Summer 2016 - Volume 20 Number 3


Weight Loss and the Prevention of Weight Regain: Evaluation of a Treatment Model of Exercise Self-Regulation Generalizing to Controlled Eating
James J Annesi, PhD, FAAHB, FTOS, FAPA; Ping H Johnson, PhD; Gisèle A Tennant, PhD; Kandice J Porter, PhD; Kristin L McEwen
For decades behavioral weight-loss treatments have been unsuccessful beyond the short term. In this study, women with obesity were randomized into either a comparison treatment that incorporated a print manual plus telephone follow-ups (n = 55) or into an experimental treatment of The Coach Approach exercise-support protocol followed after 2 months by group nutrition sessions focused on generalizing self-regulatory skills from an exercise support to a controlled eating context (n = 55). Improvements in all psychological measures, physical activity, and fruit and vegetable intake were significantly greater in the experimental group. Change in self-regulation best predicted weight loss, whereas change in self-efficacy best predicted maintenance of lost weight.

A Pharmacist-Staffed, Virtual Gout Management Clinic for Achieving Target Serum Uric Acid Levels: A Randomized Clinical Trial
Robert Goldfien, MD; Alice Pressman, PhD, MS; Alice Jacobson, MS; Michele Ng, PharmD; Andrew Avins, MD, MPH
The authors conducted a parallel-group, randomized, 26-week, controlled trial of a pharmacist-staffed, telephone-based program for managing hyperuricemia vs usual care. Among 37 participants randomized to the intervention group, 13 (35%) had a serum uric acid level (sUA) ≤ 6.0 mg/dL at 26 weeks vs 5 of 40 participants (13%) in the control group (p = 0.03). A structured pharmacist-staffed program was more effective than usual care for achieving target sUA levels. These results suggest that a structured program could significantly improve gout management.

Exploring the Reality of Using Patient Experience Data to Provide Resident Feedback: A Qualitative Study of Attending Physician Perspectives
Steffanie Campbell, MD; Heather Honoré Goltz, PhD, LMSW, MEd; Sarah Njue, MPH; Bich Ngoc Dang, MD
From 7/2013 to 8/2013, in-depth, face-to-face, semistructured interviews were conducted with 9 attending physicians who precept residents in internal medicine at 2 continuity clinics (75% of eligible attendings). Content analysis identified 6 potential barriers in using patient experience survey data: 1) perceived inability of residents to learn or to incorporate feedback, 2) punitive nature of feedback, 3) lack of training in the delivery of actionable feedback, 4) lack of timeliness in the delivery of feedback, 5) unclear benefit of patient experience survey data as a tool for providing resident feedback, and 6) lack of individualized feedback.

Physicians Experiencing Intense Emotions While Seeing Their Patients: What Happens?
Joana Vilela da Silva, MD; Irene Carvalho, PhD
A self-report survey was completed by 127 physicians, with 52 (43%) reporting experiencing intense emotions frequently. Coping strategies to deal with the emotion at the moment included behavioral and cognitive approaches. Choking-up/crying, touching, smiling, and providing support were significantly associated with an immediate positive impact on the physician-patient relationship. Withdrawing from the situation, imposing, and defending oneself were associated with a negative impact.

Difference in Effectiveness of Medication Adherence Intervention by Health Literacy Level
Ashli A Owen-Smith, PhD, SM; David H Smith, PhD, RPh; Cynthia S Rand, PhD; Jeffrey O Tom, MD, MS; Reesa Laws; Amy Waterbury, MPH; Andrew Williams, PhD; William M Vollmer, PhD
Promoting Adherence to Improve Effectiveness of Cardiovascular Disease Therapies (PATIENT) was a randomized clinical trial designed to test the impact, compared with usual care, of two technology-based interventions that leveraged interactive voice recognition to promote medication adherence. The differences in intervention effects for high vs low health literacy in this exploratory analysis are consistent with the hypothesis that individuals with lower health literacy may derive greater benefit from this type of intervention compared with individuals with higher health literacy.

