PubMed Health⌕ Search

Biomedical subjects

T J Marrie

Publications and source records attributed to T J Marrie.

At least 55 records · Page 3Linked to original sources
PubMed1998

Patients hospitalized after initial outpatient treatment for community-acquired pneumonia.

STUDY OBJECTIVE: To determine the incidence, causes, and outcomes of patients hospitalized within 30 days of initiating outpatient treatment for community-acquired pneumonia (CAP). DESIGN: Patients were enrolled in the Pneumonia Patient Outcomes Research Team's multicenter, prospective cohort study of CAP. All hospitalizations within 30 days of study enrollment of patients initially treated as outpatients for CAP were recorded. Two physicians used a set of predetermined definitions to independently categorize the reasons for these subsequent hospitalizations. Thirty-day mortality rate and measures of resolution of pneumonia were assessed. The setting included three university teaching hospitals, a community teaching hospital, and a staff model medical practice within a health maintenance organization. RESULTS: Of the 944 enrollees with CAP initially treated in the outpatient setting, 71 (7.5%) were subsequently hospitalized within 30 days. The reason for subsequent hospitalization was CAP related in 40 patients and comorbidity related in 26 patients; 5 refused an initial offer of hospitalization. Ninety percent of pneumonia-related hospitalizations occurred within 10 days of initial presentation. Patients who were subsequently hospitalized required a median of 14 days to return to usual activities compared with 6 days for those who were not hospitalized (P<.0001). Patients with a subsequent hospitalization had a higher 30-day mortality rate, 4.2% compared with .3% (P<.01). CONCLUSION: A small proportion of patients with CAP initially treated in the outpatient setting are subsequently hospitalized. Such patients face a higher risk of delayed recovery or death. However, the vast majority of outpatients, whether subsequently hospitalized or not, had a successful resolution of their illness. Subsequent hospitalization by 10 days after initial outpatient treatment seems a reasonable screening tool for potentially unsatisfactory quality of care for patients with CAP.

Adult↗
PubMed1998

Seroprevalence of lymphocytic choriomeningitis virus in Nova Scotia.

An ELISA system was used to determine the rate of seropositivity to lymphocytic choriomeningitis virus (LCMV) among a random sample of 505 Nova Scotians. Twenty (4%) were positive. Complete questionnaire data were available on all 20 seropositive subjects and on 449 seronegative subjects. Seventeen (85%) of the seropositive subjects were females (P = 0.03). It is concluded that infection with LCMV is present in Nova Scotia and females are more likely to be infected than males.

Adolescent↗
PubMed1998

Epidemiology of mild pneumonia.

Clinicians define mild pneumonia as patients who are "not too sick," have normal respiratory and mental status, and are able to maintain oral intake. As yet there is no uniform definition of mild pneumonia. By inference, mild pneumonia occurs in younger patients with less comorbidity and has a better outcome than pneumonia that is moderate to severe. "Atypical" pathogens such as Mycoplasma pneumoniae, Chlamydia pneumoniae and respiratory tract viruses are common causes of mild pneumonia.

Ambulatory Care↗
PubMed1997

Influence of age on symptoms at presentation in patients with community-acquired pneumonia.

BACKGROUND: Advanced age has become a well-recognized risk factor for death in patients with pneumonia. It may also be associated with reduced symptom reporting, raising the possibility that diagnosis and treatment may be delayed in older patients. OBJECTIVE: To evaluate the association between age and the presenting symptoms in patients with community-acquired pneumonia. METHODS: This study was conducted at inpatient and outpatient facilities at 3 university hospitals, 1 community hospital, and 1 staff-model health maintenance organization. Patients included adults (age > or = 18 years) with clinical and radiographic evidence of pneumonia, who were able to complete a baseline interview. The presence of 5 respiratory symptoms and 13 nonrespiratory symptoms were recorded during a baseline patient interview. A summary symptom score was computed as the total number of symptoms at presentation. RESULTS: The 1812 eligible study patients were categorized into 4 age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 symptoms, there were significant decreases in reported prevalence with increasing age (P < .01). In a linear regression analysis, controlling for patient demographics, comorbidity, and severity of illness at presentation, older age remained associated with lower symptom scores (P < .001). CONCLUSIONS: Respiratory and nonrespiratory symptoms are less commonly reported by older patients with pneumonia, even after controlling for the increased comorbidity and illness severity in these older patients. Recognition of this phenomenon by clinicians and patients is essential given the increased mortality in elderly patients with pneumonia.

