Wayne L. Gold

The effect of English language proficiency on length of stay and in-hospital mortality

AbstractBACKGROUND: In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients. OBJECTIVE: To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality. DESIGN: Retrospective analysis of administrative data at 3 tertiary care teaching hospitals (University Health Network) in Toronto, Canada. PARTICIPANTS: Consecutive inpatient admissions from April 1993 to December 1999 were analyzed for LOS differences first by looking at 23 medical and surgical conditions (59,547 records) and then by a meta-analysis of 220 case mix groups (189,119 records). We performed a similar analysis for in-hospital mortality. MEASUREMENTS: LOS and odds of in-hospital death for limited English-proficient (LEP) patients relative to English-proficient (EP) patients. RESULTS: LEP patients stayed in hospital longer for 7 of 23 conditions (unstable coronary syndromes and chest pain, coronary artery bypass grafting, stroke, craniotomy procedures, diabetes mellitus, major intestinal and rectal procedures, and elective hip replacement), with LOS differences ranging from approximately 0.7 to 4.3 days. A meta-analysis using all admission data demonstrated that LEP patients stayed 6% (approximately 0.5 days) longer overall than EP patients (95% confidence interval, 0.04 to 0.07). LEP patients were not at increased risk of in-hospital death (relative odds, 1.0; 95% confidence interval, 0.9 to 1.1). CONCLUSIONS: Patients with limited English proficiency have longer hospital stays for some medical and surgical conditions. Limited English proficiency does not affect in-hospital mortality. The effect of communication barriers on outcomes of care in the inpatient setting requires further exploration, particularly for selected conditions in which length of stay is significantly prolonged.

Interferon-Mediated Immunopathological Events Are Associated with Atypical Innate and Adaptive Immune Responses in Patients with Severe Acute Respiratory Syndrome

ABSTRACT It is not understood how immune inflammation influences the pathogenesis of severe acute respiratory syndrome (SARS). One area of strong controversy is the role of interferon (IFN) responses in the natural history of SARS. The fact that the majority of SARS patients recover after relatively moderate illness suggests that the prevailing notion of deficient type I IFN-mediated immunity, with hypercytokinemia driving a poor clinical course, is oversimplified. We used proteomic and genomic technology to systematically analyze host innate and adaptive immune responses of 40 clinically well-described patients with SARS during discrete phases of illness from the onset of symptoms to discharge or a fatal outcome. A novel signature of high IFN-α, IFN-γ, and IFN-stimulated chemokine levels, plus robust antiviral IFN-stimulated gene (ISG) expression, accompanied early SARS sequelae. As acute illness progressed, SARS patients entered a crisis phase linked to oxygen saturation profiles. The majority of SARS patients resolved IFN responses at crisis and expressed adaptive immune genes. In contrast, patients with poor outcomes showed deviated ISG and immunoglobulin gene expression levels, persistent chemokine levels, and deficient anti-SARS spike antibody production. We contend that unregulated IFN responses during acute-phase SARS may culminate in a malfunction of the switch from innate immunity to adaptive immunity. The potential for the use of the gene signatures we describe in this study to better assess the immunopathology and clinical management of severe viral infections, such as SARS and avian influenza (H5N1), is therefore worth careful examination.

Possible SARS Coronavirus Transmission during Cardiopulmonary Resuscitation

Infection of healthcare workers with the severe acute respiratory syndrome–associated coronavirus (SARS-CoV) is thought to occur primarily by either contact or large respiratory droplet transmission. However, infrequent healthcare worker infections occurred despite the use of contact and droplet precautions, particularly during certain aerosol-generating medical procedures. We investigated a possible cluster of SARS-CoV infections in healthcare workers who used contact and droplet precautions during attempted cardiopulmonary resuscitation of a SARS patient. Unlike previously reported instances of transmission during aerosol-generating procedures, the index case-patient was unresponsive, and the intubation procedure was performed quickly and without difficulty. However, before intubation, the patient was ventilated with a bag-valve-mask that may have contributed to aerosolization of SARS-CoV. On the basis of the results of this investigation and previous reports of SARS transmission during aerosol-generating procedures, a systematic approach to the problem is outlined, including the use of the following: 1) administrative controls, 2) environmental engineering controls, 3) personal protective equipment, and 4) quality control.

