Fall 2016 - Volume 20 Number 4


Diagnostic Prevalence of Ankylosing Spondylitis Using Computerized Health Care Data, 1996 to 2009: Underrecognition in a US Health Care Setting
Jeffrey R Curtis, MD; Leslie R Harrold, MD, MPH; Maryam M Asgari, MD, MPH; Atul Deodhar, MD; Craig Salman; Joel M Gelfand, MD, MSCE; Jashin J Wu, MD; Lisa J Herrinton, PhD
In the computerized data, 5568 adults had diagnostic codes indicating axial spondyloarthritis (axSpA). Observed prevalence in the Kaiser Permanente Northern California population, compared with national estimates for axSpA and ankylosing spondylitis, suggests there is substantial underrecognition of these conditions in routine clinical practice. However, use of computerized data is able to identify true cases of ankylosing spondylitis, facilitating population-based research.

CMESafe and Effective Implementation of Telestroke in a US Community Hospital Setting
Kori Sauser-Zachrison, MD, MSc; Ernest Shen, PhD; Navdeep Sangha, MD; Zahra Ajani, MD; William P Neil, MD; Michael K Gould, MD, MS; Dustin Ballard, MD; Adam L Sharp, MD, MS
A stepped-wedge cluster randomized trial of 10 community hospitals connected to 2 tertiary care centers via telestroke was implemented at each hospital incrementally over a 1-year period. Among 2657 patients, utilization of tissue plasminogen activator (tPA) increased from 6.3% to 10.9%, without a significant change in complication rates. Postintervention patients were more likely to receive tPA than were preintervention patients. Before implementation, 8 of the 10 community hospitals were significantly less likely to administer tPA than the highest-volume tertiary care center; however, after implementation, 9 of 10 were at least as likely to administer tPA.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program Analysis
Efstathios Karamanos, MD; Nathan Schmoekel, DO; Dionne Blyden, MD; Anthony Falvo, DO; Ilan Rubinfeld, MD
Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear. In this retrospective study, patients older than age 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). As American Society of Anesthesiology score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality. Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.

Preferential Use of Total Thyroidectomy without Prophylactic Central Lymph Node Dissection for Early-Stage Papillary Thyroid Cancer: Oncologic Outcomes in an Integrated Health Plan
Meena Said, MD; Michele Fujimoto, MD; Cara Franken, MD; Sunee Woo, MD; Brooke Vuong, MD; Philip I Haigh, MD, MSc, FRCSC, FACS
This retrospective cohort study of patients with clinically node-negative papillary thyroid cancer who underwent total thyroidectomy with or without prophylactic central lymph node dissection (pCLND) in Kaiser Permanente Southern California Region hospitals, between January 1996 and December 2008, identified 864 patients, 34 (3.9%) of whom underwent pCLND. The TNM (tumor, node, metastasis) stages for the 2 groups were not significantly different (p = 0.18). There were 23 (2.8%) recurrences in the no-pCLND group and 1 (2.9%) recurrence in the pCLND group (p = 0.95. Presently, routine pCLND is difficult to advocate in our medical system.

Standardizing Management of Adults with Delirium Hospitalized on Medical-Surgical Units
Clay Angel, MD; Kristen Brooks, MD; Julie Fourie
Delirium, common among inpatients aged 65 and older, is associated with multiple adverse consequences, including increased length of stay (LOS). However, delirium is frequently unrecognized and poorly understood. During a pilot from 9/2010 to 7/2012 (including 470 patients), a delirium management team included a redesigned role for consulting psychiatrists and a new clinical nurse specialist role. Electronic health record functions supported accurate problem list coding, referrals to the team, and standardized documentation. Average LOS decreased (8.5 to 6.5 days; p = 0.001) while average LOS for the Medical Center remained stable. The delirium team is an effective model that can be quickly implemented with few additional resources.

The Kaiser Permanente Northern California Adult Member Health Survey
Nancy Gordon, ScD; Teresa Lin, MPH
Between 1999 and 2011 the adult Health Plan membership became better educated and less non-Hispanic white. Compared with 1999, in 2011, the prevalence of self-reported diabetes and hypertension significantly increased in most age groups. There was a significant increase in the percentage of those age 25-64 years who considered their health to be very good or excellent, primarily among those with higher education. There was an increase in the percentage of adults who indicated that physical or emotional health problems interfered at least moderately with their daily activities.

Reduced Trauma Symptoms and Perceived Stress in Male Prison Inmates through the Transcendental Meditation Program: A Randomized Controlled Trial
Sanford Nidich, EdD; Tom O’Connor, PhD; Thomas Rutledge, PhD;Jeff Duncan; Blaze Compton, MA; Angela Seng; Randi Nidich, EdD
Trauma events are 4 times more prevalent in inmates than in the general public and are associated with increased recidivism and other mental and physical health issues. Inmates (N = 181) with a moderate- to high-risk criminal profile were randomly assigned to either a Transcendental Meditation (TM) program or to a no-treatment control group. Significant reductions in total trauma symptoms in the TM group were found compared with controls.

