Perceptions and identity: Poverty in 19th century Rockingham County

The historical analysis of poverty has lain silent for nearly two decades, with only recent authors, such as Nancy Isenberg and Kerri Leigh Merritt, broaching the topic. While several others have taken a deep dive into understanding the causes and effects of contemporary poverty, it seems to me a great deal has yet to be written on the identity of those impoverished and their active endeavors to define themselves in economic circumstances largely beyond their control. Until we truly explore the complexity of economic dearth and its relation to collective identity, we cannot fully understand the topic of “poverty.” In this way, poverty is a very complex topic, as it cannot ever truly be reduced to a discussion of those immediately affected by want and its causes. It requires one to understand perceptions of the impoverished, how these perceptions informed the identity of the poor, and how the poor interacted with members outside and within their immediate social group. In reality, poverty is a messy subject, but one that deserves attention. Thus, through this analysis of poverty in antebellum Rockingham County, I hope to illustrate the many indivisible connections of race, class, and gender in the construction of perceptions and responses to poverty

Exploring Rockingham County’s Past: Recapturing Local History and Promoting Accessibility

In 2018 Exploring Rockingham’s Past (ERP) launched. ERP is an online repository created to house local records from the Rockingham County, Virginia circuit court. Just a little over a year before its launch, Clerk of the Court, Chaz Haywood entreated facility and graduate students within the history department of James Madison University to help develop community access to the records housed within his institution. Sadly, over the decades the records of the courthouse had fallen into disarray, rendering them useless. Seeing this as a significant loss of culture and heritage, Haywood and James Madison University began developing a platform that could house digital versions of individual records, and while students collected, arranged, and described collections to be digitized. The first collection to be featured on the site was the Shenandoah National Park collection, consisting of records related to the creation of Shenandoah National Park and the removal of families from their lands. Within a year, ERP has grown and launched its newest collection, the Rockingham County\u27s Prohibition Records, which details the history of illegal production, transportation, and importation of ardent spirits in Rockingham from 1921-1935. As the repository continues to grow, new concerns develop as well. While making the records digitally accessible constitutes a large part of the project, it is now time to consider how to make the collections more usable. The current article discusses the development of ERP past, present, and future, detailing the ways current graduate student Kayla Heslin seeks to transform the project

Vitamin D Level Testing in an Urban Midwest Clinic: To Test or Not to Test?

Vitamin D deficiency (VDD) is significantly higher among urban populations in the U.S. Midwest, with African Americans being disproportionately affected. There is ongoing debate surrounding who and how often individuals should be screened for VDD. This study aimed to understand the prevalence of VDD, associated risk factors, and discrepancies in testing at an urban-based internal medicine residency clinic. Data were retrospectively collected on all adult patients seen by the clinic during 2018 and descriptive statistical analysis performed. Among 3976 total patients (mean age: 53 years), 18% (n = 698) had vitamin D levels analyzed, with deficiency found in 71% of those tested. Mean age of the tested cohort was 59 years, and women (68%) and African Americans (72%) were found more likely to be tested. Women and patients with certain medical conditions were more likely to be tested (P \u3c 0.02 for all) but were not more likely to have VDD. Individuals with a diagnosis of chronic kidney disease were less likely to have VDD (P = 0.002). Vitamin D levels typically showed improvement after retesting. A low testing rate could contribute to missed diagnoses. Overall, this study revealed that differences in rate of testing do not necessarily correlate to patients’ demographical risk of VDD. Clinicians may benefit from a standardized vitamin D testing protocol

Can Variables From the Electronic Health Record Identify Delirium at Bedside?

Delirium, a common and serious disorder in older hospitalized patients, remains underrecognized. While several delirium predictive models have been developed, only a handful have focused on electronic health record (EHR) data. This prospective cohort study of older inpatients (≥ 65 years old) aimed to determine if variables within our health system’s EHR could be used to identify delirium among hospitalized patients at the bedside. Trained researchers screened daily for delirium using the 3-minute diagnostic Confusion Assessment Method (3D-CAM). Patient demographic and clinical variables were extracted from the EHR. Among 408 participants, mean age was 75 years, 60.8% were female, and 82.6% were Black. Overall rate of delirium was 16.7%. Patients with delirium were older and more likely to have an infection diagnosis, prior dementia, higher Charlson comorbidity severity of illness score, lower Braden Scale score, and higher Morse Fall Scale score in the EHR (P \u3c 0.01 for all). On multivariable analysis, a prior diagnosis of dementia (odds ratio: 5.0, 95% CI: 2.5–10.3) and a Braden score of \u3c 18 (odds ratio: 2.8, 95% CI: 1.5–5.1) remained significantly associated with delirium among hospitalized patients. Further research in the development of an automated delirium prediction model is needed

Data in the electronic health record can be used at the bedside to identify older hospitalized patients with delirium