Adult↗
PubMed1997

Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia.

CONTEXT: The American Thoracic Society (ATS) published guidelines based on expert opinion and published data--but not clinically derived or validated--for treating adult outpatients with community-acquired pneumonia. OBJECTIVE: To compare medical outcomes and antimicrobial costs for patients whose antimicrobial therapy was consistent or inconsistent with ATS guidelines. DESIGN: Multicenter, prospective cohort study. SETTING: Emergency departments, medical clinics, and practitioner offices affiliated with 3 university hospitals, 1 community teaching hospital, and 1 health maintenance organization. PARTICIPANTS: A total of 864 immunocompetent, adult outpatients with community-acquired pneumonia: 546 aged 60 years or younger with no comorbidity and 318 older than 60 years or with 1 comorbidity or more. MAIN OUTCOME MEASURES: Patients' antimicrobial therapy was classified as being consistent or inconsistent with the ATS guidelines. Mortality, subsequent hospitalization, medical complications, symptom resolution, return to work and usual activities, health-related quality of life, and antimicrobial costs were compared among those treated consistently or inconsistently with the guidelines. RESULTS: Outpatients aged 60 years or younger with no comorbidity who were prescribed therapy consistent with ATS guidelines (ie, erythromycin with some exceptions) had 3-fold lower antimicrobial costs ($5.43 vs $18.51; P<.001) and no significant differences in medical outcomes. Outpatients older than 60 years or with 1 comorbidity or more who were prescribed therapy consistent with ATS guidelines (ie, second-generation cephalosporin, sulfamethoxazole-trimethoprim, or beta-lactam and beta-lactamase inhibitor with or without a macrolide) had 10-fold higher antimicrobial costs ($73.50 vs $7.50; P<.001); despite trends toward higher mortality and subsequent hospitalization, no significant differences in medical outcomes were observed. CONCLUSION: Our findings support the use of erythromycin as recommended by the ATS guidelines for outpatients aged 60 years or younger with no comorbidity. Although the antimicrobial therapy recommended in outpatients older than 60 years or with 1 comorbidity or more is more costly, this observational study provides no evidence of improved medical outcomes in the small subgroup who received ATS guideline-recommended therapy.

Adult↗
PubMed1997

A prediction rule to identify low-risk patients with community-acquired pneumonia.

BACKGROUND: There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation. METHODS: From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of > or = 30 or a temperature of > or = 40 degrees C), and abnormal laboratory findings (such as a pH <7.35, a blood urea nitrogen concentration > or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration <130 mmol per liter) at presentation. RESULTS: There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients. CONCLUSIONS: The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.

Adult↗
PubMed1997

The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital admission decision directly influences the magnitude of resource use in patients with community-acquired pneumonia, yet little information exists on how medical practitioners make this decision. OBJECTIVES: To determine which factors medical practitioners consider in making the hospital admission decision and which health care services they believe would allow ambulatory treatment of low-risk hospitalized patients with community-acquired pneumonia. METHODS: Medical practitioners responsible for the hospital admission decision for low-risk patients with community-acquired pneumonia were asked to describe patient characteristics at initial examination that influenced the hospitalization decision, and to identify the health care services that would have allowed initial outpatient treatment of hospitalized patients. RESULTS: A total of 292 medical practitioners completed questionnaires for 472 (76%) of the 624 low-risk patients eligible for this study. Although all patients had a predicted probability of death of less than 4%, practitioners estimated that 5% of outpatients and 41% of inpatients had an expected 30-day risk of death of more than 5%. Univariate analyses identified 3 practitioner-rated factors that were nearly universally associated with hospitalization: hypoxemia (odds ratio, 173.3; 95% confidence interval, 23.8-1265.0), inability to maintain oral intake (odds ratio, 53.3; 95% confidence interval, 12.8-222.5), and lack of patient home care support (odds ratio, 54.4; 95% confidence interval, 7.3-402.6). In patients without these 3 factors, logistic regression analysis demonstrated that practitioner-estimated risk of death of more than 5% had a strong independent association with hospitalization (odds ratio, 18.4; 95% confidence interval, 6.1-55.7). Practitioners identified home intravenous antibiotic therapy and home nursing observation as services that would have allowed outpatient treatment of more than half (68% and 59%, respectively) of the patients initially hospitalized for treatment. CONCLUSIONS: Practitioners' survey responses suggest that the availability of outpatient intravenous antimicrobial therapy and home nursing care would allow outpatient care for a large proportion of low-risk patients who are hospitalized for community-acquired pneumonia. These data also suggest that methods to improve practitioners' identification of low-risk patients with community-acquired pneumonia could decrease the hospitalization of such patients. Future studies are required to help physicians identify which low-risk patients could safely be treated in the outpatient setting on the basis of clinical information readily available at presentation.

