Summer 2011 - Volume 15 Number 3

Original Research and Contributions

Black Men Have Lower Rates Than White Men of Biochemical Failure with Primary Androgen-Deprivation Therapy
Pejvak Sassani, MD; Jeremy M Blumberg, MD; T Craig Cheetham, PharmD, MS; Fang Niu; Stephen G Williams, MD; Gary W Chien, MD
Black men have a higher incidence of advanced stage at diagnosis and mortality from prostate cancer. From the Kaiser Permanente Southern California Cancer Registry 681 men with prostate cancer on androgen deprivation therapy from 1/2003 to 12/2006 were studied. Black men were the only group with a lower risk of treatment failure compared to whites. Although the etiology of this finding is unclear, it suggests the possibility that prostate cancer in black men may be more androgen sensitive.

Building Teams in Primary Care: What Do Nonlicensed Allied Health Workers Want?
George W Saba, PhD; Stephanie Taché, MD; Lisa Ward, MD, MScPH; Ellen H Chen, MD; Hali Hammer, MD
During semistructured interviews, 11 health coaches reflected on their yearlong experience in the teamlet model at an underserved urban primary care clinic. Emerging themes included: 1) responsibilities and roles varied from theoretical expectations of model, 2) communication and relationships were key to health-coach experience, 3) prior education and health care roles influenced the experience, and 4) there were systems and personnel obstacles to model effectiveness.

Coffee, Caffeine, and Risk of Hospitalization for Arrhythmias
Arthur L Klatsky, MD; Amatul S Hasan, MD; Mary Anne Armstrong, MA; Natalia Udaltsova, PhD; Cynthia Morton, MD
From data on the coffee habits of 130,054 people, this study assessed coffee-related risk in 3137 persons hospitalized for cardiac arrhythmia and caffeine-related risk in an 11,679-person subgroup with data about other caffeine intake. The adjusted hazard ratio for any arrhythmia was 1.0 for <1 cup/day, 0.9 for 1–3 cups/day, and 0.8 for >4 cups/day. Results were similar for persons with history or symptoms of possible cardiorespiratory disease and for those without such history or symptoms.

Optimizing Treatment of Intra-amniotic Infection and Early-Onset Postpartum Endometritis: Advantages of Single-Agent Therapy
Norma Stiglich, MD; Meredith Alston, MD; Simone vanSwam, MD
Intra-amniotic infection and early-onset postpartum endometritis occur in 9% of delivering patients at Denver Health Medical Center, the safety-net hospital for the city and county. In this retrospective study of 337 patients, 185 received the standard multi-agent antibiotic regimen and 152 received a single-agent (ampicillin/sulbactam). The results support the use of a single-agent. These patients collectively received 558 fewer medication doses.

Virtual Visitation in the Neonatal Intensive Care: Experience with the Use of Internet and Telemedicine in a Tertiary Neonatal Unit
CL Yeo, MD; Selina KY Ho, MD; KC Khong, RN, BHSN; YY Lau, RN, BHSN
Families of newborns requiring prolonged neonatal intensive care faced emotional and financial difficulties. To evaluate Internet-based telemedicine, eligible newborns were identified and written consent was obtained before a Web camera was installed by the baby's cot. Using the child specific, confidential password, families viewed real-time video images of their newborns through a secure portal via an Internet browser or third-generation (3G) phone. Virtual visitation was well accepted by families.

Building a System of Care: Integration across the Heart Failure Care Continuum
Jackie Cawley, DO; Cassandra Cote Grantham, MA
Disparate heart failure (HF) services existed across MaineHealth until an interdisciplinary joint HF workgroup was convened and created a comprehensive set of strategies that better linked HF activities and care settings across the health system, which resulted in: better communication, coordination, reliability, and standardization of HF care; improved readmission rates for Medicaid/Medicare (18.5% to 12.7%); increased prescribed ACE inhibitors (77% to 96%); smoking cessation counseling (77% to 97%); and completed discharge instructions (65% to 87%).

Qualitative Assessment of the Impact of Implementing Reiki Training in a Supported Residence for People Older Than 50 Years with HIV/AIDS
Lewis Mehl-Madrona, MD, PhD, MPhil; Nita M Renfrew; Barbara Mainguy, MA
Reiki is a Japanese form of energy healing popular in the US. The authors set out to implement a program to train clients of a supported residence in Brooklyn, NY. who were all older than age 50 years and had HIV/AIDS and substance-abuse and/or mental-health disorders. A qualitative, narrative-inquiry study was conducted. Stories were collected from 35 participants who all reported benefit, many with life-changing experiences, from participation in Reiki and training that can be successfully implemented in this population.

Special Report

Hospital Medicine's Evolution: Literature Search and Interview Study with Practices
Ruth Greenwald, MA, MS; Marianne Novelli, MD; Tom Lorence, MD
In the early years of hospital medicine, research focused on clinical outcomes, efficiency, and cost effectiveness. Increasing attention now is on the patient and hospitalist experience. A literature search was used to develop a semistructured interview guide with Kaiser Permanente (KP) hospitalists and physician leaders and KP experts. Factors influencing sustainability include scheduling, workload, comanagement responsibilities, and recruitment and retention. Respondents viewed themselves as the center of a web involving communication with patients, other physicians, nurses, and other hospitalists.