Voices of the "99 Percent": The Role of Online Narrative to Improve Health Care
Beth Sundstrom, PhD, MPH; Stephanie J Meier; Michael Anderson; Kathleen E Booth; Lacey Cooper; Ellie Flock; Jackelyn B Payne; Priya Hirway, ScM
Researchers conducted a qualitative content analysis of 2003 blog posts. Bloggers discussed medical crises and the role of injury and illness in maintaining financial solvency. Difficulty of obtaining health care and lack of accessible quality care emerged as themes. In particular, under- and unemployment limited access to health insurance coverage. Results suggest opportunities to address health care gaps of marginalized populations and to develop public health policy.

Trend of Decreased Length of Stay in the Intensive Care Unit (ICU) and in the Hospital with Palliative Care Integration into the ICU
Eluned Mun, MS, MSN, DNP, APRN-Rx, AGNP-BC, CCRN; Clementina Ceria-Ulep, PhD, RN; Lillian Umbarger, MD; Craig Nakatsuka, MD
A comparison between pre- and postintervention data in the Intensive Care Unit (ICU), incorporating palliative care into the routine ICU workflow, showed positive trends in measured outcomes, including increased early identification of advance directives, code status, and goals of care along with a decrease in the ICU length of stay and hospital length of stay. The number of ICU family meetings and palliative care consultations increased.

Development and Application of a Plant-Based Diet Scoring System for Japanese Patients with Inflammatory Bowel Disease
Mitsuro Chiba, MD, PhD; Kunio Nakane, MD, PhD; Yuko Takayama, RD; Kae Sugawara, MD; Hideo Ohno, MD; Hajime Ishii, MD, PhD; Satoko Tsuda, MD; Tsuyotoshi Tsuji, MD, PhD; Masafumi Komatsu, MD, PhD; Takeshi Sugawara, MD
A semivegetarian diet (a plant-based diet [PBD]) has been shown to prevent a relapse in Crohn disease. PBD scores were assigned according to the frequency of consumption provided on a food-frequency questionnaire, obtained on hospitalization for 159 patients with ulcerative colitis and for 70 patients with Crohn disease. Higher PBD scores indicated greater adherence to a PBD. The PBD scores in the ulcerative colitis and Crohn disease groups were 10.9 ± 9.5 and 8.2 ± 8.2, respectively. For patients with Crohn disease, those with long-term remission and normal C-reactive protein concentration were significantly more likely to have PBD scores of 25 or greater.

Accreditation Council for Graduate Medical Education Core Competencies at a Community Teaching Hospital: Is There a Gap in Awareness?
Mohammed Al-Temimi, MD, MPH; Michael Kidon; Samir Johna, MD, MACM
Physicians at the Kaiser Permanente Fontana Medical Center (480) were surveyed for their knowledge of ACGME core competencies before starting new residency programs. Of the 164 physicians who taught residents, 65 (39.7%) were unsure of their knowledge of the core competencies. However, most stated that they provided direct teaching to residents related to the knowledge, skills, and attitudes stated in each of the 6 competencies. Full-time faculty (teaching 10-12 rotations per year) were more likely to provide competency-based teaching. Discrepancy between knowledge of the competencies and acclaimed provision of competency-based teaching emphasizes the need for standardized teaching methods that incorporate the values of these competencies.

Anal Health Care Basics
Jason Chang, MD; Elisabeth McLemore, MD, FACS, FASCRS; Talar Tejirian, MD, FACS
Although countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags, most of which can be avoided by improving bowel habits. Adequate fiber intake is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases. This Special Report provides an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists.

Implementation of the YMCA Diabetes Prevention Program throughout an Integrated Health System: A Translational Study
Ron Adams, MD; Christopher J Hebert, MD, MS; Linda McVey; Roger Williams, MEd
This observational study focused on engagement, persistence, recruitment, and adherence to the evidence-based YMCA Diabetes Prevention Program (DPP) of Greater Cleveland. Of the 2200 Medicare-eligible patients at risk of prediabetes, 351 (16.0%) responded by attending an information session; 228 enrolled in the DPP (11.3%) and persisted through at least Week 9. Because of the motivation and reinforcement provided to patients through YMCA-provided signs, brochures, and posters; a Web site; and in-person conversations with primary care physicians, an improvement occurred over the 1.7% who responded to the mailing for the previous DPP study.

