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Objective Individuals with both physical and mental health problems may have elevated levels of emergency department (ED) service utilization either for index conditions or for associated comorbidities. This study examines the use of ED services by Medicaid beneficiaries with comorbid diabetes and schizophrenia, a dyad with particularly high levels of clinical complexity. Methods Retrospective cohort analysis of claims data for Medicaid beneficiaries with both schizophrenia and diabetes from fourteen Southern states was compared with patients with diabetes only, schizophrenia only, and patients with any diagnosis other than schizophrenia and diabetes. Key outcome variables for individuals with comorbid schizophrenia and diabetes were ED visits for diabetes, mental health-related conditions, and other causes. Results Medicaid patients with comorbid diabetes and schizophrenia had an average number of 7.5 ED visits per year, compared to the sample Medicaid population with neither diabetes nor schizophrenia (1.9 ED visits per year), diabetes only (4.7 ED visits per year), and schizophrenia only (5.3 ED visits per year). Greater numbers of comorbidities (over and above diabetes and schizophrenia) were associated with substantial increases in diabetes-related, mental health-related and all-cause ED visits. Most ED visits in all patients, but especially in patients with more comorbidities, were for causes other than diabetes or mental health-related conditions. Conclusion Most ED utilization by individuals with diabetes and schizophrenia is for increasing numbers of comorbidities rather than the index conditions. Improving care in this population will require management of both index conditions as well as comorbid ones.

A 41-year-old man was evaluated for an upper gastrointestinal bleed. He was stabilized and an upper esophagogastroduodenoscopy revealed gastritis and esophageal varices. A computed tomography (CT) scan of the abdomen showed hepatosplenomegaly and moderate ascites. Analysis of the ascitic fluid was consistent with portal hypertension. A liver biopsy demonstrated noncaseating granuloma consistent with sarcoidosis, there was no evidence of liver cirrhosis on pathology. Portal hypertension associated with sarcoidosis is rare; after the first reported case in 1949, 35 other cases have been reported in the English literature, with only 16 patients presenting with portal hypertension without evidence of liver cirrhosis. Our patient is among the small group reported to have sarcoidosis-related portal hypertension without evidence of liver cirrhosis. The present case illustrates the importance of recognizing an uncommon manifestation of sarcoidosis Case PresentationA 41-year-old man presented to the emergency department complaining of palpitations and dizziness with exertion for one month. He reported passing dark stools for three weeks and noted decreased appetite. He denied chest pain, cough, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain, nausea, vomiting, diarrhea or weight loss. His medical history included sarcoidosis and steroidinduced diabetes mellitus while on prednisone, glipizide and insulin. The patient migrated from Nigeria 20 years earlier, and denied toxic exposures, use of alcohol, nicotine or recreational drugs.On examination, he was afebrile with a blood pressure of 121/61 mmHg, a pulse rate of 93 beats/min, a respiratory rate of 16 breaths/min and oxygen saturation of 98% on room air. He was anicteric with pale conjunctiva. Respiratory, cardiovascular and neurological examinations were normal. His abdomen was soft, with mild epigastric tenderness but no guarding or rebound tenderness. His liver span was 14 cm and his spleen extended 4 cm below the left costal margin. No masses were palpated and bowel sounds were normal. The rectal examination revealed dark stools.Laboratory studies revealed a white blood cell count of 1.6×10 9 /L, a hemoglobin level and hematocrit of 53 g/L and 16.7%, respectively, with a mean corpuscular volume of 68 fL, and a platelet count of 6.4×10 9 /L. Electrolytes and coagulation studies were normal, with alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase levels of 37 U/L, 27 U/L and 127 U/L, respectively. He was admitted for symptomatic anemia due to gastrointestinal blood loss and was transfused three units of packed red blood cells. Esophagogastroduodenoscopy revealed gastritis and grade 2, moderately sized esophageal varices that were not actively bleeding. A CT scan of the abdomen showed hepatosplenomegaly, ascites and thickening of the colonic mucosa with a patent portal sytem (Figure 1). Colonoscopic biopsy of the colonic mucosa was normal. An HIV 1/2 ELISA test was negative and hepatitis serology revealed previous exposure to h...

Background Recently published analysis of contemporary atrial fibrillation (AF) cohorts showed an association between digoxin and increased mortality and hospitalizations, however other studies have demonstrated conflicting results. Many AF cohort studies did not or were unable to examine racial differences. Our goal was to examine risk factors for hospitalizations and mortality with digoxin use in a diverse real-world AF patient population and evaluate racial differences. Methods and Results We performed a retrospective cohort analysis of claims data for Medicaid beneficiaries, aged 18 – 64 years, with incident diagnosis of AF in 2008 with follow up until December 31, 2009. We created Kaplan Meier curves and constructed multivariable Cox proportional-hazard models for mortality and hospitalization. We identified 11,297 persons with an incident diagnosis of AF in 2008, of those, 1, 401 (12.4%) were on digoxin. Kaplan Meier analysis demonstrated an increased risk of hospitalization with digoxin use overall and within race and heart failure groups. In adjusted models, digoxin was associated with an increased risk of hospitalization (aHR=1.54; 95% CI=1.39 – 1.70) and mortality (aHR=1.50; 95 % CI=1.05 – 2.13). Overall, African Americans had a higher risk of hospitalization but similar mortality when compared to whites regardless of digoxin use. We found no significant interaction between race and digoxin use for mortality (p=0.4437) and hospitalization (p=0.7122). Conclusions Our study demonstrates an overall increased risk of hospitalizations and mortality with digoxin use but no racial/ethnic differences in outcomes were observed. Further studies including minority populations are needed to critically evaluate these associations.

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