Winter 2011 - Volume 15 Number 1

Original Research and Contributions

Survey Respondents Planning to Have Screening Colonoscopy Report Unique Barriers
Jennifer Vincent, DO; Angela K Hochhalter, PhD; Kristine Broglio, MS; Andrejs E Avots-Avotins, MD, PhD
Scott & White Health Plan, a health maintenance organization, surveyed 4000 members with a response rate of 31%. Men and women of all ages reported similar barriers to colonoscopy, but barriers differed between those planning a colonoscopy within six months and those not. The most commonly identified barrier across groups was lack of physician recommendation.

Multiple Health Behaviors in an Ethnically Diverse Sample of Adults with Risk Factors for Cardiovascular Disease
Katie M Heinrich, PhD; Jay Maddock, PhD
Results of a 3607-person, random-digit-dial telephone survey (6% diabetes, 16% hypertension, 16% high cholesterol, and 19% obesity) demonstrated that different eating-and-activity behaviors predicted each of the four medical conditions: not eating a healthy diet predicted diabetes; not eating a healthy diet and no vigorous physical activity predicted hypertension; consumption of high dietary fat and fast food predicted high cholesterol; and not eating a healthy diet, high consumption of dietary fat, not eating breakfast, and not performing vigorous physical activity, but less consumption of fast food, predicted obesity. Ethnic differences existed.

The Relationship of Unemployment and Depression with History of Spine Surgery
Mohammad Sami Walid, MD, PhD; Nadezhda Zaytseva, PhD
A retrospective chart review of 629 persons who underwent inpatient spine surgery between the ages of 25-65 showed 29% unemployed and 32% with a history of depression. Unemployment was more common among depressed patients, and depression was more common among unemployed patients. A history of prior spine surgery was most prevalent in unemployed female patients with a history of depression.

Behaviorally Supported Exercise Predicts Weight Loss in Obese Adults Through Improvements in Mood, Self-Efficacy, and Self-Regulation, Rather Than by Caloric Expenditure
James J Annesi, PhD
Adults with severe obesity (n = 137) entered a 26-week exercise-support and nutrition-education treatment based on social cognitive theory. Measures included: mood, self-regulation, and self-efficacy. Changes in total mood disturbance and exercise self-efficacy were significantly related to changes in self-efficacy to control emotional eating. Only 12.4% of the observed weight change was accounted for through associated caloric expenditures. Exercise may support weight loss primarily through psychological rather than physiological pathways.

Practice Leaders Programme: Entrusting and Enabling General Practitioners to Lead Change to Improve Patient Experience
Marion Lynch, PDHSc, MSc,PgCMed Ed, PgCStComm RGN RMN; Nigel McFetridge, MB, BCh, MRCGP, DFPHM
In a region of social deprivation and quality underperformance in the United Kingdom, 19 new and experienced general practitioners entered a yearlong, narrative and complex systems program to: support change in leadership thinking and practice, facilitate practice-led service improvement, support career development, and contribute to extended GP specialty training. Statistically significant increases occurred in leadership competencies, services and care, confidence and changed culture.

Implementation Study­­­ —Vohs National Quality Award
Community Implementation and Translation of Kaiser Permanente's Cardiovascular Disease Risk-Reduction Strategy
Winston Wong, MD, MS; Marc Jaffe, MD; Michelle Wong, MPH, MPP; R James Dudl, MD
Forty-six clinics at community health centers and in public hospital/health systems in California initiated Kaiser Permanente's (KP) cardiovascular disease (CVD) risk-reduction program. Success included: 2245 patients received at least 1 of the 3 cardiovascular medications within 18 months, demonstrating successful translation of the strategy to the non-KP community. This may be a model for spread of CVD prevention measures, and prevention programs for other diseases, to all populations throughout the US.

