Winter 2016 - Volume 20 Number 1


cmesmallPopulation Variations in Rheumatoid Arthritis Treatment and Outcomes, Northern California, 1998-2009
Lisa J Herrinton, PhD; Leslie Harrold, MD, MPH; Craig Salman; Liyan Liu, MD, MS;
Robert Goldfien, MD; Maryam Asgari, MD, MPH; Joel M Gelfand, MD, MSCE;
Jashin J Wu, MD; Jeffrey R Curtis, MD, MS, MPH
An assessment of 28,601 patients (1998-2009) with rheumatoid arthritis, with all levels of severity from 16 Kaiser Permanente Northern California Medical Centers was performed. Increased use of disease-modifying antirheumatic drugs (from 38% to 63% of the time) and declines in prednisone (23% to 15%) are encouraging. Opioid use initially rose but then fell to 23%. Opioid use may need intervention.

cmesmallEvaluation of Small Adrenal Incidental Nodules: Is Imaging Follow-Up Necessary?
Kara M Young; Michael K Wong; Myles M Mitsunaga, MD; Hyo-Chun Yoon, MD, PhD
The authors’ performed a retrospective analysis of all patients (392) found with an incidental adrenal nodule on abdominal computed tomography scan during a 27-month period. The electronic medical record was reviewed to determine clinical outcomes. The mean clinical follow-up was 6.7 years. None of these patients (200 men,192 women, mean age 66) developed primary adrenocortical carcinoma during the follow-up period. Patients with small incidental adrenal nodules do not require additional imaging to exclude the possibility of adrenocortical carcinoma.

cmesmallPredicting the Risk of Clostridium difficile Infection upon Admission: A Score to Identify Patients for Antimicrobial Stewardship Effort
Jennifer L Kuntz, PhD; David H Smith, PhD; Amanda F Petrik, MS; Xiuhai Yang, MS; Micah L Thorp, DO, MPH; Tracy Barton, RPh; Karen Barton, RPh; Matthew Labreche, PharmD, MSc, BCPS; Steven J Spindel, MD; Eric S Johnson, PhD
In a cohort of Kaiser Permanente Northwest patients admitted from 7/1/2005 through 12/30/2012 and identified with Clostridium difficile infection (CDI) in the 6 months following discharge, the authors identified 721 CDIs following 54,186 admissions—a 6-month incidence of 13.3 CDIs/1000 patients. Patients with the highest predicted risk of CDI had an observed incidence of 53 CDIs/1000 patients. The authors’ risk score accurately predicted 6-month risk for CDI using preadmission characteristics. Accurate predictions could benefit review of inpatient antibiotic use or enhanced educational efforts at the time of discharge planning.

Effect of Advancing Age and Multiple Chronic Conditions on Mortality in Patients with End-Stage Renal Disease after Implantable Cardioverter-Defibrillator Placement
Ashok Krishnaswami, MD, MAS; Mary-Lou Kiley, MBA; Faith F Anthony, MA; Yuexin Chen; Jason Chen, MA; Sumanth Rajagopal, MD; Taylor I Liu, MD, PhD; Charlie Young, MD; Elizabeth W Paxton, MA
A population-based, retrospective cohort study, conducted using data from the national Kaiser Permanente Cardiac Device Registry of patients who underwent placement of an implantable cardioverter-defibrillator between 1/1/2007 and 12/31/2013, identified 7825 patients. End-Stage Renal Disease (ESRD)-affected patients constituted 4.0% of the cohort, were similar in age, and had a larger comorbidity burden (3.3 vs 2.4). Even when ESRD was independently associated with a 3-fold greater hazard of mortality, advancing age and increasing number of multiple chronic conditions have less of an effect on mortality risk in patients with ESRD compared with their non-ESRD counterparts.

Association of Dental Care with Adherence to HEDIS Measures
David Mosen, PhD, MPH; Dan Pihlstrom, DDS; John Snyder, DMD; Ning Smith, PhD; Elizabeth Shuster, MS; Kristal Rust
Using a retrospective cohort design, the authors identified 5216 adults who received regular dental care and 5216 persons who did not. The groups were matched on propensity scores, followed for 3 years, and retained medical and dental benefits. Dental care was associated with higher adherence to all 3 cancer screening measures, 1 of 4 disease management services (higher retinopathy screening), and 3 of 4 health outcomes (better glycemic control in the diabetes mellitus [DM] population and better blood pressure control in the DM and hypertensive populations).

