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ObjectiveTo survey barriers in prescribing naltrexone for alcohol use disorder.MethodsA 12-question survey related to naltrexone prescribing patterns, perceptions, and knowledge was sent to 770 prescribers in the departments of internal medicine, family medicine, and psychiatry across a health system with sites in Arizona, Florida, and Minnesota.ResultsResponses were obtained and included for 146/770 prescribers (19.0% response rate). Most respondents were in the department of internal medicine (n = 94, 64.4%), but the departments of psychiatry (n = 22, 15.1%) and family medicine (n = 30, 20.5%) were also represented. Only 34 (23.3%) respondents indicated they had prescribed naltrexone in the previous 3 months. The most common reasons for not prescribing naltrexone were “unfamiliarity with naltrexone for treatment of alcohol use disorder” and “patients do not have appropriate follow-up or are not in a formal treatment program.” Compared with those representing internal/family medicine, psychiatry respondents were more likely to prescribe naltrexone and answer knowledge questions correctly.ConclusionIn this survey among primarily non-addiction-trained prescribers, a disparity was shown for prescribing naltrexone and in knowledge barriers between staff in internal/family medicine and psychiatry. There exist opportunities for education and quality improvement that promote the prescribing of naltrexone for alcohol use disorder by non-addiction specialists.

Background and Objectives: Teaching medical students patient-centered approaches to weight loss counseling occurs in myriad ways. We examined lectures and direct faculty observation to see which was associated with better patient-centered care in medical students, measured by both self-perception and independent observer evaluation. Methods: Third- and fourth-year students attending one medical school were surveyed regarding their education in (1) weight loss and health behavior counseling, (2) obesity stigma, and (3) whether they had experienced direct faculty observation of their weight loss counseling. Several weeks later, the students were observed during a standardized patient encounter for obesity and an obesity-relevant comorbidity. A postencounter survey assessed overall student satisfaction with the encounter and with the care they provided. Independent coders rated their patient-centered communication using a validated measure. Results: There was no consistent association between any dependent variable and student ratings of adequacy of instruction, nor with instructional content. Direct faculty observation was not associated with overall encounter satisfaction or their overall patient-centeredness. However, experiences with direct faculty observation were significantly and positively associated with students’ perceptions of patient engagement (b=0.1, P=.05), and with independent coders’ ratings of student friendliness (b=0.13, P=.01), responsiveness (b=0.113, P=.03), and lower student anxiety (b=-0.1, P=.01). Conclusions: Independent observation and self-report of instruction adequacy and content had no consistent association with care quality. However, direct faculty observation predicted improvement in both student self-reports and independent observer ratings of students’ interpersonal quality of care. Further work is needed to define optimal methods of imparting patient-centered care.

Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire–9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9 <5. Persistent depressive symptoms (PDS) were defined as PHQ-9 ≥10 at 6 months. Treatment in both CCM and UC were compared. Results: Using intention to treat analysis, depressed smokers treated with CCM were 4.60 times as likely (95% CI 3.24-6.52, P < .001) to reach CR and were significantly less likely to have PDS at 6 months (adjusted odds ratio [AOR] 0.19, 95% CI 0.14-0.25, P < .001) compared with smokers in UC. After a 6-month follow-up, depressed smokers treated with CCM were 1.75 times as likely (95% CI 1.18-2.59, P = .006) to reach CR and were significantly less likely to have PDS (AOR 0.45, 95% CI 0.31-0.64, P < .001) compared with smokers in UC. Conclusions: CCM significantly improved depression outcomes for smokers at 6 months compared with UC. However, in the UC group, smoking outcomes were not statistically different at 6 months for either remission or PDS. Also, nonsmokers in CCM had the best clinical outcomes at 6 months in both achieving clinical remission and reduction of PDS when compared with smokers in UC as the reference group.

