Identifying patients with needs related to Social Determinants of Health (SDOH) and connecting them with appropriate resources in an effective, efficient, and timely way can prove challenging. Primary care clinicians (PCC’s) interact with the EHR thousands of times daily; this engagement can be leveraged to better address the SDOH.
Objective:
To understand our health system PCC’s use of the EHR to identify adult patients who are experiencing adverse SDOH.
Study Design:
Descriptive study conducted by a learning collaborative (LC).
Setting:
A large health system including urban and rural regions in Minnesota, Wisconsin, Iowa, Florida, and Arizona.
Population studied:
Community-based physicians, nurse practitioners, and physician assistants practicing in family medicine, general internal medicine, or pediatrics.
Instrument:
A brief intranet survey was sent to members of the system’s primary care learning collaborative. The survey included multiple-choice questions, with additional space provided for optional narrative responses.
Outcome Measures:
Assess PCC’s practice patterns for addressing the SDOH through utilization of the EHR tools.
Results:
87 responses were received out of 192 surveys issued (45%). Most PCC’s see patients who are negatively impacted by SDOH either daily (85%) or weekly (92%). Fifty-six percent review the patient specific SDOH information in the EHR at the time of the clinical encounter, while 29% do not review the information at all. Of those who review the SDOH in the EHR, 63% refer the patient to someone else to manage the identified needs; 78% use social workers, 44% use nursing staff, and 24% use case managers. Only 11% rated the EHR as very useful in identifying SDOH, 55% find it somewhat useful and 32% do not find it helpful at all. Most (78%) were unaware of how to use the EHR to refer a patient to a community-based organization. Forty-four percent of PCC’s were interested in learning, in written or webinar form, more about using the EHR to screen and intervene on the SDOH.
Conclusion:
PCC’s frequently see patients with needs related to the SDOH. While the EHR is a tool to screen patients for barriers to optimal health, it is not currently being well utilized by PCCs to intervene on these barriers. PCCs tend to engage ancillary team members to address the complex care needs of their patients. There is interest in learning ways to use the EHR to identify and intervene when adverse SDOH are identified.
Radiographic changes of rickets are well characterized, but no method of grading the severity of these changes has been in general use. Consequently, it is difficult to compare objectively or follow radiographic improvement. We prospectively evaluated the utility and reproducibility of a scoring method for measuring the severity of rickets. A 10-point score for radiographs of wrists and knees was devised to assess the degree of metaphyseal fraying and cupping and the proportion of the growth plate affected. The score progresses in half point increments from zero (normal) to 10 points (severe). Four trained physicians independently scored radiographs on two separate occasions from 67 children with active rickets. A broad representation of mean radiographic scores was moderately correlated with alkaline phosphatase (r=0.58). Interobserver correlation of radiographic scores was 0.84 or greater for all observer pairs and intraobserver correlation was 0.89 or greater for each observer. Researchers and clinicians should find the score useful to assess objectively the severity of rickets.
Genetic forms of vitamin D-dependent rickets (VDDRs) are due to mutations impairing activation of vitamin D or decreasing vitamin D receptor responsiveness. Here we describe two unrelated patients with early-onset rickets, reduced serum levels of the vitamin D metabolites 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D, and deficient responsiveness to parent and activated forms of vitamin D. Neither patient had a mutation in any genes known to cause VDDR; however, using whole exome sequencing analysis, we identified a recurrent de novo missense mutation, c.902T>C (p.I301T), in CYP3A4 in both subjects that alters the conformation of substrate recognition site 4 (SRS-4). In vitro, the mutant CYP3A4 oxidized 1,25-dihydroxyvitamin D with 10-fold greater activity than WT CYP3A4 and 2-fold greater activity than CYP24A1, the principal inactivator of vitamin D metabolites. As CYP3A4 mutations have not previously been linked to rickets, these findings provide insight into vitamin D metabolism and demonstrate that accelerated inactivation of vitamin D metabolites represents a mechanism for vitamin D deficiency.
