Summer 2009 - Volume 13 Number 3

Original Articles

5-2-1–Almost None: Parents' Perceptions of Changing Health-Related Behaviors in Their Obese Child
Michael Campbell, PhD, LCSW; Jane M Benton, MD; Lloyd N Werk, MD, MPH
Clinical guidelines to prevent childhood overweight and obesity are clear but parents' perception of these key messages are less clear. Parents from 193 families indicated the importance of changing eating habits and increasing physical activity (63%), however eliminating sugary drinks (4%) was the only actionable behavior in the 5-2-1–Almost None message parents felt significantly more confident they could achieve.

Using Implementation and Dissemination Concepts to Spread 21st-Century Well-Child Care at a Health Maintenance Organization
Arne Beck, PhD; David A Bergman, MD; Alanna K Rahm, MS; James W Dearing, PhD; Russell E Glasglow, PhD
Twenty-First Century Well-Child Care is a parent-centered, team-based, primary care model that includes online previsit assessments, facilitated through a Web-based diagnostic, management, tracking, and resource information tool. Validated models of team-based health care have multiple components that must be made compatible with complex sociotechnical systems-- interpersonal communication, work, coordination, and judgment

Use of a Computerized Medical Database and Reminder Letters to Increase Preventive Care Use in Kaiser Permanente Patients
Cecily Y L Ling, MD; Eric Kajioka, MD; Van Luu, MD; Wipat Phanthawimol, MD; Hitoshi Honda, MD; Linda Kuribayashi, MD
Patients not seen by their primary care physician in more than one year ("low-utilizing patients") and overdue for preventive health care services were identified using Kaiser Permanente's electronic medical database. Outreach letters that target these patients may be an efficient and cost-effective way of improving patient use rates of preventive health care

Reducing Newborn Office Visits and Improving Satisfaction through Parent Education and Learning Communities
Andrea Rudominer, MD, MPH
A pilot program targeted at parents of newborns tested the hypothesis that education, specifically group education with phone follow-up, could reduce unnecessary newborn office visits while simultaneously increasing member satisfaction. Satisfaction was significantly higher in the intervention group, and there were 52% fewer unnecessary visits by parents, with even greater reduction in visits among those participating in at least one follow-up conference call

Nursing Responses to Transcultural Encounters: What Nurses Draw on When Faced with a Patient from Another Culture
Celeste Cang-Wong, RN, MS Candidate; Susan O Murphy, RN, DNS; Toby Adelman, RN, PhD
In exploring nurses' experiences when they encounter patients from cultures other than their own and their perception of what helps them deliver culturally competent care, this research confirmed that nurses are drawing heavily on prior experience, including family experiences and experiences with friends and coworkers from different cultures. Schools of nursing are also providing valuable preparation for working with diverse populations

Review Article

Laparoscopic Repair of Incisional and Other Complex Abdominal Wall Hernias.
Randall O Craft, MD; Kristi L Harold, MD
Incisional hernia is one of the most common complications of abdominal surgery, with a reported occurrence rate of up to 20% after laparotomy, and with recurrence rates after primary repair reported to range from 24% to 54%. This review discusses standardized, well-researched techniques, and the group's surgical experience that have contributed to lowering reported recurrence rates after laparoscopic ventral hernia repair to <10%


Interview with Lawrence Weed, MD--The Father of the Problem-Oriented Medical Record Looks Ahead
Lee Jacobs, MD
During this interview, Dr Weed describes his electronic tool for applying medical knowledge to patient data--"coupling"--to aid the accuracy and completeness of diagnostics and treatment. In addition, he describes his view of the failing of the current medical education system, which fosters a misplaced faith in the efficacy of a physician's intellect

Biostatistics 101: Understanding Data
David Etzioni, MD, MSHS; Maher A Abbas, MD, FACS, FASCRS
Research studies can generate complex data and results that require analysis to demonstrate the effect of therapies and interventions, to establish the efficacy or limitation of treatments, and to prove or to refute a scientific hypothesis. An understanding of biostatistics is critical to the researcher investigating clinical questions. Equally important is an appreciation of statistics by the reader and interpreter of published studies. This article, the first of a three-part series on statistics for clinicians, notes: types of data: quantitative (continuous or discrete) and qualitative (ordered or discrete); and describes data as measurements of the center and the distribution