Implementation Study
Implementation and Methodology of a Multidisciplinary Disease-State-Management Program for Comprehensive Diabetes Care
Catherine Antoline, PharmD; Amy Kramer, PharmD; Mark Roth, MD
Within one year, this regional multidisciplinary Diabetes Mellitus disease-state management intervention resulted in improvements in blood pressure (BP), lipid levels, and glycemic control as indicated by 2009 HEDIS scores. Main contributors included: the BP service run by licensed practical nurses, dedicated panel-management time, use of a multidisciplinary team, and expanding treatment beyond glucose control to include BP and lipid management.

Maintaining Optimal Oxygen Saturation in Premature Infants
Yoke Yen Lau, RN, BHSN; Yih Yann Tay, RN, BHSN; Varsha Atul Shah, MD, MBBS, MRCP; Pisun Chang, RN; Khuan Tai Loh, PEN
Advances in technology have resulted in increasing survival rates for premature infants. Oxygen therapy is commonly used in neonatal units as part of respiratory support. The number of premature infants in our institution surviving with severe (stage ≥3) retinopathy of prematurity (ROP) prompted a review of oxygen therapy as a contributing factor. Prolonged exposure to high concentrations of oxygen may cause irreversible damage to the eyes of very-low-birth-weight preterm infants and is a potential cause of blindness.

Nurse Empowerment from a Middle-Management Perspective: Nurse Managers' and Assistant Nurse Managers' Workplace Empowerment Views
Loretta C Regan, RN, MS; Lori Rodriguez, RN, PhD
Nurse managers (NMs) and assistant nurse managers (ANMs) play an essential role in creating an empowering work environment for their staff. Empowerment is defined as the ability to get things done and includes a capacity to mobilize resources and to provide support, opportunity, and information. Additionally, for NMs and ANMs to be able to empower others, management must provide access to resources.

Special Reports

Making the Hospital Safer for Older Adult Patients: A Focus on the Indwelling Urinary Catheter
Eric A Lee, MD; Camille Malatt
The insertion of an indwelling urinary catheter (IUC) can cause iatrogenic complications: urosepsis, delirium, functional impairment. Thoughtful and judicious use of the IUC, such as minimizing catheterization, either by not inserting it or removing it as soon as not needed, will most likely reduce inpatient morbidity and improve the health of the hospitalized older adult.

Sustaining Primary Care Practice: A Model to Calculate Disease Burden and Adjust Panel Size
Belinda Potts; Ronald Adams, MD; Mark Spadin
Facing severe staffing shortages in a primary care physician group with very large patient panels, resulting in physician burnout, the group identified six chronic diseases in a new Permanente Online Interactive Network Tool to determine the disease burden of each physician's panel. In a new delivery structure physicians are partnered on a team with a nurse practitioner who successfully supports them.

Review Article

Surgical Care in Jamaica in the Laparoendoscopic Era: Challenges and Future Prospects for Developing Nations
Joseph Martin Plummer, DM; Patrick Oral Roberts, DM; Pierre Anthony Leake, DM; Derek Ian Mitchell, DM, FACS
Challenges developing countries face in an era of technology-dependent surgery are being addressed at the University of the West Indies where a combination of fellowship-trained team leaders and partnerships with resource-rich institutions promises to meet their health care needs.

Case Study

Candida Mastitis: A Case Report
Louisa Hanna, MD, Stacie A Cruz, MD
Breastfeeding has many benefits for both mother and child. Nipple pain is a common complaint, and second most common cause of breastfeeding discontinuation in the first six months. This case report addresses the characteristics of breast pain induced by Candida mastitis and the risk factors for and treatment of mastitis.

Clinical Medicine

ECG Diagnosis: Monomorphic Ventricular Tachycardia
Joel T Levis, MD, PhD, FACEP, FAAEM
The differential diagnosis of a wide-complex regular tachycardia includes supraventricular tachycardia (SVT) with intraventricular aberrant conduction, SVT conducting to the ventricles over an accessory pathway, and ventricular tachycardia (VT).The most common causes of VT are ischemic heart disease, acute myocardial infarction, and prior VT.

Image Diagnosis: Shoulder Dislocations
Shoreh Kooshesh, MD; Gus M Garmel, MD, FACEP, FAAEM
Anterior, posterior, and inferior shoulder dislocations are imaged in multiple planes with mini-summaries of signs and treatments.