Lifestyle and Self-Management by Those Who Live It: Patients Engaging Patients in a Chronic Disease Model
Michelle T Jesse, PhD; Elizabeth Rubinstein; Anne Eshelman, PhD, ABPP; Corinne Wee; Mrunalini Tankasala; Jia Li, PhD; Marwan Abouljoud, MD, CPE, MMM, FACS
Of 1862 patient satisfaction surveys, 823 were returned (44.2%). Patients and their supports appreciated that the program volunteer was a transplant recipient and noted gratitude for the lifestyle information. Five areas were associated with the success of Transplant Living Community: 1) a “champion”; 2) a receptive health care environment; 3) a high level of visibility to physicians and staff; 4) a lifestyle plan (“Play Your ACES” [Attitude, Compliance, Support, and Exercise]), and 5) a strong volunteer structure. It is feasible to integrate a sustainable patient-led lifestyle and self-management educational group into a busy tertiary care clinic for patients with complex chronic illnesses.

Special Report

Improving Care in Older Patients with Diabetes: A Focus on Glycemic Control
Eric A Lee, MD; Nancy E Gibbs, MD; John Martin, MD; Fred Ziel, MD; Jennifer K Polzin, PharmD; Darryl Palmer-Toy, MD, PhD
Diabetes affects more than 25% of Americans older than age 65 years. This article discusses the seminal research findings that strongly suggest that hemoglobin A1c goals should be relaxed in older patients. The authors then recommend an age-specific and functionally appropriate hemoglobin A1c reference range for patients receiving medications to improve glycemic control. Other interventions are suggested that should make diabetes care safer in older patients receiving hypoglycemic medications.

Special Report

Evidence-Based Workflows for Thyroid and Parathyroid Surgery
Charles Meltzer, MD; Amer Budayr, MD; Annette Chavez, MD; Richard Dlott, MD; William Greif, MD; Deepak Gurushanthaiah, MD; Andrew Klonecke, MD; Matthew Lando, MD; Joyce Leary, MD; Sundeep Nayak, MD; Ryan Niederkohr, MD; Judith Park, MD; Alison Savitz, MBA, MD; Henry Schwartz, MD
A need exists to reduce care variations by standardizing the practice of thyroid and parathyroid surgery. During the course of a year, a task force developed algorithms representing decision points and workflows based on American Thyroid Association guidelines and on three internal studies of surgical practices in the Northern and Southern California Regions of Kaiser Permanente conducted in collaboration with Health Information Technology Transformation & Analytics (HITTA).

Special Report

The Truth about Truth-Telling in American Medicine: A Brief History
Bryan Sisk, MD; Richard Frankel, PhD; Eric Kodish, MD; J Harry Isaacson, MD
Transparency has become an ethical cornerstone of American medicine. For most of American history, the intentional withholding of information was the accepted norm in medical practice. The authors trace the ethics and associated practices of truth-telling during the past two centuries and outline the many pressures that influenced physician behavior during that time period. They conclude that the history of disclosure is not yet finished, as physicians still struggle to find the best way to share difficult information without causing undue harm to their patients.

Special Report

Refining Reporting Mechanisms in Oregon’s Patient-Centered Primary Care Home Program to Improve Performance
Sherril Gelmon, DrPH; Billie Sandberg, PhD; Nicole Merrithew, MPH; Rebekah Bally, MP
To achieve the Triple Aim, the Oregon Health Authority implemented the Patient-Centered Primary Care Home (PCPCH) Program in 2009. To assist in evaluating 500 primary care practices’ achievement along its 6 core attributes the research team developed an innovative scoring method. Initial results demonstrate that the scores enable stakeholders to compare results across similar practices and across the model’s core attributes, and to identify opportunities for improvement and technical assistance. This strategy could be replicated in other states. The article offers insights on implementation strategies, efficacy of the PCPCH model, and lessons learned.

Review Articles

Hyperparathyroidism of Renal Disease
Noah K Yuen, MD; Shubha Ananthakrishnan, MD; Michael J Campbell, MD
Patients with renal hyperparathyroidism (rHPT) experience increased rates of cardiovascular problems and bone disease. Guidelines recommend that screening and management be initiated for all patients with chronic kidney disease stage III (estimated glomerular filtration rate, < 60 mL/min/1.73 m2). Improving medical management with vitamin D analogs, phosphate binders, and calcimimetic drugs has expanded the treatment options for patients with rHPT, but some patients still require a parathyroidectomy to mitigate the sequelae of this challenging disease.