Adult↗
PubMed1997

The hospital discharge decision for patients with community-acquired pneumonia. Results from the Pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital discharge decision directly influences the length of stay in patients with community-acquired pneumonia, yet no information exists on how physicians make this decision. OBJECTIVES: To identify the factors physicians considered the factors responsible for extending length of hospital stay in clinically stable patients, and the outpatient medical services that would allow earlier hospital discharge for patients with community-acquired pneumonia. METHODS: Physicians responsible for the hospital discharge decision of patients with community-acquired pneumonia were asked to identify the factors responsible for extending stay in patients hospitalized beyond stability, and the medical services that could have allowed earlier hospital discharge to occur. RESULTS: For the 418 eligible patients with community-acquired pneumonia identified during the study, 332 questionnaires (79%) were completed by 168 physicians. Physicians believed 71 patients (22%) were discharged from the hospital 1 day or more (median, 2.5 days) after reaching clinical stability. The most common factors rated as being "very important" in delaying discharge were diagnostic evaluation or treatment of comorbid illness (56%), completion of a "standard course" of antimicrobials (15%), and delays with arrangements for long-term care (14%). Among the 302 patients with available information on both length of hospital stay and stability at discharge, median length of stay was 7.0 days for the 29 low-risk patients hospitalized beyond reaching clinical stability and 5.0 days for the remaining 128 low-risk patients (P < .005); median length of stay was 12.5 days for the 42 medium- and high-risk patients hospitalized beyond reaching clinical stability and 8.0 days in the remaining 113 medium- and high-risk patients (P < .001). Frequently cited medical services that "probably" or "definitely" would have allowed earlier discharge to occur included availability of home intravenous antimicrobial infusion (26%) and home visits by nurses (20%). CONCLUSIONS: Physicians believed that diagnostic evaluation or treatment of comorbid illness, completion of a standard course of antimicrobial therapy, and delays with arrangements for long-term care delayed hospital discharge in clinically stable patients. Addressing the efficiency of these aspects of inpatient medical care, as well as providing home treatment programs, could decrease the length of hospital stay in patients with community-acquired pneumonia.

Adult↗
PubMed1997

Fever, lymphadenopathy, eosinophilia, lymphocytosis, hepatitis, and dermatitis: a severe adverse reaction to minocycline.

A 17-year-old female patient who had been taking oral minocycline (50 mg twice daily) for 3 weeks for acne developed an eruption that progressed to an exfoliative dermatitis. This illness was also characterized by fever, lymphadenopathy, pharyngitis, a leukemoid reaction, lymphocytosis, eosinophilia, hepatitis, and noncardiogenic pulmonary edema. Dramatic improvement followed institution of corticosteroid therapy. Studies for infectious and collagen vascular diseases were negative. This severe illness was likely caused by minocycline, and we speculate that minocycline may have acted as a superantigen, causing lymphocyte over-activation and massive cytokine release.

Acne Vulgaris↗
PubMed1997

Measuring symptomatic and functional recovery in patients with community-acquired pneumonia.

