analysis

Background

Venous thromboembolism (VTE) is a significant clinical and public health concern. We evaluated a variety of multilevel factors—demographics, clinical and insurance status, preexisting comorbid conditions, and hospital characteristics—for VTE diagnosis among hospitalizations of US adults.

Methods

We generated adjusted odds ratios with 95% confidence intervals (CIs) and determined sources of outcome variation by conducting multilevel logistic regression analysis of data from the 2011 Nationwide Inpatient Sample that included 6,710,066 hospitalizations of US adults nested within 1,039 hospitals.

Results

Among hospitalizations of adults, age, sex, race or ethnicity, total days of hospital stay, status of health insurance, and operating room procedure were important determinants of VTE diagnosis; each of the following preexisting comorbid conditions—acquired immune deficiency syndrome, anemia, arthritis, congestive heart failure, coagulopathy, hypertension, lymphoma, metastatic cancer, other neurological disorders, obesity, paralysis, pulmonary circulation disorders, renal failure, solid tumor without metastasis, and weight loss—was associated independently with 1.04 (95% CI: 1.02−1.06) to 2.91 (95% CI: 2.81−3.00) times increased likelihood of VTE diagnosis than among hospitalizations of adults without any of these corresponding conditions. The presence of 2 or more of such conditions was associated a 180%−450% increased likelihood of a VTE diagnosis. Hospitalizations of adults who were treated in urban hospitals were associated with a 14%−15% increased likelihood of having a VTE diagnosis than those treated in rural hospitals. Approximately 7.4% of the total variation in VTE diagnosis occurred between hospitals.

Conclusion

The presence of certain comorbidities and hospital contextual factors is associated with significantly elevated likelihood of VTE diagnosis among hospitalizations of adults. The findings of this study underscore the importance of clinical risk assessment and adherence to evidence-based clinical practice guidelines in preventing VTE, as well as the need to evaluate potential contextual factors that might modify the risk of VTE among hospitalized patients.     

Non-Specific Factors that may influence Significance of Urinary Steroid Excretion in Breast Cancer

The urinary excretion of corticosteroids (17-oxogenic steroids) and adrenal androgens (11-deoxy-17-oxosteroids) was studied in women below the age of 50 in a variety of clinical situations for comparison with a normal group. The conditions studied were: chronic debility from non-malignant disease, weight reduction, admission to hospital and surgery for varicose veins, hepatic non-malignant disease, and non-mammary cancer.The objective of the study was to determine whether the changes found in early and advanced breast cancer and used to judge the prognosis of the disease are specific to the disease or are merely incidental to the degree of illness caused by the disease.Similar changes to those found in breast cancer—principally a reduction in the excretion of the androgens—were found in the women with severe hepatic disease and in advanced non-mammary cancer. These were also found to follow the effects of severe surgical stress.It is concluded that the changes found in breast cancer are a measure of the general systemic disturbance caused by the disease and are not due specifically to it. Nevertheless, the value of their prognostic significance remains unchallenged.     

Changing Use of Hospital Beds by the Elderly

Recent changes in the age structure of the mental hospital population in the Birmingham Region are first examined. The proportion of patients aged 65 and over of the total in residence has steadily increased and at the end of 1967 was 43%, and more than half the female patients are now in this age group.Admissions of elderly persons to both psychiatric and general hospitals have increased, and these hospitals have responded to the increased demand on their services by increasing bed-turnover rates. During 1967 on average one-fifth of all patients occupying beds for acute cases (excluding maternity) were 65 years of age or over.In the geriatric hospital service, on the other hand, accommodation per head of the population decreased between 1961 and 1967, as did the total annual number of admissions and the rate of turnover. This suggests that the geriatric service is overstretched and that it is under-organized, understaffed, or undercapitalized—possibly all three. The enforced expedient of admitting “excess” elderly patients to mental hospitals does not recommend itself.     

Molecular Diagnostics for Lassa Fever at Irrua Specialist Teaching Hospital,Nigeria: Lessons Learnt from Two Years of Laboratory Operation

Background

Lassa fever is a viral hemorrhagic fever endemic in West Africa. However, none of the hospitals in the endemic areas of Nigeria has the capacity to perform Lassa virus diagnostics. Case identification and management solely relies on non-specific clinical criteria. The Irrua Specialist Teaching Hospital (ISTH) in the central senatorial district of Edo State struggled with this challenge for many years.

