Assessment of single-item literacy questions, age, and education level in the prediction of low health numeracy.

OBJECTIVE: Determining a patient's health literacy is important to optimum patient care. Single-item questions exist for screening written health literacy. We sought to assess the predictive potential of three common screening questions, along with patient age and education level, in the prediction of low health numerical literacy (numeracy). METHODS: After demographic and educational information was obtained, 441 patients were administered three health literacy screening questions. The three-item Schwartz-Woloshin Numeracy Scale was then administered to assess for low health numeracy (score of 0 out of 3). This score served as the reference standard for Receiver Operating Characteristics (ROC) curve analysis. ROC curves were constructed and used to determine the area under the curve (AUC); a higher AUC suggests increased statistical significance. RESULTS: None of the three screening questions were significant predictors of low health numeracy. However, education level was a significant predictor of low health numeracy, with an AUC (95% CI) of 0.811 (0.720-0.902). This measure had a specificity of 95.3% at the cutoff of 12 years of education (<12 versus > or = 12 years of education) but was non-sensitive. CONCLUSION: Common single-item questions used to screen for written health literacy are ineffective screening tools for health numeracy. However, low education level is a specific predictor of low health numeracy.

Posterior lumbar vein off the retrohepatic inferior vena cava: a novel anatomical variant with surgical implications.

PURPOSE: Resection of tumors involving the inferior vena cava requires vascular control of posteriorly draining lumbar veins to ensure a bloodless field. Surgical texts and atlases assert that lumbar veins do not insert into the inferior vena cava superior to the renal hilum. However, at our institution we have encountered patients undergoing inferior vena cava tumor thrombectomy who have a posterior lumbar vein cephalad to the renal veins. Since this represents an unrecognized source of hemorrhage, we investigated the frequency of a superior lumbar vein in cadaveric dissection. MATERIALS AND METHODS: Retroperitoneal cadaveric dissection of the inferior vena cava was done to assess the frequency of a lumbar vein draining into the inferior vena cava cephalad to the renal veins. RESULTS: Of the 49 cadaveric dissections performed 19 (38.8%) showed a single posterior lumbar vein between the diaphragm and the renal hilum. Of these 19 cadavers 15 (78.9%) were male. This vein was located an average ± SD of 7.4 ± 0.6 cm cephalad to the right renal vein and it was 3.7 ± 1.6 cm in diameter. In all cadavers this vein inserted within 30 degrees to the left or right of the posterior (also termed dorsal) aspect of the inferior vena cava. CONCLUSIONS: The identification of a lumbar vein between the renal hilum and the diaphragm represents an important anatomical variant that occurs in a significant percent of individuals. Surgeons will benefit from the knowledge of this variant of inferior vena cava vasculature and should anticipate the presence of this vein to prevent unnecessary morbidity and mortality secondary to unexpected hemorrhage, particularly in male patients.

IPSS quality of life question: a possible indicator of depression among patients with lower urinary tract symptoms.

INTRODUCTION: Depression and benign prostatic hyperplasia (BPH) are prevalent, especially in older patient populations. Emerging data suggest potential interactions between depression and BPH. We sought to assess whether the questions of the International Prostate Symptom Score (IPSS), specifically the quality of life (QoL) question, predict depression. MATERIALS AND METHODS: We asked 541 consecutive male patients over the age of 40 in a tertiary care clinic to self-administer the IPSS QoL score and the Geriatric Depression Scale (GDS), a validated screening tool for depression. Receiver operating characteristics (ROC) curves were depicted and used to determine the area under the curve (AUC) and relative sensitivity and specificity of the individual questions of the IPSS relative to the GDS. RESULTS: Of the cohort, 17.2 percent screened positive for depression. More than half (54.7%) of nondepressed patients had a QoL score of 0-2, while a similar number of depressed patients (50.8%) had a QoL score of 5 or 6. The QoL question of the IPSS exhibited an AUC (95% CI, p value) of 0.735 (0.669-0.800, p < 0.001). A cut-off of QoL scores > 5 exhibited the highest specificity (93.1%)while a cut off of QoL scores > 1 exhibited a sensitivity of 90.0%. CONCLUSIONS: Future studies should validate these findings and shed further light on this tool's clinical utility. Pending this future validation, patients with a score of 6 could be considered for further mental health evaluation.

Evaluation of a Pharmacist-Led Penicillin Allergy Assessment Program and Allergy Delabeling in a Tertiary Care Hospital.