Case Studies

Successful Treatment with Intravenous Immunoglobulin of Acute Flaccid Paralysis Caused by West Nile Virus
Mohammad Sami Walid, PhD; Fade Aziz Mahmoud, MD
West Nile virus is one of the leading causes of insect-borne encephalitis and acute flaccid paralysis in the US. Acute flaccid paralysis manifests itself as a Guillain-Barré-like syndrome with generalized weakness and shortness of breath. We report a case involving a patient who presented with acute flaccid paralysis because of West Nile virus infection and was successfully treated with intravenous immunoglobulin from Israeli donors

Responding to the Language Challenge: Kaiser Permanente's Approach
Kate Meyers, MPP; Gayle Tang, MSN, RN; Alicia Fernandez, MD
A qualitative case study of the Kaiser Permanente San Francisco Medical Center's approach to developing linguistic access services and subsequent organizationwide initiatives: language-specific care modules focused on Chinese- and Spanish-speaking patients, a centralized Multicultural Services Center, improving interpreter services, optimizing use of bilingual staff, and creating a translation infrastructure

Clinical Medicine

Image Diagnosis: Abnormal Plain Films from the Emergency Department
Gus M Garmel, MD, FACEP, FAAEM
In image 1, acute epiglottitis looks like a thumbprint at the level of the hyoid bone. Although now relatively rare in children, it can occur in adults and remains an airway emergency. In image 2, free air under both hemidiaphragms is an ominous sign. Although it may be present in postoperative patients and has been reported following vigorous sexual activities

Acute Phosphate Nephropathy
Antoine Abcar, MD; Aviv Hever, MD; Jasminder S Momi, MD; John J Sim, MD
The risk for acute phosphate nephropathy is increased in patients with underlying chronic kidney disease, older age, and female sex; in patients taking angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, diuretics, nonsteroidal anti-inflammatory drugs; and after exposure to sodium-phosphate bowel-cleansing solutions

The Importance of Accurate Blood Pressure Measurement
Joel Handler, MD
The most important commonly performed office test is blood pressure measurement, yet it is considerably undervalued. Populationwide, small inaccuracies in blood pressure measurement can have considerable consequences. Overestimating true blood pressure by 5 mm Hg would lead to inappropriate treatment with antihypertension medication in almost 30 million Americans, with attendant exposure to adverse drug effects, the psychological effects of misdiagnosis, and unnecessary cost.


East Asian Attitudes toward Death--A Search for the Ways to Help East Asian Elderly Dying in Contemporary America
Sok K Lee, MD, MA
Most people in the West and the East wish to die at home; however, about 50% of Americans die in acute care hospitals. For better care of the dying elderly, this article is written to help American physicians understand the unique aspects of East Asian Confucian Ethics--the relational autonomy of family, Confucian creative self-transformation, and the unity of transcendence and the human being

SERVE Ethiopia
Phillip J Tuso, MD, FACP
The incidence of chronic kidney disease in Ethiopia is rising because of high blood pressure and diabetes mellitus; End Stage Renal Disease remains mostly fatal. Treatment considered the norm in industrialized countries is limited in Africa--dialysis is dependent on the availability of funding and charitable contributions; few governments cover the cost of renal replacement therapy

The World Health Organization's Evidenced-Based Approach to Chronic Diseases: Primary Prevention or Caring for End-Stage Disease?
Several hundred evidence-based (EB), national and global Clinical Practice Guidelines have been mapped by the World Health Organization (WHO) in the past ten years, allowing simulation and analysis of the health services' resource requirements of various countries. This approach reflects a balance between primary prevention interventions (eg, as demonstrated for hypertension and diabetes) and investing in ongoing EB Medicine treatment. Examples are cited from personal experience with WHO initiatives in Kyrgyzstan and Mexico

The Perfect System
George Halvorson
Health care needs and deserves the perfect computer system. Here are ten criteria, detailed in a chapter from Health Care Will Not Reform Itself, for that ultimate American health care database system design: 1) patient focused, 2) complete, 3) accessible by all relevant parties, 4) current, 5) easy to use, 6) linked to care improvement programs, 7) accessible to patients as well as caregivers, 8) transportable, 9) interoperable, 10) confidential

Book Reviews

House Calls
A film by Ian McLeod; produced by Gerry Flahive
Review by Richard Della Penna, MD

Review by Vincent J Felitti, MD, FACP

Soul of the Healer

Original Visual Art

"Zion 3 – Along the River Walk"
Fred M Freedman, MD

"Grand Teton Range"
Gary Larsen

"Six Tulips"
C Shore

"Le Café Jaune"
C Shore

On the Cover

Diagnosis: Atrial Flutter
Pattie Palmer-Baker


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