Social Determinants and COVID-19 in a Community Health Center Cohort.

Associations between social determinants of health (SDOH), demographic factors including preferred language, and SARS-CoV-2 detection are not clear. We conducted a retrospective cohort study among those seeking testing for SARS-CoV-2 at a multi-site, urban community health center. Logistic regression and exact matching methods were used to identify independent predictors of SARS-CoV-2 detection among demographic, SDOH, and neighborhood-level variables. Of 1,361 included individuals, SARS-CoV-2 was detected among 266 (19.5%). Logistic regression demonstrated that SARS-CoV-2 detection was less likely in White participants relative to Hispanic participants (adjusted odds ratio [aOR] 0.18, 95% confidence interval [CI] 0.05-0.46). and more likely in patients who prefer Spanish relative to those that prefer English (aOR 2.04, 95% CI 1.43-2.96). No observed SDOH predicted SARS-CoV-2 detection in adjusted models. A robustness analysis using a matched subset of the study sample produced findings similar to those in the main analysis. Preferring to receive care in Spanish is an independent predictor of SARS-CoV-2 detection in a community health center cohort.

Screening for Social Determinants of Health Among Children: Patients' Preferences for Receiving Information to Meet Social Needs and a Comparison of Screening Instruments.

To characterize optimal strategies for screening for social determinants of health (SDOH) among children, the authors performed a cross-sectional study of parents and adolescents ages ≥13 years in a community health center. Participants were queried about how they prefer to receive information about social needs resources and 2 screening instruments were compared: Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) and Accountable Health Communities (AHC). In July 2019, 154 parents and 21 adolescents were surveyed. Surveys were administered via tablet and required 5.6 minutes (standard deviation [SD] 3.9 minutes) for parents and 3.9 minutes (SD 1.4 minutes) for adolescents to complete. Parents identified technology (text message, email) and informational printouts as preferred mechanisms for information receipt (58% and 32% of participants, respectively); adolescents preferred text message (57%) and printouts (19%). Few (<10% overall) preferred in-person consultation with a care coordinator. Adolescent/parent pairs (n = 19 pairs) agreed, on average across SDOH, 82% of the time for WE CARE and 85% for AHC. AHC elicited more positive screens than WE CARE for housing insecurity (12% of parents versus 7%) and food insecurity (47% versus 16%) but fewer positive screens than WE CARE for difficulties paying for utilities (27% versus 39%). Routine screening for SDOH in children requires 2-3 minutes per screening instrument. Screening can target parents of young children and either adolescents themselves or their parents. Families prefer to receive information about meeting social needs via technologically-based methods as opposed to in-person consultation with enabling services providers.

Construction of a Pediatrics Risk Score to Predict High Health Care Costs Among a Community Health Center Cohort.

Risk-stratification strategies are needed for ambulatory pediatric populations. The authors sought to develop age-specific risk scores that predict high health care costs among an urban population. A retrospective cohort study was performed of children ages 1-18 years who received care at Fair Haven Community Health Care (FHCHC), a community health center in New Haven, Connecticut. Cost was estimated from charges in the electronic health record (EHR), which is shared with the only hospital system in the city. Using multivariable logistic regression models, independent predictors of being in the top decile of total charges during the 2017 calendar year were identified, drawing from covariates collected from the EHR prior to 2017. Random forest modeling was used to verify the feature importance of significant covariates and model performance from 2017 cost data were compared to those using 2018 cost data. Regression models were used to construct age-specific nomograms to predict cost. Among 8960 children who received care at FHCHC in the 18 months prior to 2017, covariate frequencies clustered in age groups 1-5 years, 6-11 years, and 12-18 years, so 3 age-specific models were constructed. Prior utilization variables predicted future costs, as did younger children who received specialty care and older children with behavioral health diagnoses. Final models for each age group had C statistics ≥0.68 using both 2017 and 2018 cost data. Prediction models can draw from elements accessible in the EHR to predict cost of ambulatory pediatric patients. Strategies to impact utilization among high-risk children are needed.

The Association of Loneliness and Non-prescribed Opioid Use in Patients With Opioid Use Disorder.

