Illness Severity among Non-English, Non-Spanish Speaking Patients in a Public Emergency Department

Background: Patients with limited English proficiency (LEP) have poor health outcomes compared to English proficient patients. Most studies on language proficiency and health disparities focus on Spanish. Objective: This study examines whether non-Spanish speaking LEP patients experience greater disparities than Spanish speaking LEP patients by comparing disease acuity and language proficiency in an emergency department. Design: This is a retrospective case-control study from November 2010 to February 2012 comparing differences between non-English non-Spanish (NENS) speaking patients to English speaking patients with differences between Spanish speaking and English speaking patients. Main outcomes: Primary endpoints include the emergency severity index (ESI) score, area of triage, days in hospital, and the rates of admission, in-hospital surgery, intensive care unit admission, and all-cause mortality. Results: Among all of the study patients, the average age was 55.1 (+/- 12.4). Comparing the NENS sample to the English sample yielded differences in surgery rates (NENS 11.3%, English 1.9%, p=0.002), admission rates (NENS 38.8%, English 24.7%, p=0.025), and days in hospital (NENS 2.49 +/-5.43, English 1.93+/-8.56, p Conclusions and relevance: We were able to demonstrate greater healthcare needs among NENS patients compared to the other two groups. The NENS patients were more likely to be admitted, have surgery, and stay longer than those speaking English or Spanish. These findings are important because they suggest further research, awareness of these disparities by healthcare providers, and public health interventions focusing on this population are warranted

Review of Human Coronaviruses and Other Respiratory Viruses and their Neurological Impact on the Central Nervous System

Comprehensive reporting shows that some pathogens, including COVID-19, influenza A and SARS-CoV have sometimes caused pandemics and were linked to more serious diseases and death. A number of respiratory viruses can travel from the respiratory tract to the central nervous system, causing alterations and damage and resulting in long-term neurological diseases.

Psychosis in Azheimer\u27s Disease

Much of the basic science literature on Alzheimer\u27s Disease (AD) reflects ongoing research into pathophysiology and neuropathology. Yet, despite reports of the association between psychotic symptoms and Alzheimer\u27s disease, relatively little is known about why such symptoms develop in certain patients and not in others. Neuroimaging and genetic studies may provide greater understanding of this association and allow clinicians and researchers to prevent, predict and treat the onset of psychotic symptoms in the future. This paper will review the current literature on the topic of psychosis in Alzheimer\u27s disease and focus on current recommendations for interventions by clinicians and caregivers

Why the Drug War is Unstoppable

The purpose of this symposium is to search for a breakthrough in drug policy, or, to put it more simply, to stop the War on Drugs

Intestinal transplantation

Intestinal transplantation is often the only alternative form of treatment for patients dependent on total parenteral nutrition for survival. Although a limited number of intestinal transplantations have been performed, results with FK 506 immunosuppression are comparable to those for other organ transplants. The impact of successful intestinal transplantation on gastroenterology will likely be similar to the impact of kidney and liver transplantation on nephrology and hepatology

Efficacy and Cost Effectiveness of Adjuvant Chemotherapy in Women with Node-Negative Breast Cancer — A Decision-Analysis Model

Abstract BACKGROUND. In 1988 the National Cancer Institute issued a Clinical Alert that has been widely interpreted as recommending that all women with node-negative breast cancer receive adjuvant chemotherapy. Acceptance of this recommendation is controversial, since many women who would not have a recurrence would be treated. METHODS. Using a decision-analysis model, we studied the cost effectiveness of chemotherapy in cohorts of 45-year-old and 60-year-old women with node-negative breast cancer by calculating life expectancy as adjusted for quality of life. The analysis evaluated different scenarios of the benefit of therapy: improved disease-free survival for five years, with a lesser effect on overall survival (base line); a lifelong benefit from chemotherapy; and a benefit in disease-free survival with no change in overall survival by year 10. The base-line analysis assumed a 30 percent reduction in the relative risk of recurrence for five years after treatment. RESULTS. For the 45-year-old woman, the base-line analysis found an average lifetime benefit from chemotherapy of 5.1 quality-months at a cost of $15,400 per quality-year. The 60-year-old women gained 4.0 quality-months at a cost of$18,800 per quality-year. Under the more and less optimistic scenarios, the benefit of chemotherapy varied from 1.4 to 14.0 quality-months for both groups. CONCLUSIONS. Chemotherapy substantially increases the quality-adjusted life expectancy of an average woman at a cost comparable to that of other widely accepted therapies. This benefit decreases markedly if the changes in long-term survival are less than in disease-free survival. Given its uncertain duration, the benefit may be too small for many women to choose chemotherapy. Selective use of chemotherapy to maximize the benefit to individual patients may be possible with refinements in risk stratification and explicit assessment of the patients\u27 risk preferences. (N Engl J Med 1991; 324:160–8.

