Faculty Bibliography

OBJECTIVE:To evaluate outcome predictors of patients with cirrhosis admitted to an intensive care unit (ICU). METHODS:One hundred and twenty-nine consecutive patients with cirrhosis admitted to the ICU at a tertiary care transplant centre in Saudi Arabia between March 1999 and December 2000 were entered prospectively in an ICU database. Liver transplantation patients and readmissions to the ICU were excluded. The following data were documented: demographic features, severity of illness measures, parameters of organ failure, presence of gastrointestinal bleeding, and sepsis. The need for mechanical ventilation, renal replacement therapy and pulmonary artery catheter placement was recorded. The primary endpoint was hospital outcome. RESULTS:Cirrhotic patients admitted to the ICU had high hospital mortality (73.6%). However, the actual mortality was not significantly different from the predicted mortality using prediction systems. There was an association between the number of organs failing and mortality. Coma and acute renal failure emerged as independent predictors of mortality. All patients who were monitored with pulmonary artery catheterisation in this study died. Patients requiring mechanical ventilation and renal replacement therapy had very high mortalities (84% and 89%, respectively). All 13 cirrhotic patients admitted to ICU immediately post-cardiac arrest in this study died. CONCLUSIONS:Cirrhotic patients admitted to ICU have a poor prognosis, especially when admitted with coma, acute renal failure or post-cardiac arrest. The consistently poor prognosis associated with certain ICU interventions should raise new awareness regarding limitations of medical therapy. These mortality statistics compel a critical re-examination of uniformly aggressive life support for the critically ill cirrhotic patient, a percentage of whom will not benefit from invasive measures.

CAP in elderly patients carries a significant economic and clinical burden and will be more commonly encountered in the future as the US population ages. Diagnosis may be obscured by a nonclassic presentation in an elderly patient, and the clinician needs to be especially suspicious of pneumonia whenever the clinical status of an elderly patient deteriorates. The single most important clinical decision is the site of care; this determination is not always based on clinical factors but also on social factors. Severity assessment is key to stratifying appropriate therapy and to predicting outcome. Timely and appropriate empiric therapy enhances the likelihood of a good clinical outcome, although clinical resolution may be more delayed than in younger patients. Newly emerging patterns of antibiotic resistance have altered recent guidelines for CAP treatment; DRSP is now a consideration in elderly patients because an age older than 65 years is a well-described risk factor for infection with this organism. Prevention should always be implemented, with a focus on pneumococcal and influenza vaccination.

The Kingdom of Saudi Arabia occupies four-fifths of the Arabian Peninsula, with a land area of 2 million square kilometres. Saudi Arabia holds a unique position in the Islamic world, as the custodian of the two holiest places of Islam, in Mecca and Medina. Annually, some 2 million Muslims from over 140 countries embark on Hajj. This extraordinary en masse migration is a unique forum for the study of travel epidemiology since the Hajj carries various health risks, both communicable and non-communicable, often on a colossal scale. Non-communicable hazards of the Hajj include stampede and motor vehicle trauma, fire-related burn injuries and accidental hand injury during animal slaughter. Communicable hazards in the form of outbreaks of multiple infectious diseases have been reported repeatedly, during and following the Hajj. Meningococcal meningitis, gastroenteritis, hepatitis A, B and C, and various zoonotic diseases comprise some of the possible infectious hazards at the Hajj. Many of these infectious and non-infectious hazards can be avoided or averted by adopting appropriate prophylactic measures. Physicians and health personnel must be aware of these risks to appropriately educate, immunize and prepare these travellers facing the unique epidemiological challenges of Hajj in an effort to minimize untoward effects. Travel epidemiology related to the Hajj is a new and exciting area, which offers valuable insights to the travel specialist. The sheer scale of numbers affords a rare view of migration medicine in action. As data is continually gathered and both national and international policy making is tailored to vital insights gained through travel epidemiology, the Hajj will be continually safeguarded. Practitioners will gain from findings of travel related epidemiological changes in evolution at the Hajj: the impact of vaccinating policies, infection control policies and public health are afforded a real-world laboratory setting at each annual Hajj, allowing us to learn from this unique phenomenon of migration medicine.

Worldwide, community-acquired pneumonia (CAP) is a common respiratory tract infection and is now a growing public health concern in Saudi Arabia. In an effort to simplify treatment regimens to aid the practitioner, empirical treatment guidelines for CAP have evolved across the international medical community, reducing the number of antibiotics used and improving outcomes. Saudi Arabia and the surrounding region have no such consensus guidelines and this document aims to redress this lack. The potential impacts of developing and implementing CAP treatment guidelines in Saudi Arabia, which are new to the Kingdom, will be examined. Widespread adoption of these SACAP guidelines could lead to nationwide reductions of antibiotic resistance and improvement of clinical outcomes. Ultimately, Kingdomwide uniformity of treatment algorithms provides a foundation for both database generation and valuable outcomes of research in the future.