On-call absences and academic recognition: A retrospective cohort analysis.

BACKGROUND: Resident call schedules require careful planning and are vulnerable to unanticipated absences from unpredictable factors. We tested whether unplanned absences from resident call schedules were associated with the likelihood of subsequent academic recognition. METHODS: We examined unplanned absences from call shifts for internal medicine residents at the University of Toronto from 2014 to 2022 (8 years). We identified institutional awards granted at the end of the academic year as an indicator of academic recognition. We defined the resident-year as the unit-of-analysis that started in July and ended in June of the subsequent year. Secondary analyses examined the association between unplanned absences and the likelihood of academic recognition in later years. RESULTS: We identified 1668 resident-years of training in internal medicine. In total, 579 (35%) had an unplanned absence, and the remaining 1089 (65%) had no unplanned absence. Baseline characteristics were similar between the two groups of residents. In total, 301 awards were received for academic recognition. The likelihood of receiving an award at the end of the year was 31% lower for residents who had any unplanned absence compared with those who had no absence (adjusted odds ratio = 0.69, 95% confidence interval 0.51-0.93, p = 0.015). The likelihood of receiving an award was further decreased for residents with multiple unplanned absences compared with those with none (odds ratio 0.54, 95% confidence interval 0.33-0.83, p = 0.008). An absence during the first year of residency was not significantly associated with the likelihood of academic recognition in later years of training (odds ratio 0.62, 95% confidence interval 0.36-1.04, p = 0.081). CONCLUSIONS: The results of this analysis suggest unplanned absences from scheduled call shifts may be associated with a decreased likelihood of academic recognition for internal medicine residents. This association could reflect countless confounders or the prevailing culture of medicine.

COVID-19 deaths on weekends.

BACKGROUND: Mortality statistics about daily deaths might change on weekends due to delays in reporting, uneven staffing, a different mix of personnel, or decreased efficiency. We hypothesized that reported deaths for COVID-19 might increase on weekends compared to weekdays. METHODS: We collected data from the World Health Organization COVID-19 database. All deaths from March 7, 2020 to March 7, 2022 were included (two years). The primary analysis evaluated mean daily deaths on weekends compared to the preceding five workdays. Analyses were replicated in ten individual countries: United States, United Kingdom, France, Germany, Italy, Spain, Russia, India, Brazil, and Canada. RESULTS: The mean COVID-19 daily deaths was higher on weekends compared to weekdays (8,532 vs. 8,083 p < 0.001), equal to a 6% relative increase (95% confidence interval 3% to 8%). The highest absolute increase was in the United States (1,483 vs. 1,220 deaths, p < 0.001). The second highest absolute increase was in Brazil (1,061 vs. 823 deaths, p < 0.001). The increase in deaths on weekends remained significant during the earlier and later months of the pandemic, as well as during the greater and lesser weeks of the pandemic. CONCLUSIONS: The apparent increased COVID-19 deaths reported on weekends might potentially reflect patient care, confound community trends, and affect the public perception of risk.

Hemophagocytic lymphohistiocytosis secondary to unrecognized Bartonella henselae infection: a case report.

BACKGROUND: Bartonella henselae is a species of intracellular bacteria transmitted to humans through animal bites and scratches contaminated with the feces of arthropod vectors, and are most commonly associated with cat exposure although transmission from other mammals has been reported. Bartonella henselae infection has a spectrum of clinical manifestations and has rarely been reported as cause of hemophagocytic lymphohistiocytosis (HLH) in immunocompromised hosts. CASE PRESENTATION: We present a report of Bartonella henselae infection progressing to HLH in an immunocompetent patient. The patient initially presented with regional lymphadenopathy but the diagnosis was not suspected as the patient reported no exposure to cats. On further history, he did report a scratch from a dog prior to development of symptoms. The patient was treated with methylprednisolone, intravenous immunoglobulin and anakinra for the HLH and three months of Doxycycline for Bartonella infection, with complete resolution of symptoms. CONCLUSIONS: Although commonly associated with cat exposure, Bartonella henselae transmission can occur after exposure to other animals and vectors including dogs and clinicians need to maintain an index of suspicion for timely diagnosis. Bartonella henselae is associated with a spectrum of clinical manifestations which can include disseminated infection with severe complications such as hemophagocytic lymphohistiocytosis. Prompt initiation of Bartonella treatment is essential when thought to be the trigger for hemophagocytic lymphohistiocytosis although the optimal treatment regimen is unclear.