A 20-year-old otherwise healthy male presented to his primary care clinic with a 1-week history of fevers, rash, and polyarthralgias affecting his knees, elbows, and wrists that began 5 days following an acute diarrheal illness. In the clinic he was febrile to 38.5°C with a petechial rash initially on the palms and soles, which then spread to his trunk. The examination was also notable for cervical lymphadenopathy, two tongue ulcerations with clean bases, and the absence of joint effusion. Testing for influenza virus was negative, and the patient was sent home with a preliminary diagnosis of a nonspecific viral illness. Subsequently, the patient's malaise and migratory arthralgias worsened, resulting in ambulation difficulties, and so he presented to the Emergency Department. He continued to complain of low-grade fevers and rash with intermittent headache and mild dysuria. He reported a monogamous heterosexual relationship, but he denied abnormal urethral discharge, genital lesions, intravenous drug use, tick exposure, or recent travel outside his Midwestern home state. The exam was notable for a whole-body diffuse petechial rash (Fig. 1) but negative for joint effusions or stigmata of endocarditis. Laboratory analysis revealed mildly elevated white blood cells at 11.5 ϫ 10 9 /liter (normal range, 3.4 ϫ 10 9 to 9.6 ϫ 10 9 /liter) with neutrophilia, hemoglobin at 13.0 g/dl (normal range, 13.2 to 16.6 g/dl), and a C-reactive protein level of 79.1 mg/liter (normal range, 3.0 to 8.0 mg/liter). Hepatic enzyme testing, blood chemistry panel, urinalysis, and urine Gram stain were unremarkable. Given his history and lack of overseas travel, the differential for his illness included enterovirus, parvovirus, viral hepatitis, sexually transmitted infection, reactive arthritis, rheumatic disease, and bacteremia. Influenza and tick-borne illness were additional considerations, although the patient presented during the winter months, making influenza more likely than tick-borne illness. However, given a negative outpatient influenza result and the endemic nature of local tick-borne illnesses, a tick-borne panel was obtained that included testing for Lyme disease, Anaplasma phagocytophilum, Ehrlichia chaffeensis, and Babesia microti. In addition, blood cultures, urine studies for Neisseria gonorrhoeae and Chlamydia trachomatis, and a multiplex molecular stool panel for gastrointestinal pathogens (BioFire, Salt Lake City, UT) were performed, and blood for hepatitis, HIV, and syphilis serologies was obtained. Given the absence of joint effusions, no diagnostic joint aspiration was performed. The patient received a single dose of ceftriaxone to cover for sexually transmitted infections before being admitted. The patient received analgesia with naproxen and reported rapid improvement in his arthralgias. Overnight, blood cultures turned positive for Gram-negative rods in four

Background The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study aimed to identify patient-related factors where a face to face (FTF) evaluation is indicated, measured by the need for pre-operative testing. Methods A retrospective chart review was conducted on patients age ≥ 18 years who had a PAME between January 2019–June 2020 at a rural primary care clinic in Southeast Minnesota. Data collected included age, gender, Charlson Comorbidity Index Score, medications, revised cardiac risk index (RCRI), smoking status, exercise capacity, body mass index, and pre-operative testing. Logistical regression modeling for odds ratios of outcomes was performed. Results 254 patients were included, with an average age of 64.1 years; 43.7% were female. Most were obese (mean BMI 31.6), non-smoking (93.7%) with excellent functional capacity (87.8% ≥ 5 METs). 76.8% of the planned surgeries were intermediate or high risk. 35.0% ( n = 89) of visits resulted in medication adjustments and 76.7% ( n = 195) in pre-operative testing. Age ≥ 65 years, ≥7 current medications, and diabetes all significantly increased the odds of requiring pre-operative testing ( P < .05). Conclusions This study was able to identify patient-related factors that increased the likelihood of requiring pre-operative testing. Patients who are age ≥ 65 years, ≥7 current medications, and those with diabetes could be scheduled for a FTF evaluation. Others could be scheduled for a telemedicine visit to minimize health-care exposures.

A 19-year-old male presented to the clinic and was found to be prehypertensive and have proteinuria on urine testing. He was subsequently diagnosed with focal segmental glomerulosclerosis (FSGS). Initial workup for pediatric hypertension includes urinalysis, chemistry panel, lipid panel, and renal ultrasound. Abnormalities on urinalysis, including proteinuria, hypercholesterolemia, and low serum albumin in children are characteristic of nephrotic disease. FSGS is a type of kidney pathology that often contributes to nephrotic disease and results from a variety of causes. For the primary care provider, being aware of the guidelines for pediatric hypertension screening and evaluation is important as 20% of children with hypertensive disease are due to kidney disease. FSGS is the third leading cause of end-stage renal disease in children aged 12 to 19 years, and its incidence was found to be rising in a study of Olmsted County, MN residents. Treatment to complete or partial remission of the proteinuria can slow the progression of renal disease. In this case report, we will discuss the evaluation of pediatric hypertension workup with proteinuria, specifically due to FSGS, and review current management strategies.