Winter 2009 - Volume 13 Number 1

Original Articles

Improving D-dimer Positive Predictive Value for Outpatients with Suspected Deep Vein Thrombosis
Craig M Nelson, PhD, CLS; Geary S Wright, BA, MLT; Tom R Silbaugh, CPT; Louis J Cota, CLS
In a retrospective review, 1015 continuous patients with suspected deep vein thrombosis (DVT) were clinically evaluated in a laboratory with a D-dimer assay: 503 with a bioMérieux system and 512 with a Trinity Biotech system. With the Trinity Biotech assay, specificity increased from 41.3% to 66.9%, positive predictive value increased 2.3 times from 8.8% to 20.0%, and the probability of DVT increased from 25% to 38%. A significant number of unneeded compression ultrasounds were saved.

From Our Lips To Whose Ears? Consumer Reaction to Our Current Health Care Dialect
Murray Ross, PhD; Toyomi Igus; Sophia Gomez
Every profession spawns a dialect, however, this qualitative study, conducted with consumers from Boston, New York City, St Paul, Billings, and San Diego, revealed a tremendous gap between what health care professionals say and what health care consumers hear. Negative language associations for consumers include: "medical decision support," "guidelines," "integrated care," "evidence-based medicine," and "best practices." Positive language associations include: "communication," "treatment," and "coordination."

Review Articles

Blood-Management Programs: A Clinical and Administrative Model with Program Implementation Strategies
Christopher Tokin; Jose Almeda, MD; Saurabh Jain, MD, MRCS; Jennifer Kim; Randy Henderson; Mitra Nadim, MD; Linda Sher, MD; Robert R Selby, MD
Blood-management programs ensure that patients can access treatment without having to forfeit their beliefs, through an enlightened approach to medical and surgical treatment that can be used to benefit the Jehovah's witness population and the general population. The authors review a comprehensive approach to blood conservation, including acute normovolemic hemodilution simultaneous removal of the patient's blood and its replacement with a nonblood product.

Medical, Surgical, and Endoscopic Management of Gastroesophageal Reflux Disease
Deron J Tessier, MD
This article reviews the pathophysiology, presentation, workup, treat-ment, and emerging therapies for GERD with an emphasis on surgical management and outcomes to help primary care physicians have a better understanding of the role of surgery in this complex disease.

National Practice Recommendations for Hematuria: How to Evaluate in the Absence of Strong Evidence?
Ronald Loo, MD; Joel Whittaker, MPH; Violeta Rabrenivich, MHA, CHIE
Hematuria is one of the most common conditions confronting clinical urologists, and generalists, however the existing lack of scientific evidence has created variations in clinical practice. Consequently, many patients with microscopic or gross hematuria undergo low-yield workups that include invasive testing and imaging with radiation. As a response, a national group of KP urology chiefs developed national practice recommendations.

Laparoscopic Surgery for Rectal Cancer
Adrian Indar, MD, MBBS, FRCS, DM; Jonathan Efron, MD, FACS, FASCRS
Because of the confined space within the pelvis, laparoscopic surgery for rectal cancer is much more challenging than that for colon cancer, particularly maintenance of resection margins. Nonrandomized studies have shown both that it produces short-term outcomes equivalent to open surgery, performed safely from an oncologic perspective. This review summarizes the technical considerations, early outcomes, late outcomes, costs, and complications.

Case Studies

This is an unusual case of a user, age 56 years, of crack cocaine who presented with progressive dyspnea of subacute duration. One prior case report describes the development of a pleural effusion via an eosinophilic process. In contrast, in this patient the most probable mechanism is that crack cocaine induced a prothrombotic state that promoted formation of pulmonary emboli
Recognition of Kawasaki Disease
Janelle R Cox, MD; Robert E Sallis, MD
One of the most common vasculidities of childhood is the leading cause of acquired heart disease in children in the US. Though it should be included in the differential diagnosis for any child with prolonged fever that is unresponsive to antibiotics, the diagnosis is often difficult in that the symptoms tend to present at different times, and require multiple examinations on different days.