Confessions of a Wilderness Fellow: I Can't Live Without My Smartphone, Can You?
Anil Menon, MD
Recent experiences in Haiti revealed the indispensable nature of a smartphone: core medical programs were especially important in the fast-moving, low-infrastructure environment; contacting other physicians or transferring patients difficult without text messaging; storing and organizing thousands of PDF references for immediate use or teaching; and storing pictures of physical examination findings.

Social Media and the Health System
Ted Eytan, MD, MS, MPH; Jeffrey Benabio, MD; Vince Golla; Rahul Parikh, MD; Sara Stein, MD
As early as 1960, Sidney Garfield, MD, the co-founder of Kaiser Permanente (KP), foresaw how computers would become powerful tools to help patients. It is in his maverick spirit that we examine the potential for social media to be powerful tools to help our patients today. Social media, or content created and exchanged within virtual communities through the use of online tools, are used by millions of people to converse and to connect. Health systems can use social media to engage members and potential members by building trust and making large organizations more accessible and approachable. Social media can help patients manage their chronic conditions and make healthy choices; it also can accelerate knowledge acquisition and dissemination for patients and clinicians.


Innovation in Our Nation's Public Hospitals: Three-Year Follow-Up Interview with Five CEOs and Medical Directors—Part 1
Tom Janisse, MD
Revisiting leaders from four hospitals systems, this interview includes comments on community interventions (a health fair that offered testing for prostate cancer); the relationship between community clinics and the hospital (a medical respite and mobile video translation conferencing); system integration (wellness programs for people who frequent the system and a nurse practitioner-staffed "bridge clinic"); and integration of people in the system (primary care-specialty care referrals, and multidisciplinary teams).

Letters to the Editor

Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index and Its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes
Although I wholeheartedly agree with Dr Felitti that providing basic education, alone, has not made even a dent in the obesity problem, I also have concerns with several of his statements made in his Letter to the Editor, which appeared in the Fall 2010 issue. Some issues may have their basis in my being a behavioral scientist (focused on health behavior change) within the emerging field of health psychology. For example, his concern that we, "and with many others," lack focus on "Why these children became obese …" seems to be indicative of a common criticism of behaviorists who, admittedly, are more concerned with obtaining sustained behavioral changes than dwelling on possible underlying psychological factors.

Narrative Medicine

HAITI: The Kaiser Permanente Experience—Part 2

Personal Stories

Sarah Beekley, MD
This is a collection of stories of medical volunteers whose lives are changed forever by: walking the line; band-aids for hemorrhage; everybody got something; "Good afternoon, my friends"; fear of eating fish; the place where vegetables grow; a four year old with hydrocephalus; childrens Tylenol, creams, pills, and Vicks Vaporub; and things you'll never again take for granted.

Letter Home
Randy Bergen, MD

Kimberly H Kim, MD

Walking The Line
Debra A Cohen, MD

Getting Back
Pascale Vermont Evers, PhD, CT

Bonswa, Mes Amis
Brian Hertz, MD

February 1, 2010
Suzy Fitzgerald, MD

Lessons from Haiti
Sai Praveen Haranath, MBBS, MPH, FCCP

Haiti Journal
Paula J Pearlman, MD

The Baby
Lydia S Segal, MD, MPH

Day By Day in Haiti
Joshua B Weil, MD

Book Reviews

The Poisoner's Handbook
Deborah Blum
Book review by Albert Ray, MD

The Lived Experience of Violation: How Abused Children Become Unhealthy Adults
Anna Luise Kirkengen, MD, PhD
Book review by David D Clarke, MD

Soul of the Healer

Original Visual Art

"Hippo Pod Watching"
David Clarke, MD

"Pathos of the Dispossessed"
Lorenzo Mills, MD

"Combatting the Chill"
Philip R Brunner, MD

"Self Portrait"
Mark DuLong, MD

On The Cover

"Pigeon Point Light"
Steve Henry, MD,


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