Garrison, Gregory M.

Anticoagulant-related nephropathy (ARN) is a rare, newly recognized cause of acute kidney injury and significant but underdiagnosed complication of anticoagulation therapy. ARN occurs in patients taking oral anticoagulant therapy most often warfarin or a novel oral anticoagulant (NOAC). It is a potentially devastating disorder with serious renal consequences and increased all-cause mortality. Anticoagulant-related nephropathy presents as an acute kidney injury (AKI) in the setting of a supratherapeutic INR with profuse glomerular hemorrhage seen as renal tubules filled with red cells and red cell casts on renal biopsy. Being that millions of Americans are on warfarin, a thorough understanding and awareness of the clinical presentation, diagnosis, and therapeutic interventions are crucial to protecting the renal function, lowering all-cause mortality and optimizing treatment. Our goal is to provide education on a newly recognized form of AKI and significant but underdiagnosed complication of anticoagulation therapy.

To examine whether high school student-athletes who experienced more COVID-19 disruptions had increased anxiety, increased dejection, increased anger, decreased excitement, and decreased happiness as measured by the validated Sports Emotion Questionnaire (SEQ). During the COVID-19 pandemic high school student-athletes faced disruptions which resulted in cancelation of competitions, reduced in-person training sessions, and quarantine of athletes. The impact of these disruptions on the mental health and well-being of student-athletes is unknown. An anonymous cross-sectional online survey was electronically distributed to high school student-athletes in one school district during the spring of the 2020 to 21 academic year. Basic demographic questions, sport information, and personal and team disruptions were collected. Multivariate linear regression was used to assess correlation between each emotional domain on the SEQ with independent variables such as personal or teammate quarantines, cancelations, season, sport gender, indoor or outdoor location, and level of competition. 125 surveys were returned representing 28 different sports. Student-athletes who were personally quarantined (22.4%) during their athletic season experienced greater dejection (β = 0.78, P = .003) and greater anger (β = 0.78, P = .005). Those with teammates quarantined (61.6%) experienced more anxiety (β = 0.30, P = .048). Spring sports, which faced fewer restrictions, were associated with less anger (β = −0.48, P = .048). Student-athletes who were directly affected by COVID-19 disruptions experienced increased anxiety, more dejection, and more anger. Public health authorities and school districts should minimize disruptions to athletic participation using established COVID-19 safety protocols to avoid causing harm to athletes’ social-emotional well-being. If athletics must be disrupted, student-athletes should receive wellness support and virtual or remote training options.

This case involves a patient with severe COVID-19 pneumonia and massive pulmonary embolism requiring mechanical ventilation. His clinical course was complicated by delirium likely triggered by his critical illness and failed initial extubation, isolation from family, and escalating fear and desperation. In hopeful preparation for subsequent successful extubation, a unique approach was taken to decrease the risk of panic, delirium, and decompensation leading to reintubation. As a means of orienting him to his treatment pathway and to provide encouragement for continued recovery, an impromptu patient-directed checklist was constructed. The recovery checklist, written in simplified language, outlined the stages of severe illness that the patient had overcome after his emergent intubation. The list also outlined the tasks he needed to complete prior to hospital discharge. Unexpectedly, the checklist received a great deal of engagement from both the patient and medical team and played an important role in this patient’s successful recovery and rehabilitation.

Background While socioeconomic status has been linked to hospital readmissions for several conditions, reliable measures of individual socioeconomic status are often not available. HOUSES, a new measure of individual socioeconomic status based upon objective public data about one's housing unit, is inversely associated with overall hospitalization rate but it has not been studied with respect to readmissions. Purpose To determine if patients in the lowest HOUSES quartile are more likely to be readmitted within 30 days (short-term) and 180 days (long-term). Methods A retrospective cohort study of 11 993 patients having 21 633 admissions was conducted using generalized linear mixed-effects models. Results HOUSES quartile did not show any significant association with early readmission. However, when compared to the lowest HOUSES quartile, the second quartile (OR = 0.90, 95%CI 0.83-0.98) and the third quartile (OR = 0.91, 95%CI 0.83-0.99) were associated with lower odds of late readmission while the highest quartile (OR = 0.91, 95%CI 0.82-1.01) was not statistically different. Conclusion HOUSES was associated with late readmission, but not early readmission. This may be because early readmissions are influenced by medical conditions and hospital care while late readmissions are influenced by ambulatory care and home-based factors. Since HOUSES relies on public county assessor data, it is generally available and may be used to focus interventions on those at highest risk for late readmission.