OBJECTIVE: To investigate the relationship between loneliness and non-prescribed opioid use in patients diagnosed with opioid use disorder (OUD). METHODS: This was a cohort study conducted at a federally qualified health center (FQHC) in New Haven, CT. Patients who were treated for OUD by health center providers and prescribed buprenorphine were eligible. Participants were asked to complete the UCLA-Loneliness Scale Version 3. From the electronic medical record, we collected patient demographic and clinical characteristics as well as the results of biological fluid testing obtained throughout their treatment course since entry into care. Multivariable logistic regression was performed to identify independent predictors of the detection of non-prescribed opioids within biological fluid. RESULTS: Of the 82 patients enrolled in the study, 33 (40.3%) of the participants had at least 1 biological fluid test positive for non-prescribed opioids after maintenance onto buprenorphine treatment. A higher loneliness score was associated with increased odds of non-prescribed opioids (adjusted odds ratio 1.16; 95% confidence interval 1.06-1.27). Patient age, the number of problems on the problems list, and cocaine use were also positively associated with the presence of non-prescribed opioids whereas having diabetes was negatively associated. CONCLUSIONS: Among the individuals being treated with buprenorphine for OUD, loneliness may be a risk factor for the use of non-prescribed opioids or treatment failure.

Geographic Localization of Housestaff Inpatients Improves Patient-Provider Communication, Satisfaction, and Culture of Safety.

This study assesses whether geographic localization of housestaff patients contributes to improved patient knowledge of diagnosis, patient satisfaction, provider satisfaction, and workplace culture of safety. Due to national changes to graduate medical education, housestaff patients were localized to a single general medicine ward. Ninety-three patients prelocalization, 64 patients postlocalization, 26 localized physicians, and 10 localized nurses were surveyed. Validated questionnaires assessed patients' experiences during hospitalization, and physician and nurse job satisfaction. Fifty-seven percent of patients knew their diagnosis prior to localization, compared to 80% postlocalization (p < .0001). Prior to localization, 39% of patients who reported experiencing anxieties or fears during hospitalization felt physicians frequently discussed these emotions with them compared to 85% after localization (p < .0001). Before localization, 51% of patients stated that doctors spent 4 min or more daily with them discussing care, compared to 91% after localization (p < .0001). Both physician and nurse opinion significantly improved regarding some but not all aspects of collaboration, teamwork, patient safety, appropriate handling of errors, and culture of safety. The average length of stay was unchanged and the change in 30-day readmission rate was not statistically significant. Localization of patients to a single inpatient ward improved patient knowledge and satisfaction, and some aspects of interprofessional communication and workplace culture of safety.

The residency application abyss: insights and advice.

Most medical students apply for residency training upon completion of medical school. The choice of specialty is one of a student's first major career decisions, and the application process often results in considerable anxiety, as it is competitive, unpredictable, and requires a significant investment of time and money. This article, which addresses several important facets of the residency application using both experiential and evidence-based data, is organized chronologically into sections that describe a logical approach to applying for residency: choice of a specialty, the personal statement, the interview day, and developing a rank list. A list of relevant websites is also included. This paper is a resource that provides timely and tangible guidance to medical students applying for residency training.

Community-acquired MRSA pyomyositis: case report and review of the literature.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is responsible for a broad range of infections. We report the case of a 46-year-old gentleman with a history of untreated, uncomplicated Hepatitis C who presented with a 2-month history of back pain and was found to have abscesses in his psoas and right paraspinal muscles with subsequent lumbar spine osteomyelitis. Despite drainage and appropriate antibiotic management the patient's clinical condition deteriorated and he developed new upper extremity weakness and sensory deficits on physical exam. Repeat imaging showed new, severe compression of the spinal cord and cauda equina from C1 to the sacrum by a spinal epidural abscess. After surgical intervention and continued medical therapy, the patient recovered completely. This case illustrates a case of CA-MRSA pyomyositis that progressed to lumbar osteomyelitis and a spinal epidural abscess extending the entire length of the spinal canal.

Association of patient recognition of inpatient physicians with knowledge and satisfaction.

