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COVID-19 is a global pandemic with uncertain death rates. We examined county-level population morality rates (per 100,000) and case fatality rates by US region and rural-urban classification, while controlling for demographic, socioeconomic, and hospital variables. We found that population mortality rates and case fatality rates were significantly different across region, rural-urban classification, and their interaction. All significant comparisons had p < 0.001. Northeast counties had the highest population mortality rates (27.4) but had similar case fatality rates (5.9%) compared to other regions except the Southeast, which had significantly lower rates (4.1%). Population mortality rates were highest in urban counties but conversely, case fatality rates were highest in rural counties. Death rates in the Northeast were driven by urban areas (e.g., small, East Coast states), while case fatality rates tended to be highest in the most rural counties for all regions, especially the Southwest. However, on further inspection, high case fatality rate percentages in the Southwest, as well as in overall US counties, were driven by a low case number. This makes it hard to distinguish genuinely higher mortality or an artifact of a small sample size. In summary, coronavirus deaths are not homogenous across the United States but instead vary by region and population and highlight the importance of fine-scale analysis.

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Summary In 2 non-governmental organization projects in Bangladesh 244 new leprosy patients were classified in the field according to clinical criteria. Skin smears were taken at 4 standardized sites and at the most active peripheral lesion, where a biopsy was also taken.Comparison of the clinical field classification with the results of the skin smears and biopsies gives a sensitivity of 92· 1 % for the clinical criteria, but a specificity of only 41'3%. The skin-smear results, on the other hand, have a sensitivity of 88-4% and a specificity of 98·1 %.Thus, skin smears may contribute considerably to the operational classifica tion of leprosy patients under field conditions. Quality control of the peripheral laboratory is essential. Appropriate site selection for the smear taking will also contribute to increased performance. Analysis of the skin-smear results suggests that the policy of taking smears at standardized sites should be abandoned in favour of the earlobes and active peripheral lesions.According to WHO recommendations, 1 the operational classification of leprosy cases in paucibacillary (PB) and multi bacillary (MB) patients should be based on the bacter iological index, whereby the presence of acid-fast bacilli (AFB) at any single site is the criterion used fo r classification as MB. However, the validity of skin smear results has often been questioned, 2 -4 and many leprosy control programmes base their operational

To evaluate the possibility that changes in lipid composition might be related to the functional lesion that develops when platelets are stored as concentrates for several days, we measured lipid constituents of platelets in freshly prepared concentrates and in concentrates stored for 72 hr at 4 degrees C or at 20 degrees C under standard blood banking conditions. At 20 degrees C, but not at 4 degrees C, platelets lost about 15% of total cholesterol and 7%--11% of total phospholipid. The distribution of individual phospholipids remained unchanged. This was also true of the fatty acid distribution in total phospholipids and in individual phospholipids except for a statistically significant reduction of linoleic acid (18:2) and an increase in oleic acid (18:1) in phosphatidyl inositol (PI). Platelets collected in citrate-phosphate- dextrose (CPD) anticoagulant did not differ significantly in lipid composition from those collected in acid-citrate-dextrose (ACD) anticoagulant during the period of observation. These findings do not provide a basis to suggest that functional abnormalities developing in stored platelets are related to changes in lipid composition.

Summary In 2 non-governmental organization projects 244 new leprosy patients in Bangladesh were classified in the field according to clinical criteria i.e. number of skin lesions and number of enlarged nerves.Comparison of these classification results with the results of skin smears and biopsies yielded a sensitivity (for detection of a MB case) of 92· 1 %, but the 'unconfirmed MB rate' amounted to 52·6%.In order to improve the reliability of the operational classification, several additional clinical criteria were investigated. It was found that neither the presence of anaesthesia in the skin lesions nor the presence of grade 2 disabilities or peripheral anaesthesia or voluntary muscle testing (VMT) impairment contributed to an improved classification. Counting the number of body areas showing signs of leprosy, which had proven very useful in other programmes, did not result in a more reliable classification in the 2 projects in Bangladesh.The presence of clinical signs of lepromatous leprosy, more specifically nodules or diffuse infiltration, could be a useful addition to the classification criteria. If the sensitivity must remain higher than 90%, the lowest 'unconfirmed MB rate' obtainable in Bangladesh, using clinical criteria only, is 46'4%, for a sensitivity of 91·0%. However, the inclusion of skin-smear results in the classification criteria could improve the sensitivity to 96·6% and lower the 'unconfirmed MB rate' to 40·3%. A reduction in MB overclassification will result in more efficient and more cost-effective leprosy control programmes.Many leprosy programmes rely on clinical criteria in order to classify the patients into paucibacillary (PB) and multibacillary (MB) groups. A first part of the present study l 'Il Correspondence: ALERT,

Developmental dysplasia of the hip (DDH) is a musculoskeletal condition occupying any point along a spectrum of anatomical abnormalities that alter the stability of the newborn hip. Presentation varies throughout infancy and the majority of cases, especially those that are mild in nature, tend to resolve without intervention. An analysis of outcomes was conducted on infants born over a two-year period at a single-center, community hospital in East Toronto. The unwritten norm at the institution has become to order hip ultrasonography for all infants born in the breech position through C-section. Given the healthcare expenditure associated with routine radiographic screening, a careful analysis was undertaken to ascertain whether this screening regimen was effective in preventing late-stage detection of advanced DDH and improving organization in patient management. There were a total of 4236 babies delivered over the two years. One-hundred sixty-four (164) babies were born breech and through C-section. Eight (8) babies had abnormal hip examinations, one of whom was ultimately diagnosed with DDH. Forty-six (46) babies showed abnormal hip ultrasound at six weeks. Seventeen (17) referrals were made to the orthopedic surgeon. This resulted in a total of seven cases of DDH being diagnosed over the two years. The sensitivity and specificity of clinical hip screening were 14.3% and 95.5%, respectively, while that for ultrasound screening was 100% and 75.2%.To improve the quality of care and detection of DDH, a risk factor analysis was conducted to retrospectively analyze which DDH cases would have been missed if a higher threshold to ordering hip ultrasonography had been used. Based on the test characteristics of clinical and ultrasonographic screening, held in conjunction with the risk factor analysis results, an altered screening regimen was proposed with the intention of being just as sensitive but more cost-effective. This regimen integrates clinical screening using Barlow and Ortalani maneuvers until the eight to 10-week period and examines for limited abduction from eight weeks onward. Adjuncts like the Galeazzi test and that for asymmetrical skin folds should also be included to increase the sensitivity of clinical screening. Ultrasonography is proposed for high-risk individuals, with the criteria for stratification as high-risk being extracted from the risk factor analysis. Ultrasound is also proposed to be done in a serial fashion prior to orthopedic surgery referral in cases where the age of the infant allows, which serves to better evaluate the risk for lasting DDH and understand the longitudinal trajectory of the patient. This serves the additional purpose of decreasing the psychosocial burden on families. This can be particularly significant for infants for whom the initial abnormalities are due to selfresolve with the maturation of the hip joint and the infant's growth.

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