Does this patient have Clostridioides difficile infection? A systematic review and meta-analysis.

BACKGROUND: The clinical features and predictors of Clostridioides difficile infection overlap with many conditions. OBJECTIVES: We performed a systematic review to evaluate the diagnostic utility of clinical features (clinical examination, risk factors, laboratory tests, and radiographic findings) associated with C. difficile. METHODS: Systematic review and meta-analysis of diagnostic features for C. difficile. DATA SOURCES: MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched up to September 2021. STUDY ELIGIBILITY CRITERIA: Studies that reported clinical features of C. difficile, a valid reference standard test for confirming diagnosis of C. difficile, and a comparison among patients with a positive and negative test result. PARTICIPANTS: Adult and paediatric patients across diverse clinical settings. OUTCOMES: Sensitivity, specificity, likelihood ratios. REFERENCE STANDARD: Stool nucleic acid amplification tests, enzyme immunoassays, cell cytotoxicity assay, and stool toxigenic culture. ASSESSMENT OF RISK OF BIAS: Rational Clinical Examination Series and Quality Assessment of Diagnostic Accuracy Studies-2. METHODS OF DATA SYNTHESIS: Univariate and bivariate analyses. RESULTS: We screened 11 231 articles of which 40 were included, enabling the evaluation of 66 features for their diagnostic utility for C. difficile (10 clinical examination findings, 4 laboratory tests, 10 radiographic findings, prior exposure to 13 antibiotic types, and 29 clinical risk factors). Of the ten features identified on clinical examination, none were significantly clinically associated with increased likelihood of C. difficile infection. Some features that increased likelihood of C. difficile infection were stool leukocytes (LR+ 5.31, 95% CI 3.29-8.56) and hospital admission in the prior 3 months (LR+ 2.14, 95% CI 1.48-3.11). Several radiographic findings also strongly increased the likelihood of C. difficile infection like ascites (LR+ 2.91, 95% CI 1.89-4.49). DISCUSSION: There is limited utility of bedside clinical examination alone in detecting C. difficile infection. Accurate diagnosis of C. difficile infection requires thoughtful clinical assessment for interpretation of microbiologic testing in all suspected cases.

Analysis of Resident and Attending Physician End-of-Rotation Changeover Days and Association With Patient Length of Stay.

Importance: End-of-rotation resident physician changeover is a key part of postgraduate training but could lead to discontinuity in patient care. Objective: To test whether patients exposed to end-of-rotation resident changeover have longer hospital stays and whether this association is mitigated by separating resident and attending changeover days. Design, Setting, and Participants: This retrospective cohort analysis included adult patients admitted to general internal medicine. The changeover day was the same day (first Monday of month) for both resident and attending physicians until June 30, 2013 (preseparation period), and then intentionally staggered by 1 or more days after July 1, 2013 (postseparation period). This was a multicenter analysis at 4 teaching hospitals in Ontario, Canada, from July 1, 2010, to June 30, 2019. Data analysis was conducted from July 2022 to January 2023. Exposures: Patients were classified as changeover patients if the first Monday was a resident changeover day and as control patients if the first Monday was not a resident changeover day. Main Outcomes and Measures: The primary outcome was length of hospital stay. Secondary outcomes were transfer to critical care, in-hospital death, and rate of discharge per 100 patients on the index day. Results: Of 95 282 patients. 22 773 (24%; mean [SD] age, 67.8 [18.8] years; 11 156 [49%] female patients) were exposed to resident changeover, and 72 509 (76%; mean [SD] age, 67.8 [18.7] years; 35 293 [49%] female patients) were not exposed to resident changeover. Exposure to resident changeover day was associated with a slightly longer hospital stay compared with control days (0.20 [95% CI, 0.09-0.30] days; P < .001) and decreased relative risk of patient discharge on the index day (relative risk, 0.92; 95% CI, 0.86-1.00; P = .047). These associations were similar in the preseparation and postseparation periods. Resident changeover was not associated with an increased risk of transfer to critical care or in-hospital death. Conclusions and Relevance: In this study, a small positive association between exposure to resident physician changeover and length of hospital stay as well as reduced rate of discharge was found. These findings suggest that separating changeover days for resident and attending physicians may not significantly change these associations.

Life-threatening alcohol-related traffic crashes in adverse weather: a double-matched case-control analysis from Canada.