Patient recognition of hospital providers is low and may affect patient knowledge and satisfaction with care. Our study aimed to determine the association between patient knowledge of their inpatient providers' face, name, or role with knowledge of their diagnosis, satisfaction with care, and 30-day readmission rate. We conducted a cross-sectional survey of inpatients discharged from medicine housestaff teams from 2008 to 2009. Patients identified providers by face, name, and role and stated their reason for hospitalization. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey assessed patient satisfaction with care. Eighty-nine of 95 patients (94%) participated. Seventy-five percent of patients recognized one provider face, 28% knew at least one provider name, and 21% correctly stated provider roles. Fifty-seven percent of patients knew their diagnosis. Satisfaction with care via HCAHPS varied: 78% always felt treated with courtesy and respect; 75% felt doctors always listened; and 67% felt complete involvement in care decisions. In bivariate and multivariate analyses, knowledge of providers by face, name, or role was not associated with knowledge of diagnosis, satisfaction, or 30-day readmission rates (all p>.05). Thus, patient recognition of providers was not associated with their knowledge, satisfaction, or readmission.

A fatal case of paraquat ingestion: clinical course and review of pathophysiology.

BACKGROUND: Exposure to the dipyridyl herbicide paraquat can cause many manifestations of toxicity, and is a common method of suicide in developing countries. CASE REPORT: We present a case of a 20 year old healthy gentleman who intentionally overdosed on paraquat in a suicide attempt. He presented to the hospital within 4 hours of ingestion. Despite standard supportive measures, the patient's clinical condition worsened. He developed ulceration of his oral mucosa. He also developed acute non-oliguric renal failure and acute liver injury. After his mental status began to deteriorate, the patient expired. CONCLUSIONS: There are several therapies that may have helped this patient's condition. An explanation about the pathophysiology of toxicity and updated information on treatment is provided for this common condition with poor prognosis.

Communication discrepancies between physicians and hospitalized patients.

BACKGROUND: Hospital surveys indicate lack of patient awareness of diagnoses and treatments, yet physicians report they effectively communicate with patients. Gaps in understanding and communication could result in decreased quality of care. We sought to assess patient knowledge and perspectives of inpatient care and determine differences from physician assessments. METHODS: Two validated questionnaires assessed the experiences of inpatients treated by house staff from October 10, 2008, through June 23, 2009. We surveyed corresponding internal medicine resident and attending physicians, asking them to report on their care of hospitalized patients and their understanding of their patients' perspectives on the care received. RESULTS: Eighty-nine patients and 43 physicians participated. Although 73% of patients thought there was 1 main physician, 18% correctly named that physician, compared with 67% of physicians who thought patients knew their names (P<.001). Most physicians (77%) believed patients knew their diagnosis; however, 57% of patients did (P<.001). A total of 58% of patients thought that physicians always explained things in a comprehensible way, compared with 21% of physicians who stated they always provided explanations of some kind (P<.001). Two-thirds of patients reported receiving a new medication in the hospital, yet 90% noted never being told of any adverse effects of these medications. Nearly all physicians (98%) stated that they at least sometimes discussed their patients' fears and anxieties, compared with 54% of patients who said their physicians never did this (P=.001). CONCLUSIONS: Significant differences exist between patients' and physicians' impressions about patient knowledge and inpatient care received. Steps to improve patient-physician communication should be identified and implemented.

Cutaneous extensively drug-resistant tuberculosis.

A 48-year-old immunocompetent man without known exposure to tuberculosis had a > 10-year history of recurrent skin lesions. Cutaneous tuberculosis without any current or past history of pulmonary tuberculosis was diagnosed. Culture of biopsy specimens showed the organism to be resistant to multiple first-line and second-line agents. The patient had a broad, vigorous CD4-specific immune response against multiple tuberculosis antigens. This case is the first report of cutaneous extensively drug-resistant tuberculosis.

Postrenal azotemia due to C. albicans pyocystitis and a Candidal plug.

BACKGROUND: There are many causes of acute renal failure, with cases often being classified as pre-renal, intrarenal or post-renal based on the etiology. A post-obstructive etiology is responsible in a minority of patients. Infectious causes of post-obstructive azotemia are even more rare, but as this case illustrates, should be considered as part of the differential. CASE REPORT: This case report describes a patient who developed acute renal failure (ARF) while hospitalized. Examination showed a candidal plug at his urethral meatus. Bladder washings removed a significant amount of purulent material. Treatment for C. albicans with fluconazole resolved his urinary retention and his bilateral hydronephrosis. His acute renal failure was due to an infectious, post-obstructive pyocystitis and formation of a candidal plug in his urethral meatus. CONCLUSIONS: Removal of the candidal plug and treatment of his infection with fluconazole resulted in return to baseline renal function. While not common, an infectious cause of post-renal azotemia should be considered in the appropriate clinical situation.