OBJECTIVE: To determine the rates of resolution of symptoms and return to premorbid health status and assess the association of these outcomes with health care utilization in patients with community-acquired pneumonia. DESIGN: A prospective, multicenter cohort study. SETTING: Inpatient and outpatient facilities at three university hospitals, one community hospital, and one staff-model health maintenance organization. PATIENTS: Five hundred seventy-six adults (aged > or = 18 years) with clinical and radiographic evidence of pneumonia, judged by a validated pneumonia severity index to be at low risk of dying. MEASUREMENTS AND MAIN RESULTS: The presence and severity of five symptoms (cough, fatigue, dyspnea, sputum, and chest pain) were recorded through questionnaires administered at four time points: 0, 7, 30, and 90 days from the time of radiographic diagnosis of pneumonia. A summary symptom score was tabulated as the sum of the five individual severity scores. Patients also provided responses to the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and reported the number of and reason for outpatient physician visits. Symptoms and health status 30 days before pneumonia onset (prepneumonia) were obtained at the initial interview. All symptoms, except pleuritic chest pain, were still commonly reported at 30 days, and the prevalence of each symptom at 90 days was still nearly twice prepneumonia levels. Physical health measures derived from the SF-36 Form declined significantly at presentation but continued to improve over all three follow-up time periods. Patients with elevated symptom scores at day 7 or day 30 were significantly more likely to report pneumonia-related ambulatory care visits at the subsequent day 30 or day 90 interviews, respectively. CONCLUSIONS: Disease-specific symptom resolution and recovery of the premorbid physical health status requires more than 30 days for many patients with pneumonia. Delayed resolution of symptoms is associated with increased utilization of outpatient physician visits.

Adult↗
PubMed1997

A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia.

OBJECTIVES: To determine the factors responsible for mortality and characteristics unique to patients with nursing home acquired pneumonia (NHAP). DESIGN: A prospective study of 71 patients with NHAP, 79 patients admitted from nursing homes for conditions other than pneumonia (NP), and 93 patients with community-acquired pneumonia (CAP). SETTING: A teaching hospital that serves as the community hospital for the City of Halifax. RESULTS: The 32% in-hospital mortality rate for NHAP was higher than the 14% rate for CAP (P < .05) but not significantly higher than the 23% mortality rate for NP patients. The most important determinants for long-term (52 weeks) outcome were complications during hospital stay, odds ratio for mortality 3.55, and self sufficiency at time of admission, odds ratio for mortality 0.306. While bacteremia rates were similar at 8% for NHAP, 13% for CAP, and 17% for NP, there was a trend toward a higher rate of pneumococcal bacteremia in the CAP group. CAP patients were more likely to receive ventilatory support, 13% versus 3% for NHAP and 4% for no pneumonia patients despite similar levels of hypoxemia in the two pneumonia groups. CONCLUSIONS: The in-hospital mortality rate for NHAP is higher than that for CAP. The 1-year survival rate is determined by self-sufficiency at time of admission and absence of complications during hospital stay and is not group (e.g., nursing home) dependent.

Aged↗
PubMed1997

Characterization and cloning of a 37.6-kb plasmid carried by Legionella pneumophila recovered from patients and hospital water over a 12-year period.

For 12 years, strains of Legionella pneumophila serogroup 1 harbouring a 37.6-kb (23 MDa) plasmid have predominated among patient and potable water isolates at the Victoria General Hospital, Halifax, N.S. Plasmid DNA recovered from 24 strains isolated between 1983 and 1995 was digested with the restriction endonucleases EcoRI, HindIII, KpnI, PvuII, XbaI, and BamHI. The distribution of cutting sites indicated that the 23-MDa size group had remained essentially unchanged during this period, suggesting the persistence of a single plasmid type. Further fragmentation pattern analysis permitted the construction of a physical map of the prototype 23-MDA plasmid, pLp4269. Double digestion with BamHI-HindIII enabled the cloning of 94.4% of pLp4269 into pBluescript vector. A 2.1-kb fragment was not clonable. Plasmid pLp4269 is the first of the smaller Legionella extrachromosomal DNAs to be characterized in this way.

Canada↗
PubMed1996

Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?

