Recurrent DKA results in high societal costs – a retrospective study identifying social predictors of recurrence for potential future intervention

Aims Diabetic ketoacidosis (DKA) is an emergency with high morbidity and mortality. This study examined patient factors associated with hospitalization for recurrent DKA. Methods Characteristics of 265 subjects admitted for DKA at Hennepin County Medical Center between January 2017 and January 2019 were retrospectively analyzed. Differences between subjects with a single admission versus multiple were reviewed. Results Forty-eight out of 265 patients had recurrent DKA. Risk factors included African American race (adjusted odds ratio (aOR) versus white non-Hispanic = 4.6, 95% CI 1.8–13, p = 0.001) or other race/ethnicity (aOR = 8.6, 2.9–28, p < 0.0001), younger age (aOR 37-52y versus 18-36y = 0.48, 0.19–1.16, p = 0.10; aOR 53-99y versus 18-36y = 0.37, 0.12–0.99, p = 0.05), type 1 diabetes mellitus (aOR = 2.4, 1.1–5.5, p = 0.04), ever homeless (aOR = 2.5, 1.1–5.4, p = 0.03), and drug abuse (aOR = 3.2, 1.3–7.8, p = 0.009). DKA cost a median of $29,981 per admission. Conclusions Recurrent DKA is costly, and social determinants are strong predictors of recurrence. This study highlights the need for targeted preventative care programs.

Hennepin County Adult Detention Center’s Response to a 2019 Hepatitis A Outbreak in Minnesota

Hennepin County Adult Detention Center (Jail) is Minnesota’s largest jail. In August 2019, the Minnesota Department of Health declared a statewide hepatitis A outbreak. Within three days, Hennepin County Jail Health Services made significant changes to vaccination protocols that increased vaccination rates from 0.6% to 7.1% among detainees, who have a greater risk of contracting hepatitis A. We highlight the opportunity for jails to develop sustainable public health interventions in the setting of community outbreaks. (Am J Public Health. Published online ahead of print March 18, 2021: e1–e3. https://doi.org/10.2105/AJPH.2021.306159 )

Testing behavioral interventions designed to improve on-time SNAP recertification

We report results from a series of randomized controlled trials (RCTs) run between January 2019 and February 2020 testing behavioral interventions designed to increase the likelihood that SNAP recipients recertify on-time in Hennepin County, the most populous county in Minnesota. Given the different levels of governance and the abundance of qualifying rules and processes that low-income households must negotiate to obtain and retain SNAP food assistance benefits, many households may fail to recertify for SNAP. Administrative burden includes the difficulties created by having to learn deadlines and which forms constitute the proper paperwork necessary to recertify. In our main intervention, we test a three-armed study (n=23,756), comparing the efficacy of the Hennepin County SNAP recertification auto-dialer communication, a behaviorally-informed text message, and a third arm with both the Hennepin county autodialer and our text message, against a control group that did not receive any reminder at the beginning of the recertification month but did receive other standard written communications. Results from this trial show that the autodialer is not an effective reminder. However, the interventions with text messages are effective in improving recertification rates around five percent (p<0.01) over no additional message and around two percentage points (p<0.05) over the Hennepin County autodialer message currently being used. Text messaging appears to be particularly effective for SNAP recipients under the age of 60 with low to moderate levels of education.

The Elephant in the Room

Over a three-month period in early 2017, the Hennepin County Medical Examiner’s Office investigated nine apparent opioid toxicity deaths that occurred in three separate urban, suburban, and rural counties in our jurisdiction. All decedents were known substance abusers and had reportedly recently used heroin; most were found with drug paraphernalia. Complete autopsies variably showed classic stigmata of opioid overdose with no significant injury or natural disease to explain death. Initial toxicology screens failed to identify heroin or other narcotic substances. Several cases were presumptively positive for fentanyl by immunoassay, yet failed to confirm positive for fentanyl. Following American Board of Forensic Toxicology reporting standards, these cases were reported as negative for fentanyl by the laboratory. Due to the discrepant scene and toxicology findings suggestive of an opioid toxicity death, further discussion between the medical examiners and toxicologists prompted additional testing at a referral laboratory. This resulted in quantifiable blood carfentanil in all cases (mean 0.26 ng/mL, range 0.12 – 0.64 ng/mL). Cointoxicants included ethanol (n=2), methamphetamine (n=3), benzodiazepines (n=3), and cocaine (n=1). No case had definitive evidence of acute heroin intoxication, but two cases had low concentrations of morphine present (0.03 and 0.06 ng/mL), and two others had 6-monoacetyl morphine in the urine without morphine in the blood, suggesting recent use. All deaths were certified as accidental acute or mixed carfentanil toxicity. These cases present additional information about carfentanil-related deaths and highlight the importance of collaboration between forensic pathologists and toxicologists.