Impact of Social Determinants of Health on Chronic Kidney Disease: A Review of Disparities in Renal Transplantation

Background: Striking disparity exists in the incidence and treatment of chronic kidney disease (CKD) secondary to individual social determinants of health. Additionally, the uninsured, minority racial-ethnic groups, and Medicaid enrollees receive less nephrology care prior to being diagnosed with end-stage renal disease (ESRD). The most effective treatment for the management of kidney failure is kidney transplantation. This review addresses how social determinants of health impact the workup for patients with ESRD, with emphasis on the kidney transplant process. Methods: A search was conducted via multiple online databases (MedLine, PubMed, etc.) for articles that addressed the interplay between CKD, ESRD and kidney transplantation with the social determinants of health. Findings: The impact of the social determinants of health on CKD, ESRD, and the kidney transplantation process can be qualitatively and quantitatively measured using the five categories of education, health care and access, economic stability, neighborhood and built environment, and social and community context. Conclusion: Social determinants of health impact outcomes in CKD, ESRD, and kidney transplantation. Public and private initiatives aimed at reducing social disparities among patients with kidney disease must include emphasis on education, health care and access, economic stability, neighborhood and built environment, and social and community context. This initiative is necessary to prevent progression to ESRD and to ensure quality care in the kidney transplantation process.

Limits to Neurosurgical Care for an Undocumented Immigrant in the United States

Documentation status is a well-recognized social determinant of health in the immigrant population of the United Sates. Lack of financial means and fear of legal repercussions can delay medical attention, limit treatment options, and decrease patient follow-up. This is reinforced by current government policies that limit financial assistance in emergency situations and deny coverage of preventative or follow-up care. Here we report a case of an otherwise healthy 24-year-old undocumented immigrant who presented to a rural United States emergency room with new-onset seizure, blurry vision, and headache. The patient was admitted to the neurosurgical service where he was diagnosed and treated for a symptomatic arachnoid cyst. Here we review current healthcare legislation that restricts access to preventative and follow-up healthcare in the United States. This case highlights the ways in which the undocumented immigrant patient population remains negatively impacted by these policies, often leading to late presentation and limited neurosurgical treatment options.

Risk Identification and Prediction for COVID-19 Mortality

This paper studies several key metrics for COVID-19 using a public surveillance system data set. It compares the difference between two case fatality rates: the naive case fatality rate, which has been frequently mentioned in media outlets, and one which is the sample estimate for the mortality rate. A logistic regression model is applied to modeling the daily mortality rate. The conclusion is that time, gender, age and some of their interactions, appear to have a significant impact on the mortality rate; the daily mortality rate has been decreasing since the outbreak; males older than 60 has been the most vulnerable group. The receiver operating characteristics curve and the curve under the area show that the proposed logistic model is capable of predicting the outcome of a reported case with accuracy as high as 89%. These findings are helpful in assessing the magnitude of the risk posed by the COVID-19 virus to certain groups, predicting outcome severity, and optimally allocating medical resources such as intensive care units and ventilators.

Suspected Compartment Syndrome and Rhabdomyolysis after “Pseudoephedrine” Use: A Case Report

Acute compartment syndrome and rhabdomyolysis are two life threatening diagnoses that cannot be missed in the emergency room. The increased pressure in the closed compartments of extremities can eventually lead to loss of peripheral pulses, decreased tissue perfusion, and ultimately muscle necrosis. This breakdown of muscle byproducts will ultimately lead to kidney damage and rhabdomyolysis. Although the most common cause of compartment syndromes are secondary orthopedic causes such as lower extremity fractures there are known documented toxicological causes. (1,2) Pseudoephedrine, a sympathomimetic amine, is commonly used in the treatment of nasal congestion. Its primary mechanism directly acts on the adrenergic receptor system which stimulates release of stored norepinephrine from neurons. Its alpha-adrenergic effect is believed to be the cause of vasoconstriction in the body (3) Clinically, intoxication from sympathomimetic drugs have produced toxidromes with prominent features such as tachycardia, hypertension, hyperthermia, agitation, and delirium. However, it is incredibly rare to see an association with pseudoephedrine overdose and rhabdomyolysis and compartment syndrome. There are documented cases where sympathomimetic drugs have been associated with compartment syndrome (2,4,5) This case of a 29-year-old male with suspected pseudoephedrine abuse highlights the need for consideration of rhabdomyolysis and compartment syndrome being a possible complication from pseudoephedrine overdose.

Integration of E-learning into the Physiology Education of Medical Students in their Pre-clinical Curriculum

Purpose: In our institution, we initiated integrated learning in the format of Learning Modules (LM), interactive audio/visual modules developed by the faculty in alignment with session learning objectives, as pre-work for in-class sessions.?This pilot study examined students’ perceptions of this new learning method and effectiveness in helping them achieve content mastery. Methods: The instructor provided the LMs in advance, allowing a self-paced introduction of critical concepts that were subsequently discussed in detail during the in-class learning (ICL) session. A cognitive diagnostic assessment was used to analyze the student's performance on the exams. This involved identifying six skills, one or more of which were marked to be necessary for answering each exam question correctly. A question-by-skill Q-matrix was constructed, followed by analysis using a Deterministic Input, Noisy "And" Gate (DINA) model. Results: 70% of the students rated the new approach as "Excellent or Good." 63% of the students attained skills necessary to answer questions that involved integrating information gained separately from LM and ICL sessions. However, only 23% of the students achieved mastery in all the 6 skills. Conclusion: This integrative learning system allowed for time optimization since ICL sessions could focus on more interactive aspects of the content.