Clinical Medicine

The B-SMART Appropriate Medication-Use Process: A Guide for Clinicians to Help Patients—Part 1: Barriers, Solutions, and Motivation.
Elizabeth Oyekan, PharmD, FCSHP; Ananda Nimalasuriya, MD; John Martin, MD; Ron Scott, MD; R James Dudl, MD; Kelley Green, RN, PhD
This multifaceted approach used before, during, and after any patient-clinician interaction creates a consistent method to help patients more effectively use their medications. Elements include: involving patients in the decision-making, simplifying dosage regimens, education about the medication, self-management training, ongoing reinforcement and motivation, and positive relationships. Concrete solutions are provided to nine common practice challenges, including: forgetfulness, literacy, denial, financial, depression, and lack of knowledge.

Image Diagnosis: Foot Fractures
Gus M Garmel, MD, FACEP, FAAEM
Although it may be difficult to see a Lisfranc foot fracture, significant force is needed to disrupt and dislocate this strong joint which stabilizes the midfoot. Calcaneus fractures, also the result of significant force can be associated with vertebral body fractures of the spine.

Corridor Consult
Evaluation of Hypertension with Hypokalemia
Antoine C Abcar, MD; Dean A Kujubu, MD
Hypertension that remains in poor control despite the use of many medications is a difficult problem that every primary care physician has faced. This article focuses on those less common causes of hypertension with hypokalemia—essential hypertension with diuretic use, primary aldosteronism, Cushing's syndrome, pheochromocytoma, renal vascular disease, and malignant hypertension.


SCPMG University: Helping New Physicians Adapt and Succeed
Jeffrey Weisz, MD; Nancy H Spiegel, MS
An individual's first few months with an organization are crucial. During that period, professionals develop a sense of what is important, what the organization expects from them, and what they can expect in return. Mean scores, from first-year, pre- to postprogram surveys, improved significantly on 11 of 14 items demonstrating the success of the University program in helping physicians adapt to their new positions, thus laying the foundation for a successful career within the medical group

At a Decade: Centers of Excellence in Culturally Competent Care
Melanie Tervalon, MD, MPH
Rapidly increasing national racial and ethnic diversity calls for interventions that are culturally specific to improve patients' health outcomes and to eliminate health disparities. Kaiser Permanente developed nine innovative Centers of Excellence in Culturally Competent Care that are population-based, data-driven research projects that unravel and explain the dynamic processes by which culture, race, and ethnicity interact in health care delivery settings

Narrative Medicine

Narrative-Based Medicine: Potential, Pitfalls, and Practice
Vera Kalitzkus, PhD; Peter F Matthiessen, MD, PhD
With the evolution of "modern" medicine, narratives were increasingly neglected in favor of "facts and findings," regarded as more scientific and objective. Now—through understanding the narrative structure of medical knowledge, and narrative-oriented, physician-patient relations—narratives from social science research and medical practice and patient encounters are a source of knowledge for evidence, beyond the gold standard of randomized controlled trials of evidence-based medicine. This is a systematic overview of narrative-based medicine—background, narrative genres, and application in theory, research, and medical practice.

The Desert Doctor
Tom Debley
This is the first chapter from the new book published by The Permanente Press­—The Story of Dr Sidney R Garfield: The Visionary Who Turned Sick Care into Health Care—documenting the creation of Kaiser Permanente by cofounders Sidney Garfield and Henry J Kaiser. This biography, focuses, for the first time, on Sidney Garfield's story and vision.

Book Reviews

Period. A Girl's Guide
Karen Azani

Soul of the Healer

Original Visual Art

Samir Johna, MD, FACS

"Child is the Father of the Man"
Marsha Balian, NP

Stuart Hahn, MD

"Household Saints of Dubious Virtue"
Marsha Balian, NP In Memoriam

Tribute to Robert Hippen, MD
Jeffrey Brown

Honorable Mention
Robert Hippen, MD

Old Man Waiting at a Bus Stop
Robert Hippen, MD

On The Cover

As Time Goes By


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