Figure 1 A 30-month-old girl had had progressive bowing of the legs since she began walking at the age of 11 months. She reported bilateral thigh pain. Physical examination revealed genu varum (Panel A) and enlarged wrists. A radiograph of the wrists revealed cupping and fraying of the metaphyses of the distal radius and ulna (Panel B). The child's serum alkaline phosphatase and parathyroid hormone concentrations were high, the serum calcium concentration was low, and the serum 25-hydroxyvitamin D concentration was normal (35 ng per milliliter [87 nmol per liter]). She was usually exposed to sunlight for more than three hours a day. She had stopped breast-feeding at the age of six months, and her average dietary calcium intake was 160 mg per day. Figure 1 A 30-month-old girl had had progressive bowing of the legs since she began walking at the age of 11 months. She reported bilateral thigh pain. Physical examination revealed genu varum (Panel A) and enlarged wrists. A radiograph of the wrists revealed cupping and fraying of the metaphyses of the distal radius and ulna (Panel B). The child's serum alkaline phosphatase and parathyroid hormone concentrations were high, the serum calcium concentration was low, and the serum 25-hydroxyvitamin D concentration was normal (35 ng per milliliter [87 nmol per liter]). She was usually exposed to sunlight for more than three hours a day. She had stopped breast-feeding at the age of six months, and her average dietary calcium intake was 160 mg per day. Tom D. Thacher, M.D.Jos University Teaching Hospital, Jos, Nigeria
The American Academy of Pediatrics and the National Academy of Medicine recommend vitamin D supplementation for breastfeeding infants. However, compliance with this recommendation is poor. Maternal supplementation with vitamin D is a safe and effective alternative to achieving vitamin D sufficiency in breastfeeding infants, and mothers have indicated a preference for self-supplementation over infant supplementation. Research aim: We sought to explore Family Medicine clinicians' knowledge, attitudes, and practices regarding vitamin D supplementation recommendations for breastfeeding dyads.Fifty-six Family Medicine clinicians (including faculty physicians, resident physicians, and nurse practitioners/physician assistants) completed an online, anonymous survey regarding their knowledge and practices concerning vitamin D supplementation for breastfeeding infants.The vast majority of clinicians (92.9%) correctly identified the American Academy of Pediatrics' 2008 recommended dose for vitamin D supplementation in breastfeeding infants and estimated recommending vitamin D supplementation of exclusively breastfeeding infants 70.1% of the time. If all options were equivalent, clinicians would prefer to offer maternal or infant supplementation (50%) or maternal supplementation (37.5%) over infant supplementation (12.5%). Most (69.6%) preferred daily over monthly supplementation regimens.Family Medicine clinicians are knowledgeable regarding current recommendations for vitamin D supplementation in breastfeeding infants. They are also open to recommending maternal supplementation or offering parents a choice of maternal or infant vitamin supplementation.
Differences in clinical presentation of tuberculosis (TB) have been reported in different age groups, gender and in different parts of the world. Study of gender differences in clinical presentation of patients will assist in targeting those at higher risk and ensure successful TB control planning.To describe the differences in clinical presentation and risk factors for TB in male and female Nigerian patients with pulmonary tuberculosis (PTB).Patients with cough of more than three weeks duration attending hospitals in Abuja, Nigeria were interviewed with a structured questionnaire. After clinical examination, sputum samples were examined by smear microscopy and one sample was cultured. Haematological examination, serum chemistries, HIV serology, and chest X-ray evaluation were also evaluated.Of 1186 patients who had sputum culture, 731 (62%) were positive for TB: 437 (60%) males and 394 (40%) females. The mean (SD) age of males was significantly greater than that of females, 34 (11) vs. 31 (12) years, rp = 0.001. Male patients were more likely to be employed and better educated than women. More men than women smoked cigarettes. Women were more likely to be co-infected with HIV and less likely to be smear-positive than men. Male patients had more severe radiological disease.More men than women appear to present with TB at hospitals in Abuja. Male patients were older and are more likely to have smear-positive TB, whereas, female patients were more likely to be co-infected with HIV.
Background: Perinatal factors, including gestational age, birthweight, size-for-gestational age, delivery route, maternal parity, maternal age, and socioeconomic status, have been linked to the long-term incidence of chronic comorbidities. We evaluated the association of birth size characteristics and early childhood growth trajectories with Type II diabetes (DM2) in adolescence and adulthood. Methods: We conducted a population-based, nested case-control study in a birth cohort of infants born to residents of Olmsted County, MN between 1976-1982, using the resources of the Rochester Epidemiology Project. Cases with DM2 first diagnosed after age 10 and prior to October 2020 were identified using diagnosis codes and confirmed via chart review. For each case, we randomly selected two age-and sex-matched controls from the birth cohort. Using birth certificate data, we obtained mothers' age and education level and infant sex, race, type of delivery, single/multiple birth, gestational age, and birthweight . Individual-level socioeconomic status (SES) of the household at birth was determined with the HOUSES index. Weight and height data from birth through age 66 months was abstracted from the medical records and sex-specific weight-for-age percentiles were obtained from the 2000 CDC growth charts. A nonparametric hill-climbing algorithm was used to identify distinct homogeneous clusters of weight-for-age trajectories among all cases and controls combined. Univariate conditional logistic regression models were fit to assess associations. Results: Among the 123 DM2 cases, the mean age at diagnosis 34.2 (SD, 4.9) years and 59.3% were male. None of the socioeconomic characteristics nor the type of delivery were significantly associated with DM2 case status. The odds of being a late term vs a term delivery were significantly greater for DM2 cases compared to matched controls (OR 2.09; 95%CI 1.14-3.84). The odds of being large-for-gestational-age versus average were significantly lower for DM2 cases compared to matched controls (OR 0.51; 95%CI 0.29-1.89) and the mean birthweight was significantly lower for DM2 cases compared to controls (mean [SD], 3379 [642]g vs. 3583 [540]g, p=0.002). Conclusion: Low birth weight, large for gestational age and a late term pregnancy were associated with DM2 after age 10 years compared with age- and sex-matched controls from the same birth cohort. Weight gain trajectories through 66 months of age were not associated with DM2.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)