BACKGROUND: Previous studies have reported conflicting results on whether pulmonary radiographic findings predict mortality for patients with community-acquired pneumonia (CAP). OBJECTIVE: To determine whether pulmonary radiographic findings at presentation are independently associated with 30-day mortality in patients with suspected CAP. METHODS: This study was conducted as part of the Pneumonia Patient Outcomes Research Team multicenter, prospective cohort study of ambulatory and hospitalized patients with clinical and radiographic evidence of CAP. For each patient with CAP, a structured data form was completed by a panel of radiologists to evaluate the radiographic pattern of infiltrate, number of lobes involved, presence of pleural effusion, and 8 other radiographic characteristics. Cox proportional hazards models were used to evaluate the independent association between radiographic findings and 30-day mortality, while controlling for patient demographic, clinical, and laboratory characteristics with a known association with this outcome. RESULTS: Of 2287 patients enrolled in the Pneumonia Patient Outcomes Research Team cohort study, 1906 patients (83.3%) had a pulmonary radiographic infiltrate confirmed by the radiology panel. Overall, 30-day mortality in this cohort was 4.9%. Univariate regression analyses demonstrated the following radiographic characteristics to be significantly associated with 30-day mortality: (1) bilateral pleural effusions (risk ratio [RR], 7.0; 95% confidence interval [CI], 3.9-12.6); (2) a pleural effusion of moderate or greater size (RR, 3.4; 95% CI, 1.4-8.4); (3) 2 or more lobes involved with infiltrate (RR, 2.5; 95% CI, 1.6-3.8); (4) bilateral infiltrate (RR, 2.8; 95% CI, 1.9-4.2); (5) bronchopneumonia (RR, 1.6; 95% CI, 1.0-2.7); and (6) air bronchograms (RR, 0.5; 95% CI, 0.2-0.9). Multivariate analysis of radiographic features and other clinical characteristics showed the presence of bilateral pleural effusions (RR, 2.8; 95% CI, 1.4-5.8) was independently associated with mortality. CONCLUSIONS: In patients with CAP, the presence of bilateral pleural effusions is an independent predictor of short-term mortality. This finding, which is available at presentation, can help guide physicians' assessment of prognosis in CAP.

Adolescent↗
PubMed1996

Diagnosis of 22 new cases of Bartonella endocarditis.

BACKGROUND: Bartonella species are emerging pathogens that are seldom reported as a cause of blood culture-negative endocarditis. OBJECTIVE: To report the occurrence of, risk factors for, and clinical features of Bartonella endocarditis and to evaluate the diagnostic tools available for this condition. DESIGN: Case series and comparison with past series. SETTING: Multicenter international study in Halifax, Nova Scotia, Canada; Lyon, France; and Marseille, France. PATIENTS: 22 patients from France, England, Canada, and South Africa were investigated for blood culture-negative endocarditis. MEASUREMENTS: Titer of antibodies to Bartonella species by microimmunofluorescence assay, blood or vegetation culture, and amplification of Bartonella DNA from valvular tissue by polymerase chain reaction. Cross-adsorption was done for patients with antibodies to Chlamydia species. RESULTS: 22 patients had definite endocarditis. Five were infected with B. quintana, 4 with B. henselae, and 13 with an undetermined Bartonella species. These cases were compared with the 11 previously reported cases. Of the patients with the newly reported cases, 19 had valvular surgery and 6 died. Nine were homeless, 11 were alcoholic, 4 owned cats, and 13 had preexisting valvular heart disease. Bartonella species caused 3% of the cases of endocarditis seen in the three study centers. The patients with these cases could have previously received a diagnosis of chlamydial endocarditis because of apparently high levels of cross-reacting antibodies to Chlamydia species. CONCLUSIONS: Bartonella species are an important cause of blood culture-negative endocarditis and can be identified by culture, serologic studies, or molecular biology techniques. Alcoholism and homelessness without previous valvular heart disease are risk factors for B. quintana infection but not for infection with other Bartonella species.

Adult↗
PubMed1996

Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia.

OBJECTIVE: To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). METHODS: Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. RESULTS: Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. CONCLUSIONS: Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients as well as less costly treatment for CAP.

Adult↗