AbstractObjectiveTo evaluate health care costs as a function of assigned primary care clinician type and care team characteristics.MethodsAdministrative data were collected for 68 family medicine clinicians (40 physicians and 28 nurse practitioners [NPs]/physician assistant [PAs]), on 11 care teams (variable MD, NP and PA on teams), caring for 77,141 patients. We performed a generalized linear mixed multivariable regression model of standardized per member per month (PMPM) median cost as the outcome, with four practice sites included as random effects.ResultsIn bivariate analysis, cost was higher in physicians than NP/PAs, in more complex patients, and associated with emergency department (ED) visit rate. On multivariate analysis, patient complexity, ED visit rate and higher patient experience ratings were independently associated with greater PMPM cost. More time in practice was associated with lower PMPM cost. In the adjusted multivariate model, physicians had 8.3% lower median PMPM costs than NP/PAs (p = 0.046).ConclusionsThe primary drivers of greater PMPM cost were patient complexity, ED visits and patient satisfaction.

Objectives: Health literacy is an individual’s capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. Failure to understand and correctly execute a plan of care often leads to poor health outcomes. Determining patient health literacy allows health care providers to tailor their plan of care instructions, increasing the probability of understanding, and adherence. Several validated health literacy tests have been developed to assess the health literacy of individuals and ethnic groups. However, because a proctor is required to administer these tests, their usefulness in clinical settings is limited. The issue of health literacy is especially relevant within minority groups. This research focused on producing a translatable assessment that can be administered quickly without a proctor. Methods: We developed a 15-question instrument (the RIHLA) in English using the Delphi method with a panel of bilingual experts and translated it into Spanish. Internal reliability was assessed using Cronbach’s alpha for 3 groups: Native English-speaking College students (NESC), Native English-speaking patients (NES), and Limited English Proficient Spanish-speaking patients (LEP). External validity was assessed using Pearson’s correlation coefficient to compare our instrument to a previously validated, proctored instrument measuring health literacy (the SAHL-E). Results: Four hundred fifteen subjects completed the RIHLA. Of these, 192 (46.3%) were NESC, 208 (50.1%) were NES, and 15 (3.6%) were LEP. The mean number of correct answers was 11.2, 11.6, and 8.3 respectively with the LEP group scoring lower ( P < .01). Cronbach’s alpha was >.70 for each group. Moderate correlation between the RIHLA and the previously validated instrument was present ( P < .01) with Pearson’s r = .47 (95% CI: 0.18-0.69). Conclusion: The RIHLA is a non-proctored assessment tool that may provide a measure of patients’ health literacy in multiple languages. Further studies with larger sample sizes are necessary to confirm the reliability, validity, and generalizability to a wider population.

A healthy 33 year old male presented in December with a 3 week history of fever and fatigue. He had been deer-hunting in northern Minnesota 1 month prior and had sustained a tick bite. Extensive laboratory investigations and a lumbar puncture were conducted. He was empirically with doxycycline and had rapid improvement in his symptoms. Subsequently, PCR and serologic testing returned positive for Anaplasma phagocytophlium. Anaplasmosis is a tick-borne illness caused by the bacterium Anaplasma phagocytophilum and is typically seen in the warmer months. This patient’s presentation in December was uncommon for a tick-borne illness in Minnesota. Regional weather records demonstrated unseasonably warm temperatures during the patient’s trip. Ixodes ticks are known to be sensitive to temperature and humidity, which likely contributed to increased tick activity, leading to disease transmission. This case highlights the importance for clinicians to be aware of local weather patterns and how this might influence seasonal disease presentations.

The objective was to determine if a greater proportion of physician full-time equivalent (FTE%) relative to nurse practitioners/physician assistants (NPs/PAs) on care teams was associated with improved individual clinician diabetes quality outcomes. The authors conducted a retrospective cross-sectional study of 420 family medicine clinicians in 110 care teams in a Midwest health system, using administrative data from January 1, 2017 to December 31, 2017. Poisson regression was used to examine the relationship between physician FTE% and the number of patients meeting 5 criteria included in a composite metric for diabetes management (D5). Covariates included panel size, clinician type, sex, years in practice, region, patient satisfaction, care team size, rural location, and panel complexity. Of the 420 clinicians, 167 (40%) were NP/PA staff and 253 (60%) were physicians. D5 criteria were achieved in 37.9% of NP/PA panels compared with 44.5% of physician panels ( P < .001). In adjusted analysis, rate of patients achieving D5 was unrelated to physician FTE% on the care team ( P = .78). Physicians had a 1.082 (95% confidence interval 1.007–1.164) times greater rate of patients with diabetes achieving D5 than NPs/PAs. Clinicians at rural locations had a .904 (.852-.959) times lower rate of achieving D5 than those at urban locations. Physicians had a greater rate of patients achieving D5 compared with NPs/PAs, but physician FTE% on the care team was unrelated to D5 outcomes. This suggests that clinician team composition matters less than team roles and the dynamics of collaborative care between members.