Importance: Penicillin allergies are frequently mislabeled, which may contribute to use of less-preferred alternative antibiotics. Objective: To evaluate a pharmacist-led allergy assessment program's association with antimicrobial use and clinical outcomes. Design, Setting, and Participants: A pharmacist-led allergy assessment program was launched in 2 phases (June 1, 2015, and November 2, 2016) at a single-center tertiary referral hospital. The longitudinal cross-sectional study included all study period adult admissions; hospitalwide outcomes were assessed by segmented regression. Individual outcomes were assessed within an embedded propensity score-matched case-control study of inpatients undergoing comprehensive allergy assessment following self-report of penicillin allergy. Analysis occurred from March 1, 2020, to February 29, 2020. Exposures: The longitudinal study analyzed hospital-level outcomes over 3 periods: preintervention (15 months), phase 1 (structured allergy history alone, 16 months), and phase 2 (comprehensive assessment including penicillin skin testing, 52 months). The case-control study defined cases as individuals undergoing comprehensive allergy assessment. Main Outcomes and Measures: Hospital-level outcomes included antibiotic days of therapy per 1000 patient-days and hospital-acquired Clostridioides difficile infection (CDI) incidence per 10 000 patient-days. Individual outcomes included antibiotic selection, overall survival, and CDI-free survival. Results: Longitudinal analysis spanned 2014-2020 (median admissions, 46 416 per year; interquartile range [IQR], 46 001-50 091 per year). Hospitalwide, allergy histories were temporally associated with decreased use of nonpenicillin alternative antibiotics (rate ratio, 0.87; 95% CI, 0.79-0.97) and high-CDI-risk antibiotics (rate ratio, 0.91; 95% CI, 0.85-0.98). Penicillin skin testing was temporally associated with lower hospital-acquired CDI rates (rate ratio, 0.61; 95% CI, 0.43-0.86). The embedded case-control study included 272 cases and 819 controls. Median age was 63 years (interquartile range, 51-73 years), 553 (50.7%) patients were women, and 229 (21.0%) patients were Black. Allergy-assessed patients were less likely to receive high-CDI-risk antibiotics at discharge (odds ratio, 0.66; 95% CI, 0.44-0.98). Estimated reductions in mortality (hazard ratio, 0.77; 95% CI, 0.55-1.07) and hospital-acquired CDI risk (hazard ratio, 0.53; 95% CI, 0.18-1.55) were not statistically significant. Conclusions and Relevance: Pharmacist-led allergy assessments may be associated with reduced high-CDI-risk antibiotic use at both hospitalwide and individual levels. Although individual reductions in mortality and CDI risk did not achieve significance, divergence of survival curves suggest longer-term benefits of allergy delabeling warrant future study.

Assessment of the performance of the American Urological Association symptom score in 2 distinct patient populations.

PURPOSE: Recent research suggests that low education and illiteracy may drive misunderstanding of the American Urological Association Symptom Score, a key tool in the American Urological Association benign prostatic hyperplasia guidelines. It is unclear whether misunderstanding is confined to patients of low socioeconomic status. Therefore, we reevaluated the prevalence and impact of this misunderstanding in a county vs university hospital population. MATERIALS AND METHODS: This prospective study involved 407 patients from a county hospital and a university hospital who completed the American Urological Association Symptom Score as self-administered and then as interviewer administered. Responses were compared by calculating correlation coefficients and weighted kappa statistics to assess patient understanding of the American Urological Association Symptom Score. Multivariate logistic regression analyses were used to examine the association between patient characteristics and poor understanding of the American Urological Association Symptom Score. RESULTS: Of the patients 72% understood all 7 American Urological Association Symptom Score questions. Of the measured demographic variables only education level significantly affected this understanding. Compared to patients with more than 12 years of education county hospital patients with less than 9 years of education were 57.06 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 14.32-329.34) while university hospital patients with less than 9 years of education were 38.27 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 1.69-867.83). Of county hospital patients 31% and of university hospital patients 21% significantly misrepresented their symptom severity according to current guidelines. CONCLUSIONS: Patients with low education regardless of location are more likely to misunderstand the American Urological Association Symptom Score, misrepresent their symptoms and, therefore, receive inappropriate treatment.

Things We Do For No Reason™: Failing to Question a Penicillin Allergy History.

Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™" (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Patient misunderstanding of the individual questions of the American Urological Association symptom score.