Primary Care Clinicians' Perspectives on Reducing Low-Value Care in an Integrated Delivery System
Diana SM Buist, PhD, MPH; Eva Chang, PhD, MPH; Matt Handley, MD; Roy Pardee, MA, JD; Gabrielle Gundersen; Allen Cheadle, PhD; Robert J Reid, MD, PhD
In an electronic, cross-sectional 2013 survey of 304 salaried primary care physicians and physician assistants at Group Health Cooperative, 62% (189) responded. More than 90% believe cost is important and that it is fair to ask clinicians to be cost-conscious. Most found peer-comparison resource-use reports useful for understanding practice patterns and prompting peer discussions. Key barriers to reducing low-value care included: time constraints (45%), overcoming patient preferences/values (44%), community standards (43%), and fear of patients’ dissatisfaction (41%). Salaried clinicians want to be stewards of limited health care resources.

Early Hospital Readmission and Mortality Risk after Surgical Treatment of Proximal Humerus Fractures in a Community-Based Health Care Organization
Edward Yian, MD; Hui Zhou, MS, PhD; Ariyon Schreiber; Jeff Sodl, MD; Ron Navarro, MD; Anshuman Singh, MD; Nikita Bezrukov, MD
In a retrospective cohort analysis from the Kaiser Permanente Southern California Region database, of 1387 patients with surgical repair of a proximal humerus fracture, the 30-day all-cause readmission rate was 5.6%. Surgical complications accounted for 40% of readmissions. Severe liver disease and LACE score (length of stay, acuity of admission, comorbidities, and number of Emergency Department visits in the previous 6 months) correlated best with postoperative 30-day readmission risk.

cmesmallPopulation Care Management and Team-Based Approach to Reduce Racial Disparities among African Americans/Blacks with Hypertension
Rowena E Bartolome, RN, PHN, MHA; Agnes Chen, DO; Joel Handler, MD; Sharon Takeda Platt, PhD; Bernice Gould, RN, MNA
A sustainable program to collect self-reported race, ethnicity, and language preference data integrated with successful population care management programs provided the foundation for addressing health disparities. Cultural tailoring of a multilevel team-based approach closed the gap for blacks with hypertension. At a physician practice level where 65% of patients with hypertension were black, blood pressure control rates (< 140/90 mmHg) for blacks improved from 76.6% to 81.4%, and control rates for whites increased from 82.9% to 84.2%. The racial gap narrowed from 6.3% to 2.8%.

Are Men at High Risk for Osteoporosis Underscreened? A Quality Improvement Project
Samta Jain, MD; Bilori Bilori, MD; Amit Gupta, MD; Pete Spanos; Mamta Singh, MD
The mortality rate in men within 1 year of hip fracture is 37.5%, which is 51% higher than in women. Screening does not appear to be standard practice, but it was determined in high-risk male veterans more than 50 years of age at a Veterans Affairs Medical Center in Cleveland, OH. High-risk factors included: prolonged use of steroids, hypogonadism, and autoimmune diseases. Creating more awareness among health professional trainees and nurses about the impact of osteoporosis through phased surveys and awareness building led to improved screening rates of 20% (from 11%).

E-mails in a Psychiatric Practice: Why Patients Send Them and How Psychiatrists Respond
Richard J Moldawsky, MD; Pranav V Shah, MD
One hundred patient-initiated e-mails to 1 of 2 psychiatrists in a group practice were studied retrospectively. Age, sex, and diagnoses of the e-mailers were similar to our overall panels. The most common reasons for e-mailing were refill requests (19.5%), questions about prescribed medication (16.5%), and worsening of symptoms (11.5%). The psychiatrists’ most common responses were authorizing a refill (25%) and reassurance (22%). Both psychiatrists found e-mail to be an efficient enhancement of their practice. Potential risks to patients without face-to-face or telephone contact appear to be minimal.

Review Articles

Gingival Metastasis: A Case Report and Literature Review
Brian A Nuyen; Christopher G Tang, MD
Primary lung cancer among men is one of the most common cancers to metastasize to the oral cavity, although secondary oral-cavity neoplasms are rare. Renal and cutaneous neoplasms are the next most common neoplasms to metastasize to the oral cavity. The gingiva, a tissue prone to inflammation, is noted to be a common site for secondary oral cavity neoplasms.

Cutaneous Metastasis of Rectal Cancer: A Case Report and Literature Review
Ahmed Dehal, MD; Sunal Patel, MD; Sean Kim, MD; Emanuel Shapera, MD; Farabi Hussain, MD
Cutaneous metastasis of rectal cancer is rare. A 47-year-old man presented with stage IV unresectable adenocarcinoma of the rectum and received palliative chemoradiation for local pain control. A year later he developed extensive skin lesions involving the genital area, bilateral groin, and perineum. Biopsy specimen showed mucinous adenocarcinoma compatible with rectal origin. After palliative treatment with radiation therapy, the patient responded well to treatment and is alive more than a year after diagnosis.