Recurrence of Epithelioid Hemangioendothelioma during Pregnancy: Case Report and Systematic Review
Michael McCulloch, LAc, MPH, PhD; Michael Russin, MD; Arian Nachat, MD
The authors present a case of a 28-year-old woman whose epithelioid hemangioendothelioma (EHE) recurred during pregnancy, suggesting hormonal involvement. They conducted a systematic review to provide analysis and interpretation of the potential significance of her disease recurring, with fatal outcome, during pregnancy. Very little research has explored the use of individual hormonal markers. Strongly positive expression of 17-beta estradiol receptors have been reported. Expression of placenta growth factor (PlGF) is noteworthy in our case, in that our patient’s disease quickly and dramatically flared in the 25th week of pregnancy, near the peak in maternal PlGF production.


Quality Over Quantity: Integrating Mental Health Assessment Tools into Primary Care Practice
Darrell L Hudson, PhD, MPH
Depression is one of the most common, costly, and debilitating psychiatric disorders in the US. Yet, mental health services are underutilized throughout the US. Recent policy changes have encouraged depression screening in primary care settings. However, there is not much guidance about how depression screeners are administered. There are people suffering from depression who are not getting the treatment they need. It is important to consider whether enough care is being taken when administering depression screeners in primary care settings.

Plant-Based Diets: A Physician’s Guide
Julieanna Hever, MS, RD, CPT
This article provides physicians and other health care practitioners with an overview of the myriad benefits of a plant-based diet as well as details on how best to achieve a well-balanced, nutrient-dense meal plan. It also defines notable nutrient sources, describes how to get started, and offers suggestions on how health care practitioners can encourage their patients to achieve goals, adhere to the plan, and experience success.


The Use of Narrative as a Treatment Approach for Obesity: A Storied Educational Program Description
Marcus Griffith, MD; Jeana Griffith, PhD; Mellanese Cobb, MPH; Vladimir Oge, MPH
The authors wrote an interventional children’s book and workbook (The Tale of Two Athletes: The Story of Jumper and The Thumper) and developed a three-step intervention based on the narrative. The intervention’s purpose is to increase public awareness, reduce stigma, and help members of underserved communities become more comfortable discussing obesity. Interactive storytelling is the first step. The second step is reading. Practicing positive behaviors and decision making through games and exercises from the companion workbook is the final step.

You Are Not Alone: Ten Strategies for Surviving a Malpractice Lawsuit
Audrey Sheridan, MD
I wasn’t even scheduled to work that morning. I had just gone into the office for a meeting. Most physicians, about 60%, will be sued at some point in their careers. Physicians typically do feel intense strain when faced with a lawsuit. We are more likely to suffer depression and burnout. Ten techniques are offered for coping that really work: resist isolation, use your strengths, retrain your brain, take care of yourself, give yourself a break, set priorities, approach law as a foreign culture, regain perspective, use distraction, and focus on what you can control.

The Handshake Layer Cake: Meeting and Regreeting Difficulties for a Non-French Surgeon in France
Colin G Murphy, MCh, FRCSI
As always, the first work-greeting of the day, be it a handshake or les bises, is complicated by context: age, seniority, work status, employer/employee status, family, familiarity, the other people present at that interaction, whether it is break/coffee time. All of this has to be balanced against the unthinkable, not greeting someone at all, or thinking (like an idiot) that the wave or nod from a distance that you gave earlier in the day constituted a greeting.

Ahmed Obeidat, MD, PhD
It was a very familiar object that I asked her to identify. She started to look, feel, think, and she said, “It has buttons, numbers, and glass, but I can’t put them together. I am unsure!” The last task I asked her to perform was to write a sentence, which thrilled me when she wrote in beautiful script, “Doctor, I want to know what is wrong with me.” This was alexia (word blindness) without agraphia. She was a creative writer in her third decade.

Case Reports

Metastatic Renal Cell Carcinoma Presenting as Painful Chewing Successfully Treated with Combined Nivolumab and Sunitinib
Fade Mahmoud, MD, FACP; Al-Ola Abdallah, MD; Konstantinos Arnaoutakis, MD; Issam Makhoul, MD
Metastatic renal cell carcinoma to the head and neck is the third-most common cause of distant metastasis to the head and neck, after breast cancer and lung cancer. A 71-year-old man with a single complaint of a one-year history of pain while chewing food, but without painless hematuria, weight loss, anorexia, fatigue, or anemia. An almost complete response of the metastatic disease occurred with the combination of nivolumab and sunitinib.