PURPOSE: Lower urinary tract symptoms are often assessed using the American Urological Association symptom score. However, some patients may experience difficulty completing the AUA questionnaire. We hypothesized that certain individual questions may generate more misunderstanding than others. MATERIALS AND METHODS: This study involved patients at 2 hospitals who completed the American Urological Association symptom score twice, that is 1) self-administered and 2) physician assisted. Analyses compared self-reported and physician obtained responses to each individual question. One-way ANOVA with the Tukey HSD post hoc test was done to assess whether mean disagreements between self-reported and physician administered American Urological Association symptom scores differed significantly by patient education level. RESULTS: The study group consisted of 998 patients. For each symptom score question we found an inverse relationship between education level and symptom misrepresentation. This discrepancy was the largest for questions on frequency (question 2) and urgency (question 4), which are related to irritative symptoms. Mean misrepresentation of the total American Urological Association symptom score was 2.42 and 5.33 for patients with greater than 12 and fewer than 9 years of education, respectively (p <0.001). Of patients with more than 12 years of education 28% misreported their symptoms by 4 points or greater and 1% misreported them by 10 points or greater, while 58% with fewer than 9 years of education misreported their total score by 4 points or greater and 21% misreported it by greater than 10 points. CONCLUSIONS: While the American Urological Association symptom score is a useful tool for the rapid diagnosis of benign prostatic hyperplasia, patients with low education misrepresent their scores more often and to a higher degree, possibly predisposing them to inappropriate care.

The Eyes Have It: Eyelid Swelling and Rash in a 79-year-old Woman With Macular Degeneration.

INTRODUCTION: A 79-year-old woman with macular degeneration was referred to the Allergy/Immunology clinic for the evaluation of a potential allergy to anti-vascular endothelial growth factor (anti-VEGF) treatments. The patient developed urticaria and eyelid swelling immediately following a retinal injection of aflibercept, which she had previously tolerated. She previously had allergic reactions following ranibizumab and bevacizumab injections. Injections of anti-VEGF treatments were discontinued given concern for allergy with progression of the patient's disease. OBJECTIVE: To assess the culprit medication(s) responsible for hypersensitivity reactions following anti-VEGF injections for macular degeneration. METHODS: Medication records were reviewed for each retinal injection. All medications used in each procedure, including the anti-VEGF therapy (aflibercept), topical anesthetics (tetracaine and proparacaine hydrochloride), and antiseptic (povidine), were evaluated with skin testing. She was additionally tested for alternative anti-VEGF therapies (ranibizumab and bevacizumab) as she was thought to have allergies to these agents by prior history. A test dose challenge was completed for aflibercept, ranibizumab, and bevacizumab. RESULTS: Skin prick and intradermal testing were negative to aflibercept, ranibizumab, bevacizumab, and povidine. Intradermal testing was positive to tetracaine and proparacaine hydrochloride. The patient passed test dose challenges to aflibercept, ranibizumab, and bevacizumab. Due to her positive hypersensitivity testing to 2 ester anesthetics, the patient underwent skin prick and intradermal testing to the amide anesthetic, lidocaine. This was negative and the patient tolerated a graded challenge to lidocaine. She was deemed to have an immunoglobulin E (IgE)-mediated hypersensitivity to ester-type local anesthetics. She successfully resumed anti-VEGF therapy with an amide local anesthetic. CONCLUSIONS: The reason for this consult was the concern for hypersensitivity to a biologic anti-VEGF medication. The culprit allergen, the local anesthetic, could have been overlooked without an assessment of all medications used during the procedure. This case highlights the importance of a thorough allergy evaluation of all medications used during procedures to determine the causative agent.Chief Complaint: Eyelid swelling and rash after ophthalmic procedures for macular degeneration.

Enterovirus D68 and Panton-Valentine Leukocidin-Positive Staphylococcus aureus Respiratory Coinfection with Fatal Outcome.

A previously healthy 10-year-old girl with a 2-day history of upper respiratory illness and fever rapidly developed respiratory failure and sepsis with leukopenia, and expired despite attempts at resuscitation. Postmortem examination revealed bilateral necrotizing pneumonia and evidence of disseminated intravascular coagulation. Nasopharyngeal swabs and lung tissue submitted to the Centers for Disease Control and Prevention (CDC) were positive for Enterovirus D68 (EV-D68). Blood and lung cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). The isolates were submitted to the CDC and were found to be positive for the toxin Panton-Valentine leukocidin. We describe a fatality related to invasive toxin-mediated MRSA associated with EV-D68 coinfection, along with the clinical, laboratory, and autopsy findings, which provided important clues, prompting further investigation at the CDC to arrive at the correct diagnosis.