Background: Delirium is common among hospitalized older adults and associated with adverse outcomes. Delirium remains underrecognized, and efforts are focused on early recognition and prediction. While several delirium predictive rules have been developed, only a handful have focused on electronic health record (EHR) data. The coupling of prediction rules with features of the EHR are in their infancy but hold promise in their ability to aid in identification of delirium. Purpose: To determine variables within our health system’s EHR that can be used to identify older hospitalized patients with delirium. Methods: This is a prospective study among hospitalized patients (≥65 years of age) from February 2016 to November 2017. Patients were excluded if they: 1) were non-English-speaking, comatose, ventilated, or combative; 2) were intensive care or surgical patients; or 3) had severe aphasia, severe dementia, or a critical illness. Researchers screened daily for delirium using the 3-minute diagnostic confusion assessment method (3D-CAM). Predictive variables were extracted from the EHR. Basic descriptive statistics were conducted. Chi-squared and Fisher’s exact tests were used to compare differences among those diagnosed with or without delirium. Binary logistic regression was used for multivariable modeling. Results:Among 408 participants, mean age at admission was 75 years, 61% were female, and 83% were African American. The overall rate of delirium was 16.7% (prevalent delirium: 10.5% [n=43]; incident delirium: 6.1% [n=25]). There was no statistical difference in 30-day mortality (2.9% vs 2.7%) or 30-day readmission rates (13.2% vs 14.7%) between those with and without delirium (P\u3e0.05 for both). Even so, patients with delirium were older, more likely to have a diagnosis of infection and/or cognitive impairment, and more likely to have increased severity of illness (P Conclusion: Our study found that cognitive impairment and lower Braden scores were associated with hospital delirium. Further research is needed to develop an automated, dynamic (daily) prediction model inclusive of these variables

The incidence of vitamin D deficiency in the internal medicine clinic at Aurora Sinai Medical Center

Background: According to the Centers for Disease Control and Prevention, 10% of the U.S. population has severe vitamin D deficiency (VDD), with African Americans having the highest prevalence of low vitamin D concentration. Studies have shown that VDD is significantly higher among urban midwestern populations. The detrimental effects of VDD on the bone are well known; however, recent studies suggest that VDD also might be involved in the immune, cardiovascular, and neurological system. Nevertheless, Supplement www.aah.org/jpcrr 357 there is still debate surrounding who, how, and how often individuals should be screened for VDD. Purpose: To assess the prevalence of VDD in one internal medicine clinic and identify risk factors. Methods: Data were retrospectively collected on unique adult patients (≥18 years old) who attended the clinic at any point from January 2018 to December 2018. Vitamin D levels of ≥30 ng/ml were considered normal, while levels of/ml were considered deficient. Patients who had more than one vitamin D test were tracked for further analyses. Basic descriptive statistics were used to describe the population. Chi-squared tests and t-tests were used as appropriate to compare groups. Results:Of the patient cohort (n=3,976), only 17.56% had vitamin D levels tested and 12% had a prior diagnosis of VDD. Of those tested, 68% were females, 72% were African Americans, and the average age was 59 years. Unlike race (P=0.80), women, patients with a previous diagnosis of bone fracture, and those with a current diagnosis of alcohol use disorder, celiac disease, or chronic kidney disease were significantly more likely to have vitamin D levels tested (P Conclusion: Although African Americans are generally known to have lower levels of vitamin D when compared to other races, we found they were not more likely to be tested nor have more vitamin D deficiency. Improvement of vitamin D levels for those re-tested indicates that interventions are being utilized. Parallel to results previously reported, patients with chronic kidney disease are more likely to have VDD and could benefit from annual testing for vitamin D levels. Awareness of these differences could help to lower rates of VDD in this at-risk population

The impact of goals of care conversation training

Background: Palliative interventions by nonpalliative health care providers such as hospitalists have proved to be beneficial to patients. A primary task of these providers is to hold goals of care (GOC) conversations with patients early during their hospital stay. This can help reserve the expertise of palliative care specialists for more complex patients. While a previous local evaluation focused on providers’ overall comfort in initiating GOC conversation before and after an intervention, no study has explored whether the intervention resulted in providers having more GOC conversations. Purpose: To explore whether GOC training sessions increased hospitalists’ utilization of the GOC dotphrase generated by the Epic electronic health record; also, to evaluate if there was an improvement in the overall quality of GOC conversations held with patients upon admission. Methods: Aurora Health Care hospitalists participated in training sessions covering GOC conversations during 2017–2018. We reviewed 200 history and physical notes (H&Ps) for 5 full-time hospitalists before and after training. H&Ps were reviewed only for patients who were ≥65 years of age and admitted directly to the intensive care unit. For each hospitalist, only the 20 most recent charts before and after the intervention were included. Documented GOC conversations were tabulated, including the use of the GOC dotphrase. Quality assessment was done by searching for goalconcordant keywords and their synonyms within these conversations. Basic descriptive statistics were used to describe the population. Chisquared tests and t-tests were used as appropriate to compare groups. Results:Patient demographics of H&Ps reviewed were as follows: 95% White, 59% female, and mean age 79 years. Older patients (mean: 84 years) were more likely to have a GOC conversation (P Conclusion: Half-day training sessions in conducting goals of care conversations were associated with an increased usage of the GOC dotphrase. Our next steps will be to broaden the scope of this study by not only retraining hospitalists but also including providers from other facilities in our analysis, thus increasing the number of analyzed patient history and physical notes