Case Reports

Onset of Ulcerative Colitis during a Low-Carbohydrate Weight-Loss Diet and Treatment with a Plant-Based Diet: A Case Report
Mitsuro Chiba, MD, PhD; Satoko Tsuda, MD; Masafumi Komatsu, MD, PhD; Haruhiko Tozawa, MD; Yuko Takayama, RD
The authors encountered a case in which ulcerative colitis developed while the patient was following the Atkins diet. He was age 36 years, 172 cm in height, weighed 72 kg, and noticed bloody stool. Colonoscopy revealed diffuse inflammation limited to the rectum, and he was diagnosed with ulcerative colitis. A plant-based/semivegetarian diet was provided during hospitalization. Bloody stool disappeared and he achieved remission without medication for inflammatory bowel disease. This case demonstrates that an onset of ulcerative colitis can be an adverse event to a low-carbohydrate weight-loss diet.

Pregnancy-Associated “Cutaneous Type” Pemphigus Vulgaris
Javier Rangel, MD
Pemphigus vulgaris (PV) during pregnancy is rare and manifests with mucosal and/or cutaneous erosions. Pemphigus foliaceus manifests with cutaneous-only involvement. High-dose systemic corticosteroids are first-line agents in management of PV, yet their use raises complex management issues associated with pregnancy and fetal risk.

Clinical Medicine

Image Diagnosis: Immune Thrombocytopenia Secondary to Abdominal Koch Disease
Laxmikant Ramkumarsingh Tomar, MD, MBBS; Nikhil Gupta, MD, MBBS; Sarthak Malik, MD, MBBS; Paritosh Garg, MD, MBBS; Puneet Chhabra, MD, MBBS, DM
The hematologic manifestations of tuberculosis (TB) include anemia, leukocytosis, and pancytopenia. Immune thrombocytopenia in TB, as found in this patient, is extremely rare. Thrombocytopenia is typically described in the context of pancytopenia, which develops secondary to bone marrow infiltration. The differential diagnosis includes: 1) disseminated intravascular coagulopathy, 2) thrombotic thrombocytopenic purpura, 3) Evans syndrome, and 4) hemophagocytic syndrome.

Image Diagnosis: Dental and Skeletal Fluorosis
Nishtha Gupta, MDS; Nikhil Gupta, MD, MBBS; Puneet Chhabra, DM
Sixty million people are estimated to have health problems, such as skeletal fluorosis (SF), caused by of consumption of fluoride-contaminated water. In a US survery, 23% of the population aged 6 to 49 years had some form of SF, higher in adolescents than adults. The generally accepted average serum fluoride level is 0.15 ppm.

Image Diagnosis: Knee Dislocation
Adam Gordon; Minh Van Le, MD; Clifford Swap, MD
Femorotibial dislocation is an uncommon extremity injury, typically occurring in the setting of high-energy mechanisms such as motor vehicle collisions, falls from heights, and certain sports. However, up to 46% of dislocations are in the setting of low-energy mechanisms, particularly with overweight individuals and amateur athletes. Less frequent, but of primary concern upon presentation, is concomitant vascular injury following knee dislocations.


The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety
Daniel L Cohen, MD, FRCPCH, FAAP; Kevin O Stewart, MD, BCh, MPH, FRCP, FRCPI
Although patients’ stories tell us much, less commonly heard are the stories of clinicians, and how their personal observations regarding the environments they work in and the circumstances and pressures under which they work, may degrade patient safety and lead to harm. Leaders and managers must seek and value input from those on the front lines—both clinicians and patients. Stories from clinicians provided in this article address themes that include incident identification, disclosure and transparency, just culture, the impact of clinical workload pressures, human factors liabilities, clinicians as secondary victims, the impact of disruptive and punitive behaviors, factors affecting professional morale, and personal failings.

Relationships Heal
Robert C Whitaker, MD, MPH

The Shared Context: Kaiser Permanente and the Columbia-Bassett Program
Henry FC Weil, MD
A quiet concern of graduating medical students may be that you are not ready
to be a physician. In many ways you were well prepared to be a physician before you came to medical school. That is because you already had the capacity and desire to form relationships, and even if you could not say it, you probably felt called to heal others through your relationships with them. Relationships can heal people, and you have the ability to make healing relationships. Included commentary provides context for this commencement address.


The Gut Balance Revolution
Review by David Riley, MD

Chadwick’s Child Maltreatment, Encyclopedic Volumes 1 to 3, 4th edition
Review by Anna Luise Kirkengen, MD, PhD


Gods Thunder
Phillip La Borie

Picnic at the Beach
Scott Pugel, MD

The Reconnaissance Mission
Daniela Alexandru Abrams, MD

Trapt: A Reflection on Mental Illness
Jesse Garrett O’Shea, MD


Carol Nelson



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