Nocturia associated with depressive symptoms.

OBJECTIVES: To assess the relationship between nocturia and depression, two inflammatory conditions that affect a significant number of men worldwide. METHODS: We asked 547 male patients to self-administer the American Urological Association Symptom Score (AUA-SS) and the Geriatric Depression Scale (GDS), a validated screening tool for depression. Univariate analysis identified significant differences in patient characteristics between depressed and nondepressed patients, and binary logistic regression was used to assess the potential relationship between nocturia and depression while controlling for patient demographics and quality of life. RESULTS: Of the cohort, 17.0% screened positive for depression. Depressed and nondepressed patients reported a mean (SD) of 2.7 (1.4) and 1.9 (1.4) episodes of nocturia per night, respectively (P <.001). After controlling for demographic variables and overall quality of life, patients with 5 or more episodes of nocturia per night experienced a 6.5-fold increased risk of depression compared with patients without nocturia (OR, 6.530; 95% CI, 2.107-20.239, P <.001). CONCLUSIONS: A significant correlation exists between nocturia and depression. Consequently, clinicians might use nocturia as a predictor of depression. Patients with increased frequency of nocturia may be considered for referral for further mental health evaluation.

Major depression drives severity of American Urological Association Symptom Index.

OBJECTIVES: To evaluate the unclear relationship between depression and benign prostatic hyperplasia (BPH) by assessing depression's effect on the American Urological Association Symptom Index (AUA-SI) scores. Depression is a common illness associated with chronic inflammatory disease states. Data have suggested a significant role of inflammation in the progression of BPH. METHODS: The present prospective study involved 547 male patients who completed the Geriatric Depression Scale and the AUA-SI. We evaluated whether the mean AUA-SI score and the severity categories differed by the state of depression. We then conducted binary logistic regression analysis with forward stepwise regression to assess the relationship between depression and the severity symptoms as determined by the AUA-SI score. RESULTS: Of the cohort, 22% screened positive for depressive symptoms. The depressed patients (Geriatric Depression Scale score >5) reported significantly more severe symptoms (mean AUA-SI score 16.61 ± 9.89) compared with the nondepressed patients (Geriatric Depression Scale score of ≤5 and mean AUA-SI score 10.65 ± 7.29; F = 40.19, P <.001). After controlling for socioeconomic and demographic variables, depressed patients were 3 times more likely to present with severe symptoms (odds ratio 3.079, 95% confidence interval 1.129-8.402, P = .028). CONCLUSIONS: A significant association was found between depression and BPH. However, it remains unclear whether this relationship represents unidirectional or bidirectional causality. Additional research is imperative to assess the nature of this correlation, either to address comorbid depression in patients with BPH or to ensure that depressed patients do not report falsely elevated symptoms.

Poorly numerate patients in an inner city hospital misunderstand the American Urological Association symptom score.

OBJECTIVES: To hypothesize that numeracy may also predict patient misunderstanding of the American Urological Association symptom score (AUA-SS). Health literacy consists of document and prose literacy, both considered "traditional" literacy. But, health literacy also comprises quantitative literacy or numeracy. We previously reported that document literacy independently predicts misunderstanding of the AUA-SS. However, the AUA-SS consists of written and numeric information. METHODS: Prospective cohort study of male patients who completed a validated, 3-question numeracy test once and the AUA-SS twice, which were self-administered and then interviewer-assisted. These 2 responses were compared with assessed patient understanding of the AUA-SS. Multivariate logistic regression analyses examined the association between patient characteristics and poor understanding of the symptom score, defined as understanding fewer than half of the questions, by calculating the odds ratios and corresponding 95% confidence intervals. RESULTS: A total of 571 patients completed the study, with an average age and education level of 58 and 13.5 years, respectively. On the numeracy test, 16%, 18%, 35%, and 31% correctly answered 3, 2, 1, and 0 questions, respectively. After adjusting for the highest educational level completed, written literacy, and demographics, completely innumerate respondents (score = 0 points) were more than 3 times as likely (odds ratio = 3.55; 95% confidence interval: 1.58-7.99; P = .002) to misrepresent their AUA-SS compared with those who had some numeracy (1-3 points). CONCLUSIONS: Regardless of educational or literacy status, a significant number of patients self-report AUA-SS scores that are different from interviewer-assisted scores, which may severely limit their access to appropriate care.