Reliability of Trainees\u27 Endorsements on Standardized Psychiatric Interviews

This study investigated the utilization of standardized psychiatric interviews (SPI\u27s) in psychiatric training programs. As the field of psychiatry, and the training of its\u27 new members moves to conformits\u27 principles to scientific models, the reliable use of SPI\u27s is use ful in reaching that goal, in both research and diagnostic applications. This investigation contains two studies. In Study 1, a random survey of 20 percent of all psychiatric residency training programs was conducted to determine the prevailing level of training devoted to SPI\u27s. The resulting findings are referred to as training as usual (TAU). Study 1 shows that residents are not sufficiently trained in the use of SPI\u27s in so much as more than 85 percent of training programs offered no training in their administration. Study 2 tested residents\u27 inter-judge reliabity upon administration of the Psychiatric Status Schedule (PSS) both before and after they received an intensive training intervention. The purpose of the training intervention was to increase the skills necessary for residents to improve the inter-judge reliability in administering the PSS. Results of Study 2 show a highly significant increase in the residents\u27 inter-judge reliability from before to after training (p \u3c .005). All seven residents in the study had total agreement on an average of 64 percent of the PSS items before training (that is, when they received the prevailing amount of training (TAU) as found in Study I) and on 90 per cent of the PSS items after the training intervention. This investigation was useful in showing that psychiatry can further its goal of conforming to scientific models by providing the type of training necessary to yield the high inter-judge reliability levels needed to achieve those goals

Atovaquone Compared with Dapsone for the Prevention of Pneumocystis carinii Pneumonia in Patients with HIV Infection Who Cannot Tolerate Trimethoprim, Sulfonamides, or Both

BACKGROUND Although trimethoprim–sulfamethoxazole is the drug of choice for the prevention of Pneumocystis carinii pneumonia, many patients cannot tolerate it and must switch to an alternative agent. METHODS We conducted a multicenter, open-label, randomized trial comparing daily atovaquone (1500-mg suspension) with daily dapsone (100 mg) for the prevention of P. carinii pneumonia among patients infected with the human immunodeficiency virus who could not tolerate trimethoprim–sulfamethoxazole. The median follow-up period was 27 months. RESULTS Of 1057 patients enrolled, 298 had a history of P. carinii pneumonia.P. cariniipneumonia developed in 122 of 536 patients assigned to atovaquone (15.7 cases per 100 person-years), as compared with 135 of 521 in the dapsone group (18.4 cases per 100 person-years; relative risk for atovaquone vs. dapsone, 0.85; 95 percent confidence interval, 0.67 to 1.09; P=0.20). The relative risk of death was 1.07 (95 percent confidence interval, 0.89 to 1.30; P=0.45), and the relative risk of discontinuation of the assigned medication because of adverse events was 0.94 (95 percent confidence interval, 0.74 to 1.19; P=0.59). Among the 546 patients who were receiving dapsone at base line, the relative risk of discontinuation because of adverse events was 3.78 for atovaquone as compared with dapsone (95 percent confidence interval, 2.37 to 6.01; P CONCLUSIONS Among patients who cannot tolerate trimethoprim–sulfamethoxazole, atovaquone and dapsone are similarly effective for the prevention ofP. carinii pneumonia. Our results support the continuation of dapsone prophylaxis among patients who are already receiving it. However, among those not receiving dapsone, atovaquone is better tolerated and may be the preferred choice for prophylaxis against P. cariniipneumonia

Charles Dickens’ Hard Times and the Academic Health Center: A Tale of the Urban Working Poor and the Violation of a Covert Covenant, an American Perspective

Charles Dickens’ novel “Hard Times” focuses on the struggles of urban workers in 19th century England. The situations of workers in 21st century America are not dissimilar thus making Dickens’ commentary and characters applicable to the contemporary socioeconomic scene. The number of uninsured or underinsured poor in America is rising. AHCs must go beyond their traditional mission of patient care, education and research and embrace the local neighborhoods they serve. The urban location, technical expertise, and educational mission of many AHCs make them ideally suited to assist urban populations that are at great health risk. Many Academic Health Centers (AHCs) in America found their origins in working class neighborhoods, such as those described by Dickens, and today are surrounded by the urban poor. An argument is made that AHCs have a moral obligation to these neighborhoods; it is an implied, or covert, covenant that they are obliged to honor

Discussion of the Paper by David A. Scola, M.D. on “The Hemispheric Specialization of the Human Brain and Its Application to Psychoanalytic Principles”

Dr. Scola proposes a bold and far-reaching synthesis of psychoanalytic theory, developmental neurobiology and neurophysiology of behavior. Freud found this task so frustrating in 1895 that he renounced neurology in favor of a purely psychologic approach (or so Freud claimed; Frank Sulloway sees it differently). Hypotheses that unconscious mental life is situated in the right cerebrum and that defense mechanisms are related to neuroanatomic connections are intriguing. The presentation does not include evidence which contravenes these theories. Sperry presented some evidence that the right hemisphere is self-aware and self-evaluative (I). One great problem in all cross disciplinary studies is the difference in terminology and definitions from various fields. Now that Dr. Scola has set forth his theory, the real work begins: to collect data to substantiate it. The first and most direct method is the classical neurologic observation of patients with specific lesions . This method has been used from the time of Wernicke and Freud himself, down to the late great Alexander Luria. Epidemiologic data such as that linking familial tendency to dyslexia , autoimmune disease, migraine and lefthandedness may be important. Finally, the opportunity to do careful experimental work may come, such as that which won Sperry the Nobel Prize in 1981