SARS control and psychological effects of quarantine, Toronto, Canada.

Explores effects of quarantine on those quarantined for SARS, Toronto, Canadarespiratory syndrome (SARS) was successfully contained globally by instituting widespread quarantine measures. Although these measures were successful in terminating the outbreak in all areas of the world, the adverse effects of quarantine have not previously been determined in a systematic manner. In this hypothesis-generating study supported by a convenience sample drawn in close temporal proximity to the period of quarantine, we examined the psychological effects of quarantine on persons in Toronto, Canada. The 129 quarantined persons who responded to a Web-based survey exhibited a high prevalence of psychological distress. Symptoms of posttraumatic stress disorder (PTSD) and depression were observed in 28.9% and 31.2% of respondents, respectively. Longer durations of quarantine were associated with an increased prevalence of PTSD symptoms. Acquaintance with or direct exposure to someone with a diagnosis of SARS was also associated with PTSD and depressive symptoms.

Reducing Antimicrobial Therapy for Asymptomatic Bacteriuria Among Noncatheterized Inpatients: A Proof-of-Concept Study

This proof-of-concept study demonstrates that no longer routinely reporting urine culture results from noncatheterized medical and surgical inpatients can greatly reduce unnecessary antimicrobial therapy for asymptomatic bacteriuria without significant additional laboratory workload. Larger studies are needed to confirm the generalizability, safety, and sustainability of this model of care.

Intramedullary Abscess of the Spinal Cord in the Antibiotic Era: Clinical Features, Microbial Etiologies, Trends in Pathogenesis, and Outcomes

We review the clinical features, microbial etiologies, mechanisms of infection, and outcomes of 25 cases of intramedullary abscess of the spinal cord (IASC) reported between 1977 and 1997, the modern era. All patients presented with motor and/or sensory neurological deficits. Back pain and/or radicular pain was common (60%); fever was present in a minority (40%) of patients. Preexisting abnormalities of the spinal cord and/or vertebral column were present in 44% of cases. Contiguous spread of infection through a congenital dermal sinus was the mechanism of infection in 24% of cases. The infection was fatal in 8% of cases; persistent neurological deficits were documented in 70% of patients who survived. To assess the impact of antimicrobial therapy on the pathogenesis and outcomes of IASC, cases reported in the modern era are compared with 42 cases of IASC reported between 1830 and 1944, the preantibiotic era.

Severe acute respiratory syndrome and its impact on professionalism: qualitative study of physicians' behaviour during an emerging healthcare crisis.

Abstract Objective To explore issues of medical professionalism in the context of severe acute respiratory syndrome (SARS), a new emerging health threat. Design Qualitative interviews analysed with grounded theory methodology. Setting University hospitals in Toronto, Canada, during the SARS outbreak in 2003. Participants 14 staff physicians from divisions of infectious diseases, general internal medicine, and critical care medicine. Results Of 14 attending physicians, four became ill during the outbreak. Participants described their experiences during the outbreak and highlighted several themes about values inherent to medical professionalism that arose during this crisis including the balance between care of patients and accepted personal risk, confidentiality, appropriate interactions between physicians and patients, ethical research conduct, and role modelling of professionalism for junior doctors. Conclusion Despite concerns raised by professional societies about the erosion of professionalism, participants in this study amply demonstrated the necessary qualities during the recent healthcare crisis. However, there were several examples of strained professional behaviour witnessed by the participants and these examples highlight aspects of medical professionalism that medical educators and professional organisations should address in the future, including the balance between personal safety and duty of care.