Migraine Headache associated with Multiple Sclerosis: Results from the Nationwide Inpatient Sample

Background: Multiple Sclerosis (MS) is an immune-mediated disease that targets and injures myelin and axons in the central nervous system. A high prevalence of migraine headache has been reported among MS patients. In this study, we investigated variables affecting migraine headache occurrence in MS patients.Methods: The Health Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) data was utilized. MS hospitalizations (“cases”) were identified by ICD-9-CM code 340. Non-MS Hospitalizations were matched to cases 1:1 by age and gender. Results: We identified 18955 MS patients between 2010 and 2013. The prevalence of migraine among MS patients (7%) was significantly higher than the control group (2.8%). Unspecified Migraine constituted the highest percentages of migraine subtype in both groups. All subtypes of headache, except migraine without aura, were significantly higher among MS patients compared to the control group. Among MS patients, younger age, white race, female gender, depression, and obesity were significant predictors of migraine. Conclusions: Our study provides prevalence data for different subtypes of headache and confirms depression and obesity as risk factors for migraine.

Page Kidney: A Secondary Cause of Hypertension

Page kidney is a rare cause of secondary hypertension in adults that occurs due to extrinsic compression of the kidney due to a subcapsular collection, such as a hematoma or urinoma. Usually these subcapsular formations are a result of trauma to the kidney such as from a biopsy or motor vehicle accident. Here we present a case of a 61-year old African American male who presented to the hospital with worsening shortness of breath for 2 days, a blood pressure of 203/156, and a BNP of 206. He was admitted and treatment was begun for diastolic congestive heart failure and hypertensive emergency. Clinically, he was improving but his systolic blood pressure continued to be in the 150’s despite multiple blood pressure medications. Due to this difficulty in controlling blood pressure and a negative renal ultrasound, an abdominal CT scan with contrast was ordered and revealed a subcapsular fluid collection indenting the lateral margin of the left kidney measuring approximately 7.1 x 5.4 x 2.3 cm that was suggestive of a Page kidney per radiology. Upon further history taking it was found that the patient has had received extracorporeal shock wave lithotripsy for nephrolithiasis in past several months which is a known risk factor for subcapsular hematoma formation. Ultimately it was determined that this subcapsular hematoma was resolving on its own and no intervention was needed other than follow-up as an outpatient. We feel this case is noteworthy for not only being a presentation of a Page kidney, but also demonstrates the importance of considering a secondary cause to hypertension in patients with difficult to control hypertension.

Oral Valproate Sodium as an Alternative to Benzodiazepine in the Treatment of Catatonia- A Case Report

Alternative therapies are necessary to treat catatonia in patients with comorbidities that are not amenable to therapy with benzodiazepines or ECT. This is a patient with schizophrenia with catatonic features and a history of polysubstance abuse. Consequently, he was not a candidate for treatment with benzodiazepines, so an alternative needed to be found. GABAergic medications have been used previously as alternatives to benzodiazepines and ECT. In this case we chose sodium valproate, due to its cross-reaction with GABAergic systems. There are five reported cases using sodium valproate. Three of which were treated with intravenous valproate, while the remaining two do not specify the route of administration. We present a case where oral sodium valproate was used successfully for both acute and long-term catatonic treatment. To our knowledge, no other report has looked at both acute and long-term treatment with sodium valproate. Oral sodium valproate can be considered for patients with substance use disorders like COPD, sleep apnea or myasthenia gravis in which benzodiazepines are contraindicated and where ECT is not an option for treatment.

Does Patient Self-Awareness Predict Ankle Fractures?

Introduction: Ankle injuries represent one of the most common sports and extremity related complaints presented in emergency departments (ED) with over five million ankle injuries annually arising in the United States. The 2007 US National Health Statistics Report stated that lower limb and ankle complaints accounted for 4.1% of all reported body sites undergoing injury in the ED. The purpose of this study was to examine how frequently a sample of ED patients’ perception of having a possible ankle fracture was predictively associated with results of their X-ray evaluation results. Methods: After 2017 IRB approval, a sample of consented adult patients receiving care at the authors’ two Ohio and Michigan ED were asked, “Do you think you broke your ankle?” Regardless of each patient’s answer, they received an X-ray to evaluate for an ankle fracture that was interpreted by a radiologist. Results: A total of 69 eligible patients received an ankle X-ray. The total number of ankle fractures confirmed by X-ray was 20 (29.4% of sample) while 48 (70.5%) of ankles that were X-rayed were not fractured. Six (28.5%) out of 21 males and 14 (30.4%) out of 46 females were found to have a confirmed ankle fracture. The sensitivity of the perceived ankle fracture question was at or below 50% in all sample subgroups except for smokers at 67%. Conclusion: These findings support the importance of an ED clinician’s intuition when considering a patient’s own self-assessment during their clinical decision-making processes

Retrospective Cohort Analysis of Robotic Stapler Use in Robotic-Assisted Donor Nephrectomy

Main Problem: Robotic-assisted techniques are common for living-donor nephrectomy. While robotic stapling offers increased surgeon control, there is limited comparative data versus laparoscopic linear stapler use for ligation of renal vessels. Methods: We retrospectively reviewed 32 consecutive robotic-assisted donor nephrectomies by a single surgeon for perioperative outcomes. Results: Patients in the robotic stapler (RS; N=20) and laparoscopic stapler (LS; N=12) groups were comparable in terms of age and BMI. Estimated blood loss (p = 0.62), warm ischemia time (p=0.50), and console time (p=0.56) were similar between the RS and LS groups. There were no stapler misfires or major intraoperative complications in either group and no cases required conversion to open. Conclusions: Robotic stapler use is safe and effective in robotic-assisted donor nephrectomy. Further research on prevalence of robotic stapler use is needed to quantity the associated complication rate.