Methodology/Principal Findings

A laboratory for molecular diagnosis of Lassa fever, complying with basic standards of diagnostic PCR facilities, was established at ISTH in 2008. During 2009 through 2010, samples of 1,650 suspected cases were processed, of which 198 (12%) tested positive by Lassa virus RT-PCR. No remarkable demographic differences were observed between PCR-positive and negative patients. The case fatality rate for Lassa fever was 31%. Nearly two thirds of confirmed cases attended the emergency departments of ISTH. The time window for therapeutic intervention was extremely short, as 50% of the fatal cases died within 2 days of hospitalization—often before ribavirin treatment could be commenced. Fatal Lassa fever cases were older (p = 0.005), had lower body temperature (p<0.0001), and had higher creatinine (p<0.0001) and blood urea levels (p<0.0001) than survivors. Lassa fever incidence in the hospital followed a seasonal pattern with a peak between November and March. Lassa virus sequences obtained from the patients originating from Edo State formed—within lineage II—a separate clade that could be further subdivided into three clusters.

Conclusions/Significance

Lassa fever case management was improved at a tertiary health institution in Nigeria through establishment of a laboratory for routine diagnostics of Lassa virus. Data collected in two years of operation demonstrate that Lassa fever is a serious public health problem in Edo State and reveal new insights into the disease in hospitalized patients.     

Comparison of Birth Weight/Gestation Distribution in Cases of Stillbirth and Neonatal Death According to Lesions Found at Necropsy

The birth weight/gestation distribution of a large series of cases of perinatal death has been analysed according to the lesion (or lesions) present at necropsy. Among the lesions associated with low gestation babies dying with hyaline membranes have a much higher mean birth weight for gestation than either the babies with intraventricular haemorrhage or “no cause found.” Among infants dying of intrapartum asphyxia or cerebral birth trauma it was found that those who were stillborn with trauma had, at term, a significantly higher mean birth weight than the control livebirths, and that, at all gestations, the stillbirths with trauma were, on average, heavier than the babies dying neonatally with this lesion. Cases of intrapartum asphyxia were smaller than the stillbirths with trauma, but those dying during the second stage of labour were larger than those dying during the first stage.Cases of intrauterine pneumonia—that is, stillbirths and first-day deaths—were also shown to be larger for length of gestation than cases of extrauterine pneumonia—that is, deaths between the second and the 28th day. The cases with haemorrhagic pneumonia, however, were, at least at term, smaller than the cases of extrauterine pneumonia, and cases of massive pulmonary haemorrhage showed evidence of growth retardation at all gestations.     

The Relationship between Body Mass Index and Hospitalisation Rates,Days in Hospital and Costs: Findings from a Large Prospective Linked Data Study

Background

Internationally there is limited empirical evidence on the impact of overweight and obesity on health service use and costs. We estimate the burden of hospitalisation—admissions, days and costs—associated with above-normal BMI.

Methods

Population-based prospective cohort study involving 224,254 adults aged ≥45y in Australia (45 and Up Study). Baseline questionnaire data (2006-2009) were linked to hospitalisation and death records (median follow-up 3.42y) and hospital cost data. The relationships between BMI and hospital admissions and days were modelled using zero-inflated negative binomial regression; generalised gamma models were used to model costs. Analyses were stratified by sex and age (45-64, 65-79, ≥80y), and adjusted for age, area of residence, education, income, smoking, alcohol-intake and private health insurance status. Population attributable fractions were also calculated.

Results

There were 459,346 admissions (0.55/person-year) and 1,483,523 hospital days (1.76/person-year) during follow-up. For ages 45-64y and 65-79y, rates of admissions, days and costs increased progressively with increments of above-normal BMI. Compared to BMI 22.5-<25kg/m², rates of admissions and days were 1.64-2.54 times higher for BMI 40-50kg/m²; costs were 1.14-1.24 times higher for BMI 27.5-<30kg/m², rising to 1.77-2.15 times for BMI 40-50kg/m². The BMI-hospitalisation relationship was less clear for ≥80y. We estimated that among Australians 45-79y, around 1 in every 8 admissions are attributable to overweight and obesity (2% to overweight, 11% to obesity), as are 1 in every 6 days in hospital (2%, 16%) and 1 in every 6 dollars spent on hospitalisation (3%, 14%).

Conclusions

The dose-response relationship between BMI and hospital use and costs in mid-age and older Australians in the above-normal BMI range suggests even small downward shifts in BMI among these people could result in considerable reductions in their annual health care costs; whether this would result in long-term savings to the health care system is not known from this study.     