IMPORTANCE: Drunk driving is a major cause of death in North America, yet physicians rarely counsel patients on the risks of drinking and driving. OBJECTIVE: To test whether the risks of a life-threatening alcohol-related traffic crash were further accentuated by adverse weather. DESIGN: Double matched case-control analysis of hospitalised patients. SETTING: Canada's largest trauma centre between 1 January 1995 and 1 January 2015. PARTICIPANTS: Patients hospitalised due to a life-threatening alcohol-related traffic crash. EXPOSURE: Relative risk of a crash associated with adverse weather estimated by evaluating the weather at the place and time of the crash (cases) compared with the weather at the same place and time a week earlier and a week later (controls). RESULTS: A total of 2088 patients were included, of whom the majority were drivers injured at night. Adverse weather prevailed among 312 alcohol-related crashes and was significantly more frequent compared with control circumstances. The relative risk of a life-threatening alcohol-related traffic crash was 19% higher during adverse weather compared with normal weather (95% CI: 5 to 35, p=0.006). The absolute increase in risk amounted to 43 additional crashes, extended to diverse groups of patients, applied during night-time and daytime, contributed to about 793 additional patient-days in hospital and was distinct from the risks for drivers who were negative for alcohol. CONCLUSIONS: Adverse weather was associated with an increased risk of a life-threatening alcohol-related traffic crash. An awareness of this risk might inform warnings to patients about traffic safety and counselling alternatives to drinking and driving.

Association Between Statin Use and Risk of Dementia After a Concussion.

IMPORTANCE: Concussions are an acute injury that may lead to chronic disability, while statin use might improve neurologic recovery. OBJECTIVE: To test whether statin use is associated with an increased or decreased risk of subsequent dementia after a concussion. DESIGN, SETTING, AND PARTICIPANTS: Large extended population-based double cohort study in Ontario, Canada, from April 1, 1993, to April 1, 2013 (enrollment), and continued until March 31, 2016 (follow-up). Dates of analysis were April 28, 2014, through March 21, 2019. Participants were older adults diagnosed as having a concussion, excluding severe cases resulting in hospitalization, individuals with a prior diagnosis of dementia or delirium, and those who died within 90 days. EXPOSURE: Statin prescription within 90 days after a concussion. MAIN OUTCOME AND MEASURE: Long-term incidence of dementia. RESULTS: This study identified 28 815 patients diagnosed as having a concussion (median age, 76 years; 61.3% female), of whom 7058 (24.5%) received a statin, and 21 757 (75.5%) did not receive a statin. A total of 4727 patients subsequently developed dementia over a mean follow-up of 3.9 years, equal to an incidence of 1 case per 6 patients. Patients who received a statin had a 13% reduced risk of dementia compared with patients who did not receive a statin (relative risk, 0.87; 95% CI, 0.81-0.93; P < .001). The decreased risk of dementia associated with statin use applied to diverse patient groups, remained independent of other cardiovascular medication use, intensified over time, was distinct from the risk of subsequent depression, and was not observed in patients after an ankle sprain. CONCLUSIONS AND RELEVANCE: In this study, older adults had a substantial long-term risk of dementia after a concussion, which was associated with a modest reduction among patients receiving a statin.

Dysregulation of Vascular Endothelial Progenitor Cells Lung-Homing in Subjects with COPD.

Chronic obstructive pulmonary disease (COPD) is characterized by fixed airflow limitation and progressive decline of lung function and punctuated by occasional exacerbations. The disease pathogenesis may involve activation of the bone marrow stimulating mobilization and lung-homing of progenitor cells. We investigated the hypothesis that lower circulating numbers of vascular endothelial progenitor cells (VEPCs) are a consequence of increased lung-sequestration in COPD. Nonatopic, current or ex-smokers with diagnosed COPD and nonatopic, nonsmoking normal controls were enrolled. Blood and induced sputum extracted primitive hemopoietic progenitors (HPCs) and VEPC were enumerated by flow cytometry. Migration and adhesive responses to fibronectin were assessed. In sputum, VEPC numbers were significantly greater in COPD compared to normal controls. In blood, VEPCs were significantly lower in COPD versus normal controls. There were no differences in HPC levels between the two groups in either compartment. Functionally, there was a greater migrational responsiveness of progenitors from COPD subjects to stromal cell-derived factor-1alpha (SDF-1α) compared to normal controls. This was associated with greater numbers of CXCR4(+) progenitors in sputum from COPD. Increased migrational responsiveness of progenitor cells may promote lung-homing of VEPC in COPD which may disrupt maintenance and repair of the airways and contribute to COPD disease pathogenesis.