Pyogenic Brain Abscess Caused by Streptococcus pneumoniae: Case Report and Review

While Streptococcus pneumoniae is the most common cause of bacterial meningitis in adults, cases of pneumococcal brain abscess have rarely been reported. We describe a case of otogenic brain abscess caused by S. pneumoniae that developed in a patient who was receiving ciprofloxacin for the empirical treatment of otitis media. We also review 23 additional cases of pyogenic brain abscess caused by S. pneumoniae that have previously been reported. The development of a pneumococcal brain abscess was associated with a contiguous intracranial focus of infection in 50% of cases. The majority of patients presented with headache (81%) and focal neurological deficits (86%). However, the classic triad of headache, fever, and focal neurological deficits was present in only 24% of patients. The mortality rate for patients with brain abscess caused by S. pneumoniae was 35%; persistent neurological deficits were documented in 40% of patients who survived.

Can Routine Laboratory Tests Discriminate between Severe Acute Respiratory Syndrome and Other Causes of Community-Acquired Pneumonia?

Abstract Background. The clinical presentation of severe acute respiratory syndrome (SARS) resembles that of other etiologies of community-acquired pneumonia, making diagnosis difficult. Hematological and biochemical abnormalities, particularly lymphopenia, are common in patients with SARS. Methods. With the use of 2 databases, we compared the ability of the absolute lymphocyte count, absolute neutrophil count, lactate dehydrogenase level, creatine kinase level, alanine aminotransferase level, and serum calcium level at hospital admission to discriminate between cases of SARS and cases of community-acquired pneumonia. The SARS database contained data for 144 patients with SARS from the 2003 Toronto SARS outbreak. The community-acquired pneumonia database contained data for 8044 patients with community-acquired pneumonia from Edmonton, Canada. Patients from the SARS database were matched to patients from the community-acquired pneumonia database according to age, and receiver operating characteristic curves were constructed for each laboratory variable. Results. The areas under the receiver operating characteristic curves (AUCs) demonstrated fair to poor discriminatory ability for all laboratory variables tested except absolute neutrophil count, which had an AUC of 0.80, indicating good discriminatory ability (although there was no cutoff value of the absolute neutrophil count at which reasonable sensitivity or specificity could be obtained). Combinations of any 2 tests did not perform significantly better than did the absolute neutrophil count alone. Conclusions. Routine laboratory tests, including determination of absolute lymphocyte count, should not be used in the diagnosis of SARS or incorporated into current case definitions of SARS. The role of the absolute neutrophil count in SARS diagnosis is likely limited, but it should be assessed further.

Impact of Reported Beta-Lactam Allergy on Inpatient Outcomes: A Multicenter Prospective Cohort Study

BACKGROUND Reported allergy to beta-lactam antibiotics is common and often leads to unnecessary avoidance in patients who could tolerate these antibiotics. We prospectively evaluated the impact of these reported allergies on clinical outcomes. METHODS We conducted a trainee-led prospective cohort study to determine the burden and clinical impact of reported beta-lactam allergy on patients seen by infectious diseases consultation services at 3 academic hospitals. The primary outcome was a composite measure of readmission for the same infection, acute kidney injury, Clostridium difficile infection, or drug-related adverse reactions requiring discontinuation. Predictors of interest were history of beta-lactam allergy and receipt of preferred beta-lactam therapy. RESULTS Among 507 patients, 95 (19%) reported beta-lactam allergy; preferred therapy was a beta-lactam in 72 (76%). When beta-lactam therapy was preferred, 25 (35%) did not receive preferred therapy due to their report of allergy even though 13 (52%) reported non-severe prior reactions. After adjustment for confounders, patients who did not receive preferred beta-lactam therapy were at greater risk of adverse events (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 1.28-7.89) compared with those without reported allergy. In contrast, patients who received preferred beta-lactam therapy had a similar risk of adverse events compared with patients not reporting allergy (aOR, 1.33; 95% CI, .62-2.87). CONCLUSIONS Avoidance of preferred beta-lactam therapy in patients who report allergy is associated with an increased risk of adverse events. Development of inpatient programs aimed at accurately identifying beta-lactam allergies to safely promote beta-lactam administration among these patients is warranted.