Treatment of Tracheoinnominate Fistula with Ligation of the Innominate Artery: A Case Report
Rhiana S Menen, MD; Jimmy J Pak, MD; Matthew A Dowell, PA; Ashish R Patel, MD; Simon K Ashiku, MD; Jeffrey B Velotta, MD
A 76-year-old man who underwent emergent tracheostomy placement presented on postoperative day 10 with massive hemorrhage concerning for tracheoinnominate fistula and was treated with median sternotomy and ligation of the innominate artery. The key to good outcomes is quick diagnosis and urgent surgical intervention.

Monoarticular Poncet Disease after Pulmonary Tuberculosis: A Rare Case Report and Review of Literature
Paritosh Garg, MD; Nikhil Gupta, MD, MBBS; Mohit Arora, MS
The authors describe an atypical presentation of active pulmonary tuberculosis with monoarticular Poncet disease of the right knee in a 24-year-old woman. The diagnosis of Poncet disease is mainly clinical with exclusion of other causes. It generally presents as an acute or subacute form; however, chronic forms have been described in the literature.

Clinical Medicine

Image Diagnosis: Pott Puffy Tumor
Diane Apostolakos, MD, MS; Ian Tang, MD
A 20-year-old man was admitted to our hospital with complaints of frontal headache, sinusitis, and fever for one week. Sir Percivall Pott (1714-1788), a surgeon at St. Bartholomew’s Hospital in London, first described it as Pott Puffy tumor, referring to one of the four historic manifestations of inflammation noted by Aulus Cornelius Celsus (c 25 BC-c 50 AD): rubor (redness), tumor (swelling), calor (warmth), and dolor (pain).

Image Diagnosis: Tubo-ovarian Abscess with Hydrosalpinx
Kiersten L Carter, MD; Gus M Garmel, MD, FACEP, FAAEM
Risk factors of tubo-ovarian Abscess include younger age, multiple sexual partners, nonuse of barrier contraception, and a history of pelvic inflammatory disease. Compared with ultrasonography, computed tomography has increased sensitivity to detect thick-walled, rim-enhancing adnexal masses. The aim of therapeutic management is to be as noninvasive as possible. However, if this approach fails to yield clinical improvement within 3 days, reassessment of the antibiotic regimen, with consideration for laparoscopy, laparotomy, adnexectomy, hysterectomy, or image-guided abscess drainage is necessary.

Image Diagnosis: Gastric Migration of Hookworms in a Patient with Anemia
Chalapathi Rao Achanta, MD
A 65-year-old man presented to our hospital with 4 months of fatigue and weakness. He denied any bleeding manifestations and had pallor on examination. The patients’ esophagus was normal, but there were motile hookworms in the gastric antrum and heavy loads of hookworms in the duodenum.

Image Diagnosis: Encephalopathy Resulting from Dural Arteriovenous Fistula
Ana Filipa Santos, MD; Célia Machado, MD; Sara Varanda, MD; João Pinho, MD; Manuel Ribeiro, MD; Jaime Rocha, MD; Ricardo Maré, MD; Manuel Ribeiro, MD; Jaime Rocha, MD; Ricardo Maré, MD
A 69-year-old woman presented to the Neurology Department with 2 months of progressive psychomotor slowing, inability to concentrate, and periods of disorientation. Her past medical history was unremarkable, and she was taking no medication. There was no history of trauma. The initiating events that led to the development of these symptoms are not clear, but the literature reports association with trauma, infection, recent surgery, and dural sinus thrombosis.

Nursing Research

Future Challenges of Robotics and Artificial Intelligence in Nursing: What Can We Learn from Monsters in Popular Culture?
Henrik Erikson, RNT, PhD; Martin Salzmann-Erikson, RN, MHN, PhD
The authors propose that monsters in popular culture might be studied with the hope of learning about situations and relationships that generate empathic capacities in their monstrous existences. The aim of the article is to introduce the theoretical framework and assumptions behind this idea. Both robots and monsters are posthuman creations. The knowledge we present here gives ideas about how nursing science can address the postmodern, technologic, and global world to come.

On the Cover

Roman Stonemason
Tom Janisse, MD, MBA


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