Faculty Bibliography

BACKGROUND:Adolescent and Young Adults (AYAs) are an underserved, high-risk population. Identifying health care utilization patterns, and particularly acute care visits, is important as these are high-intensity, expensive services. We investigated whether differences exist in health care utilization between the AYA lymphoma population compared to their older adult counterparts. MATERIALS AND METHODS/METHODS:Two correlated outcomes were used to measure health care utilization: 4 or more acute visits (emergency department or urgent care) and number of nonacute visits (office or telephone visits). We studied 442 patients with aggressive lymphoma patients 15 years or older at time of diagnosis managed at our cancer center within 2 years of their diagnosis. A multivariate generalized linear mixed model simultaneously estimated the effect of baseline predictors on 4 or more acute care visit with robust Poisson regression and nonacute visit counts with negative binomial regression allowing for a within-subject random effect. RESULTS:AYAs had increased risk of having ≥4 acute visits (RR = 1.96; P = .047) compared to their older counterparts. Obesity (RR = 2.04, P = .015) and living less than 50 miles from the cancer center (RR = 3.48, P = .015) were independently associated with higher risk of acute care usage. Acute care visits for psychiatric or substance use related reasons were significantly higher (P = .0001) among AYA (10/114, 8.8%) vs. non-AYA (3/328, 0.9%). CONCLUSION/CONCLUSIONS:Disease-targeted interventions to address high acute health care utilization is needed amongst AYAs. Additionally, early multidisciplinary involvement after cancer diagnosis particularly with psychiatric expertise amongst AYAs and palliative care involvement in both groups is needed.

PURPOSE:The aim of this quality improvement (QI) project was to increase the coprescription of naloxone kits at patient discharge as a harm reduction strategy to combat the opioid epidemic. An interdisciplinary team identified hospitalized medical patients who were at high risk for an opioid overdose or opioid-related adverse event. METHODS:Led by a physician champion, an interdisciplinary QI team composed of physicians (MDs and doctors of osteopathic medicine), advanced practice providers (NPs and physician assistants), RNs, care coordinators, social workers, and pharmacists developed and implemented a naloxone distribution program on one medical unit at an academic tertiary care center. The team developed and implemented criteria to identify high-risk patients, workflow for patient screening, staff and patient education programs, and processes for naloxone kit delivery to the patient's bedside. Data on naloxone kit distribution from the seven months prior to implementation (March 2018 to September 2018) and the seven months after implementation (October 2018 to April 2019) were evaluated and are reported descriptively. RESULTS:Two patients preimplementation and 64 patients postimplementation received a naloxone kit at discharge. In the postimplementation group, common reasons for identifying a patient as at high risk for an overdose or adverse event were a prescription for a pain medication at a daily dosage greater than or equal to 50 morphine milligram equivalents (50% of patients), concomitant opioid and benzodiazepine use (19%), history of substance use disorder (11%), and medication-assisted treatment (9%). Most patients in the postimplementation group (86%) received a naloxone kit at a personal cost of $1 or less. CONCLUSION:This unit-based pilot project was successful in identifying patients at high risk for an opioid overdose or opioid-related adverse event and in providing naloxone kits and education at hospital discharge.

BACKGROUND:There is little information about the impact of anthelminthic treatment on clinical symptoms other than seizures in neurocysticercosis (NC). We investigated the effect of albendazole on non-seizure symptoms experienced by patients with NC. METHODS:Data are from a randomized controlled trial comparing albendazole plus prednisone with placebo plus prednisone for treatment of NC among 173 patients with active or transitional NC cysts and new-onset symptoms. We performed negative binomial regression to examine the number of follow-up visits when a symptom was reported, logistic regression to examine the probability of experiencing the symptom and Cox proportional hazards models to examine the time to first reporting the symptom. RESULTS:Eighty-five percent of patients reported at least one non-seizure symptom at baseline. Those treated with albendazole had significantly lower odds of memory loss and/or confusion during months 1-24 (odds ratio [OR] 0.42, p=0.037) and significantly increased odds of anxiety and/or depression during months 1-12 (OR 1.87, p=0.049). No treatment difference existed in experiencing symptoms in general or in experiencing headaches, limb weakness or gait disturbances, vomiting, nausea and/or stomach pain or visual disturbances over the follow-up period. CONCLUSIONS:While the prevalence of non-seizure symptoms was high, albendazole treatment was associated with only two significant differences in the non-seizure symptoms over follow-up. Further research is needed to identify strategies to reduce the long-term symptom burden in patients with NC.

BACKGROUND Non-ketotic hyperglycemic hemichorea-hemiballism (HCHB) is a rare complication of diabetes, which is mainly described in case reports. This condition occurs more commonly in older women and is known to be associated with T1 hyperintensity basal ganglia lesions on magnetic resonance imaging (MRI). The pathophysiology of non-ketotic hyperglycemic HCHB is not well defined, although a combination of regional metabolic failure and ischemia due to hyperglycemia is suspected to occur. Treatment entails tight blood glucose control, although antipsychotic medications such as risperidone may be helpful in refractory cases. CASE REPORT We describe a case of a middle-aged man with long-standing type 2 diabetes who experienced 3 weeks of progressive unilateral arm, leg, and face choreiform movements. Laboratory testing performed just prior to symptom onset was notable for a hemoglobin A1C of >15% and a serum blood glucose of 566 mg/dl. MRI revealed diffuse T1 hyperintensity in the left lentiform nucleus. Our patient's insulin regimen was adjusted, resulting in improvement in average serum glucose (A1C of 9.4%). However, his symptoms did not improve significantly. A trial of benzodiazepine was attempted, without success. When risperidone was started, the patient experienced resolution of symptoms. Recurrence of non-ketotic hyperglycemic HCHB while off risperidone has not occurred to date. CONCLUSIONS Non-ketotic hyperglycemic HCHB is a rare but important diagnosis to consider in patients with hyperglycemia and new-onset choreiform movements. Patients with long-standing type 2 diabetes may be affected, especially when glycemic control worsens. When tight blood glucose control does not resolve symptoms, a short course of antipsychotic agents may provide relief.

We investigated the intersection of sexual minority, gender, and Hispanic identities, and their interaction with peer victimization in predicting unhealthy weight control behaviors (UWCB) among New York City (NYC) youths. Using logistic regression with data from the 2011 NYC Youth Risk Behavior Survey, we examined the association of sexual identity, gender, ethnicity, and peer victimization (dating violence, bullying at school, electronic bullying) in predicting UWCB. Sexual minority youths, dating violence victims, and youths bullied at school had 1.97, 3.32, and 1.74 times higher odds of UWCB than their counterparts, respectively (P < 0.001). The three-way interaction terms between (i) dating violence, gender, and sexual identity and (ii) electronic bullying, gender, and sexual identity were statistically significant. The effect of dating violence on unhealthy weight control practices was strongest among sexual minority males (OR = 4.9), and the effect of electronic bullying on unhealthy weight control practices was strongest among non-sexual minority males (OR = 2.9). Sexual minority and gender identities interact with peer victimization in predicting unhealthy weight control practices among NYC youths. To limit the prevalence and effect of dating violence and electronic bullying among youths, interventions should consider that an individual's experiences are based on multiple identities that can be linked to more than one ground of discrimination.