Prevalence,Awareness, Treatment and Influence of Socioeconomic Variables on Control of High Blood Pressure: Results of the ELSA-Brasil Study

High blood pressure (HBP) is the leading risk factor for years of life lost in Brazil. Factors associated with HBP awareness, treatment and control need to be understood better. Our aim is to estimate prevalence, awareness, and types of anti-hypertensive treatment and to investigate the association of HBP control with social position. Data of 15,103 (54% female) civil servants in six Brazilian state capitals collected at the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline (2008-2010) were used to estimate prevalence and cross-sectional association of HBP control with education, per capita family income and self-reported race, using multiple logistic regression. Blood pressure was measured by the oscillometric method. 35.8% were classified as presenting HBP; 76.8% of these used anti-hypertensive medication. Women were more aware than men (84.8% v. 75.8%) and more often using medication (83.1% v. 70.7%). Adjusted HBP prevalence was, in ascending order, Whites (30.3%), Browns (38.2%) and Blacks (49.3%). The therapeutic schemes most used were angiotensin-converting enzyme inhibitors, in isolation (12.4%) or combined with diuretics (13.3%). Among those in drug treatment, controlled blood pressure was more likely in the (postgraduate) higher education group than among participants with less than secondary school education (PR = 1.21; 95% CI: 1.14–1.28), and among Asian (PR = 1.21; 95% CI: 1.12–1.32) and ‘Whites (PR = 1.19; 95% CI: 1.12–1.26) compared to Blacks. Socioeconomic and racial inequality—as measured by different indicators—are strongly associated with HBP control, beyond the expected influence of health services access.     

Characterization of the Non-Polio Enterovirus Infections Associated with Acute Flaccid Paralysis in South-Western India

Non-polio enteroviruses (NPEVs) have been reported frequently in association with acute flaccid paralysis (AFP) cases during Polio Surveillance Programs (PSPs) worldwide. However, there is limited understanding on the attributes of their infections. This study reports characteristics of NPEVs isolated from AFP cases, investigated during PSPs held in 2009–2010, in Karnataka and Kerala states of south-western India having varied climatic conditions. NPEV cell culture isolates derived from stool specimens that were collected from 422 of 2186 AFP cases (<1–14 years age) and 17 of 41 asymptomatic contacts; and details of all AFP cases/contacts were obtained from National Polio Laboratory, Bangalore. The distribution of NPEV infections among AFP cases and circulation pattern of NPEV strains were determined by statistical analysis of the data. Genotyping of all NPEV isolates was carried out by partial VP1 gene sequencing and phylogenetic analysis. NPEV positive AFP cases were significantly higher in children aged <2 years; with residual paralysis; in summer months; and in regions with relatively hot climate. Genotyping of NPEVs identified predominance of human enteroviruses (HEV)-B species [81.9%—Echoviruses (E): 57.3%; coxsackieviruses (CV) B: 15%; numbered EVs: 8.9%; CVA9: 0.7%] and low levels of HEV-A [14.5%—CVA: 6%; numbered EVs: 8.5%] and HEV-C [3.6%—CVA: 2.6%; numbered EVs: 1%] species, encompassing 63 genotypes. EV76 (6.3%) and each of E3, CVB3 and E9 (4.97%) were found frequently during 2009 while E11 (6.7%), CVB1 (6.1%), E7 (5.1%) and E20 (5.1%) were detected commonly in 2010. A marked proportion of AFP cases from children aged <2 years; presenting with fever; and from north and south interior parts of Karnataka state was detected with E/numbered EVs than that found with CVA/CVB. This study highlights the extensive genetic diversity and diverse circulation patterns of NPEV strains in AFP cases from different populations and climatic conditions.     

Viral Co-Infections in Pediatric Patients Hospitalized with Lower Tract Acute Respiratory Infections

Background

Molecular techniques can often reveal a broader range of pathogens in respiratory infections. We aim to investigate the prevalence and age pattern of viral co-infection in children hospitalized with lower tract acute respiratory infection (LT-ARI), using molecular techniques.

Methods

A nested polymerase chain reaction approach was used to detect Influenza (A, B), metapneumovirus, respiratory syncytial virus (RSV), parainfluenza (1–4), rhinovirus, adenovirus (A—F), bocavirus and coronaviruses (NL63, 229E, OC43) in respiratory samples of children with acute respiratory infection prospectively admitted to any of the GENDRES network hospitals between 2011–2013. The results were corroborated in an independent cohort collected in the UK.

Results

A total of 204 and 97 nasopharyngeal samples were collected in the GENDRES and UK cohorts, respectively. In both cohorts, RSV was the most frequent pathogen (52.9% and 36.1% of the cohorts, respectively). Co-infection with multiple viruses was found in 92 samples (45.1%) and 29 samples (29.9%), respectively; this was most frequent in the 12–24 months age group. The most frequently observed co-infection patterns were RSV—Rhinovirus (23 patients, 11.3%, GENDRES cohort) and RSV—bocavirus / bocavirus—influenza (5 patients, 5.2%, UK cohort).

Conclusion

The presence of more than one virus in pediatric patients admitted to hospital with LT-ARI is very frequent and seems to peak at 12–24 months of age. The clinical significance of these findings is unclear but should warrant further analysis.