Assessing the Value of High-Quality Care for Work-Associated Carpal Tunnel Syndrome in a Large Integrated Health Care System: Study Design
Craig Conlon, MD, PhD; Steven Asch MD, MPH; Mark Hanson, PhD; Andrew Avins, MD, MPH; Barbara Levitan; Carol Roth, BSN, MPH; Michael Robbins, PhD; Michael Dworsky, PhD; Seth Seabury, PhD; Teryl Nuckols MD, MSHS
Little is known about quality of care for occupational health disorders, although it may affect worker health and workers’ compensation costs. This is a prospective observational study of 477 individuals with new workers’ compensation claims for carpal tunnel syndrome (CTS) without acute trauma, treated at 30 occupational health clinics from 2011 to 2013 and followed for 18 months. Two hundred sixty-seven subjects (56%) received a diagnosis of CTS and had claims filed around the first visit to occupational health.

Amniotic Fluid Embolism: Using the Medical Staff Process to Facilitate Streamlined Care
Peter M Hession, MD; Cynthia J Millward, MD; Joyce E Gottesfeld, MD; Thomas F Rehring, MD; Kevin B Miller, MD; Paul M Chetham, MD; S Kel Muckleroy, MD; Christopher A Bates, MD; Harris W Hollis, Jr, MD
There are no published algorithmic approaches to the management of amniotic fluid embolism (AFE). Post hoc analysis of a complicated case of AFE resulted in development of a care pathway that addresses many of its major consequences. It is a template for use by any institution willing to implement a clinical pathway to treat AFE. It is accompanied by the remarkable case outcome that prompted its development.

Integrated Research and the Garfield Memorial National Research Fund—An Unobstructed View
Ed Thomas, RN, MBA
Integrated care has been discussed for many years. Those supporting and managing the Garfield Memorial National Research Fund believe a similar idea, integrated research, must be discussed and tested, beginning with rethinking the proposal format. This article elaborates on the enhanced proposal format, presenting powerful patient stories to demonstrate how integrated research can help deliver better patient care.

Physicians', Nurses', and Medical Assistants' Perceptions of the Human Papillomavirus Vaccine in a Large Integrated Health Care System
Jordan Mills, DO, PhD; Patrick Van Winkle, MD; Macy Shen, PhD; Christina Hong, MD; Sharon Hudson, PhD
Vaccination against the human papillomavirus (HPV) decreases risks of cancer and genital warts and the need for gynecologic procedures, yet nationwide vaccination rates are low. A total of 76 surveys were completed: 52 physicians, 16 clinical nurses and medical assistants, and 8 nurse administrators. Physicians’ perception of vaccine safety or strength of recommendation did not differ by specialty department. Physicians reportedly perceive the HPV vaccine as safer compared with nurses and medical assistants. Both groups think that more education of nonphysician staff is needed.

Trends in Type of Original Psoriasis Publications by Decade, 1960 to 2010
Eric Sako, MD; Shannon Famenini, MD; Jashin J Wu, MD
A literature review was performed using the keyword psoriasis in the MEDLINE database. All original psoriasis-related articles published at the beginning of each decade were searched and categorized by study type and topic. A total of 869 original psoriasis-related articles were found. The number of publications increased 18 fold over 5 decades. The immunology and pathogenesis of psoriasis was the most frequently researched topic (36%), and retrospective studies were the most common study type (37%). Recent highly published topics included biologic therapy, genetics, and psoriasis-associated cardiovascular disease.


Refractory Depression, Fatigue, Irritable Bowel Syndrome, and Chronic Pain: A Functional Medicine Case Report
Mitsuro Chiba, MD, PhD; Kunio Nakane, MD, PhD; Yuko Takayama, RD; Kae Sugawara, MD; Hideo Ohno, MD; Hajime Ishii, MD, PhD; Satoko Tsuda, MD; Tsuyotoshi Tsuji, MD, PhD; Masafumi Komatsu, MD, PhD; Takeshi Sugawara, MD
A 72-year-old man experiencing longstanding depression, fatigue, irritable bowel syndrome, and chronic pain in the context of additional refractory illnesses was assessed and treated, guided by a system-oriented approach to underlying core imbalances termed Functional Medicine. Blood-, urine-, or stool-based measurements of relevant markers for multiple systemic issues identified previously unrecognized root causes of his constellation of symptoms. These functional measurements guided rational recommendations for dietary choices and supplementation. The patient experienced steady and significant improvement, as well as the unexpected resolution of his chronic idiopathic pancytopenia.