Review Articles

The Role of Minimally Invasive Surgery and Outcomes in Colorectal Cancer
David S Kwon, MD; George J Chang, MD, MS, FACS, FASCRS
Robotic rectal surgery has recently emerged as an attractive alternative to laparoscopic surgery because it allows for superior visualization within a narrow pelvic field and more precise dissection. Studies of robotic rectal resection have suggested similar or potentially improved short-term oncologic outcomes when compared with laparoscopic rectal resection.

Improving Diagnostic Reasoning to Improve Patient Safety
Alvin Rajkomar, MD; Gurpreet Dhaliwal, MD
Both clinicians and patients rely on an accurate diagnostic process to identify the correct illness and to craft a treatment plan. It is frequently assumed that clinical experience and knowledge are sufficient to improve diagnostic ability, but studies from fields where decision making and judgment are optimized suggest that additional effort beyond daily work is required for excellence. This article reviews the cognitive psychology of diagnostic reasoning and proposes steps to improve diagnostic accuracy.

Narrative Medicine

Retinal Drawing: A Lost Art of Medicine
LuAnn Dvorak, PhD, LPN; Stephen R Russell, MD
From 1958 to 1988, ophthalmologists created formal retinal (ocular fundus) drawings, a form of preoperative documentation. Drawings took from 30 minutes to 3 hours each to map retinal tears, detachments, and landmarks before surgical retinal detachment repair, and to rigorously educate the examiners in ocular anatomy and the use of the binocular indirect ophthalmoscope. Four of these recently found color drawings are presented.

Case Studies

The Treatment of Black Widow Spider Envenomation with Antivenin Latrodectus Mactans: A Case Series
Steven R Offerman, MD, FACEP, FACMT; G Patrick Daubert, MD, FACEP; Richard F Clark, MD, FACEP, FACMT
American poison control centers annually report over 2500 black widow spider bites, which cause severe pain, muscle cramping, abdominal pain, and back pain, often refractory to traditional analgesics. One of the four cases reported here was managed without antivenom, and three were treated successfully with antivenin, demonstrating safe and effective use.

Acute Myocardial Infarction due to Coronary Artery Embolism in a Patient with a Tissue Aortic Valve Replacement
Joel T Levis, MD, PhD, FACEP, FAAEM; Geoffrey Schultz, MD; Philip C Lee, MD, FACC
This case presents a 50-year-old man who underwent a tissue aortic valve repair 4 years before presenting to the Emergency Department with an ST-segment elevation myocardial infarction. The patient was successfully treated with percutaneous transluminal coronary angioplasty and aspiration thrombectomy.

Clinical Medicine

Image Diagnosis: Pneumomediastinum
Charlene Kiang, MD; Gus Garmel, MD, FACEP, FAAEM
An adolescent girl, age 14 years, presents to the Emergency Department after one week of cough with chest pain, neck pain, and shortness of breath. Pneumomediastinum can occur because of the increased pressures seen with sneezing, coughing, vomiting, and the valsalva maneuver.


Climate Change: It's Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure
Carol Havens, MD; Jeffrey Mallin, MD
A drastic climate change has occurred in health care with effects visible on the education, training, certification, and accreditation systems of physicians throughout the US. Continuous professional development and assessment are the basis of new faces in these areas. New forms of CME include: "just-in-time learning" in the work setting or online; problem-based, team and systems learning, and change; and multi-interventional, experiential, and/or self-assessed curricula for complex areas of practice.

Innovation in Our Nation's Public Hospitals: Three-Year Follow-Up Interview with Five CEOs and Medical Directors—Part 2
Tom Janisse, MD
This is Part 2 of a two-part conversation with leaders (Table 1) from four hospitals and systems who participated and attended the 2010 annual meeting of the National Association of Public Hospitals in Boston, MA. Part 1 appeared in the Winter 2011 issue of The Permanente Journal.


When Disaster Strikes, Humanity Becomes our Patient
Robert T Hughes, MD, Patricia Trantham, MD
I volunteered at a hospital in Haiti for one week in the month following the disastrous earthquake of January 12, 2010. This article discusses natural disasters in general with a focus on earthquakes, and the geography and timing of patient presentation.  I will also discuss the role of family physicians in disaster response, and share my own experience as a resident family doctor.

Book Reviews

Connected for Health: Using Electronic Health Records to Transform Care Delivery
Louise L Liang, Editor; Review by Robert W Hogan, MD

The Voice: Overcome Negative Self-Talk and Discover Your Inner Wisdom
Brian Alman, PHD; Review by Albert Ray, MD

Soul of the Healer

Original Visual Art

"Healing Evil Possession"
Mohamed Osman, MD

"Closing Pause"
Thomas Paluch, MD

"Namibia, Sossusvlei Dunes, 2009"
Stuart Hahn, MD

On The Cover

"Sunrise in the Columbia Gorge"
Peter Andrade


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