Effectiveness of Cannabidiol Oil for Pediatric Anxiety and Insomnia as Part of Posttraumatic Stress Disorder: A Case Report
Scott Shannon, MD, ABIHM; Janet Opila-Lehman, ND
Anxiety and sleep disorders are often the result of posttraumatic stress disorder and can contribute to an impaired ability to focus and to demonstration of oppositional behaviors. These symptoms were present in our patient, a ten-year-old girl who was sexually abused and had minimal parental supervision as a young child under the age of five. Pharmaceutical medications provided partial relief; results were short-lived with major side effects. A trial of cannabidiol oil resulted in decreased anxiety and improvement in the quality and quantity of the patient’s sleep.

A General Pediatrics and Integrative Medicine Approach to Pervasive Refusal Syndrome: A Case Report
Tido von Schoen-Angerer, MD, MPH; Elisabeth Helmschmidt, Dr Med; René Madeleyn, Dr Med; Reinhard Kindt, Dr Med; Christoph Möller, Prof Dr Med; Gunver Sophia Kienle, Dr Med; Jan Vagedes, Dr Med, MA
Pervasive refusal syndrome (PRS) describes children with social withdrawal who become unable to walk, eat, or care for themselves. A seven-year-old girl with symptoms most consistent with PRS and depression was admitted to a pediatric ward that integrates conventional pediatric and psychosomatic care with anthroposophic medicine. She was integrated into the activities of the ward and received massages, movement therapy, and color light therapy. After four weeks, she talked again, showed increased appetite, and supported herself when moved passively. She made a full recovery within four weeks after hospital discharge.

Carpal Tunnel Syndrome in Sarcoidosis: A Case Report of a Rare Neurologic Manifestation
Ajinkya Sonambekar, MD, MBBS; Nikhil Gupta, MD, MBBS; Akanksha Swadi, MD, MBBS; Laxmikant Ramkumarsingh Tomar, MD, MBBS
Sarcoidosis is a multisystemic inflammatory disease with myriad clinical manifestations. Neurologic involvement in sarcoidosis is uncommon. Peripheral neuropathic presentations include mononeuropathy, mononeuritis multiplex, and generalized sensory, motor, autonomic, and sensorimotor polyneuropathies. The authors report a case of carpal tunnel syndrome caused by sarcoidosis in a 30-year-old woman. Other causes of carpal tunnel syndrome were ruled out. The patient responded well to the standard line of corticosteroid treatment and wrist splinting. Carpal tunnel syndrome caused by sarcoidosis is a rare presentation. The mechanism of neurologic involvement in sarcoidosis is not clear.


Ethical Analysis for Physicians Considering the Provision of Life-Ending Medication in Compliance with the California End of Life Option Act
D Malcolm Shaner, MD
The End of Life Option Act in California permits physicians to prescribe lethal medication to patients confirmed to be terminally ill and capable of independently making and carrying out a decision to ingest deadly medication. A physician choosing to expand his/her role within this narrowly defined context allows the patient to assume authority for a deeply personal decision.

An Ethics of Permission: A Response to the California End of Life Option Act
Craig Nelson, PhD, CLS
The California End of Life Option Act law does not define morality, and reaching a moral understanding demands thorough reflection. An ethics of permission includes the importance of exercising professional tolerance in honoring clinicians who participate or who refuse to participate.


Image Diagnosis: Hemorrhagic Bullae in a Primary Varicella Zoster Virus Infection
Cátia Canelas, MD; João M Carvas, MD; Cristiana Sevivas, MD; Dina Carvalho, MD
A 47-year-old man, 20 pack-year smoker, and heavy alcohol drinker, with an episode of pulmonary tuberculosis 10 years before, presented to the Emergency Department with 7 days of cough, mucous sputum, and abdominal pain. Additionally he presented with 5 days of pruriginous skin rash that started on the thorax but rapidly spread to the entire body, and with 3 days of fever.


Form Follows Function: A Functional Medicine Overview
Patrick Hanaway, MD
In the article on p 104, Plotnikoff presents a case report using an innovative systems-biology approach known as Functional Medicine. Treatment focused on the correction of common physiologic imbalances, along with lifestyle modifications in diet and nutrition. This case highlights a significant opportunity to move the focus of care toward root cause analysis, which, when combined with the power of lifestyle modification, can help to bend the cost curve and improve the value of care.


Her Glistening Eyes
Ahmed Z Obeidat, MD, PhD
One day, as the end of our patient’s hospital stay neared, her son grasped my attention with these words: “Last night, she mentioned my name, touched my head, and pulled me close to her heart as if I were her baby again. She smiled and followed my steps around the room.” I was surprised to hear that she was so different at night. I inquired about that. Her son answered, “My mother became a night person after her stroke.”


Ghosts of the Northern Plains
Stephen Henry, MD

Nadia Al Khun

Bridget Bourgon, PA-C

Samuel H Glassner, MD

Girl with a Pearl Earring
Zhanna Vishnevskaya, MD


Horsetail Fall
Sapna Reddy, MD


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