Spring 2017 - Volume 21 Number 2

Original Research

Are They Too Old for Surgery? Safety of Cholecystectomy in Superelderly Patients (≥ Age 90)
Busayo Irojah, MD; Ted Bell, MS; Rodney Grim, PhD; Jennifer Martin, PhD; Vanita Ahuja, MD, FACS
Using the American College of Surgeons National Surgical Quality Improvement Program database, a retrospective analysis was performed of super-elderly patients (1007) who underwent laparoscopic and open cholecystectomy between 2005 and 2012: 80% were nonemergent, 20% emergent; 21.4% open, 78.6% laparoscopic. Mortality did not decrease significantly during the study period. Overall mortality was 5.5%, significantly less for the laparoscopic group (3.7% vs 12%) and nonemergent group (4.5% vs 9.5%). Median length of stay for open cholecystectomy was 9 days vs 5 days for laparoscopic; nonemergent cholecystectomy was 5 days vs 7 days for emergent.

Geriatric Hip Fracture Care: Fixing a Fragmented System
Mary E Anderson, MD; Kelly McDevitt, RN, MS, ONC; Ethan Cumbler, MD; Heather Bennett, MS, MBA; Zachary Robison, MBA; Bryan Gomez; Jason W Stoneback, MD
The authors designed and implemented a comprehensive geriatric hip fracture program for patients (≥ = 65 years) at an academic Medical Center (10/2014). Among 267 patients (1/1/2012-3/31/2016), 271 were admitted (154 before and 117 after program implementation). Mean hospital length of stay significantly improved from 6.4 to 5.5 days. The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly.

Factors Influencing Helmet Use, Head Injury, and Hospitalization Among Children Involved in Skateboarding and Snowboarding Accidents
Homa Sadeghian, MD; Brian Nguyen, MD; Nhan Huynh, MD; Joshua Rouch, MD; Steven L Lee, MD, FACS, FAAP; Shahrzad Bazargan-Hejazi, PhD
A cross-sectional study of skateboard- and snowboard-associated injuries (2003-2012) among individuals < 18 years using National Electronic Injury Surveillance System data from 100 hospitals. Of 1742 patients, 48.9% and 51.1% were skateboarders and snowboarders, respectively. Overall, 52.1% did not use helmets, and 40.4% sustained head injuries. Sex, race/ethnicity, helmet use, and skateboarding predicted head injury. Age, sex, skateboarding, and head injury predicted hospital admission. Injury prevention and outreach programs are needed to increase helmet use in skateboarders.

Effect of a Smoking Cessation Program on Sexual Function Recovery Following Robotic Prostatectomy at Kaiser Permanente Southern California
Seena Safavy, MD; Patrick S Kilday, MD; Jeff M Slezak, MS; George A Abdelsayed, MD; Teresa N Harrison, SM; Steven J Jacobsen, MD, PhD; Gary W Chien, MD
All patients who underwent robotic prostatectomy (3/2011-4/2013) with known smoking status were followed-up through 11/2014. All smokers were offered wellness coaching, tobacco cessation classes, and pharmacotherapy. Of smokers (139) who participated in the smoking cessation program, 56 quit smoking, whereas 83 remained smokers at last follow-up. Smoking cessation, along with bilateral nerve-sparing status, were the only 2 modifiable factors associated with improved sexual function after prostatectomy.

Improving Patient-Centered Care by Assessing Patient Preferences for Multiple Sclerosis Disease-Modifying Agents: A Stated-Choice Experiment
Caroline S Carlin, PhD; Lucas Higuera, MA; Sarah Anderson, PharmD
A sample of patients with multiple sclerosis (privately and publicly insured in a regional health plan) underwent a stated-choice experiment that asked them to select their preferred disease-modifying agent (DMA). Each respondent was randomized to 1 of 6 possible sets of 8 drug choices (48 drug pairings). Each choice included 2 hypothetical DMAs and a “no drug” option. The “no drug” alternative was a stronger substitute than the alternative drug, and the most important drivers of choice were type of side effects and risk of severe relapse.

Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection
Irmina A Elliott, MD; Irene Epelboym, MD; Megan Winner, MD, MS; John D Allendorf, MD; Philip I Haigh, MD, MSc
The authors reviewed 1165 cases of partial pancreatectomy (1998-2010). Of 1165 patients, 41.8% had preexisting diabetes. In the remaining 678 patients, at a median 3.6 months, diabetes developed in 40.4%, and pancreatic insufficiency developed in 34.7%. Independent predictors were higher Charlson Comorbidity Index (CCI), hazard ratio, and pancreatitis. Independent predictors of exocrine insufficiency were female sex and higher CCI. Distal resection and Asian race predicted decreased exocrine insufficiency.

Communication with Physicians about Health Care Costs: Survey of an Insured Population
Nora B Henrikson, PhD, MPH; Eva Chang, PhD, MPH; Kevin Ulrich, MA;Deborah King, MSW; Melissa L Anderson, MS
A cross-sectional survey of a random sample of insured (from the entire membership age ≥ 21 years) in an integrated health care system in Washington State, resulted in 2200 survey returns (7200 invitations), with 92% wanting to know their out-of-pocket costs before beginning treatment. Most preferred talking to their physician about costs (81.4%), most expressed comfort discussing costs with them (75.6%), and 21.6% reported family medical debt. Delay in seeking care was positively and independently associated with preferring to discuss costs with one’s physician; current medical financial burden was not.

Patterns of Multiple Emergency Department Visits: Do Primary Care Physicians Matter?
Daniel D Maeng, PhD; Jing Hao, PhD; John B Bulger, DO, MBA
Geisinger Health Plan claims data among adult patients who averaged more than 1 Emergency Department (ED) visit within a 12-month period (2013-2014) were obtained (N = 20,351). Multiple ED visits were significantly associated with younger age (18-39 years), having Medicaid insurance, and greater comorbidity. Higher rates of physician office visits and inpatient admissions were also associated with higher rates of multiple ED visits. Accounting for primary care physician characteristics only marginally improved the explained variation.

A Survey of Parents with Children on the Autism Spectrum: Experience with Services and Treatments
Tracy A Becerra, PhD, OTR/L; Maria L Massolo, PhD; Vincent M Yau, PhD; Ashli A Owen-Smith, PhD; Frances L Lynch, PhD; Phillip M Crawford, MS; Kathryn A Pearson; Magdalena E Pomichowski, MPH; Virginia P Quinn, PhD; Cathleen K Yoshida, MA; Lisa A Croen, PhD
Of the 1155 respondents of children and adolescents with autism spectrum disorder (ASD), the children, racially and ethnically diverse and representative of the total population, were 83% male, 57% were < age 10 years, and 64% were diagnosed with ASD. They most frequently used: Individualized Education Programs (85%), family physician visits (78%), occupational (55%) and speech therapy (60%). Home-based programs frequently included implementation of social skills training (44%) and behavior management (42%). Prescription medication use was high (48%). Caregivers reported disruption of personal and family routines because of problem behaviors.

Risk of Venous Thromboembolism after a Single Normal Proximal Lower Extremity Venous Ultrasound
Myles M Mitsunaga, MD; Shannon Kogachi, MS; Hyo-Chun Yoon, MD, PhD
Single proximal ultrasound results, and clinical data of all inpatient and ambulatory patients with suspected acute deep venous thrombosis, were reviewed (1/2014-12/2014). Of 1295 patients, 8.6% were found to have acute deep venous thrombosis on the initial proximal ultrasound. Of the remaining 1184 patients with initially normal results, sampled at 3-month follow-up, 90.8% had no venous thromboembolic event. Therefore, serial proximal ultrasound is unnecessary for most of our patients, and its elimination will save time and out-of-pocket expenses.

Real-World Experiences With a Direct-Acting Antiviral Agent for Patients With Hepatitis C Virus Infection
Vincent Louie, PharmD; Nyan L Latt, MD; Derenik Gharibian, PharmD; Amandeep Sahota, MD; Beshoy T Yanny, MD; Rasham Mittal, MD; Zoe Bider-Canfield, MPH; T Craig Cheetham, PharmD, MS
Of the 213 study patients (≥ age 18 years with hepatitis C virus who received sofosbuvir treatment), 42.3% had cirrhosis, and 38% were treatment-experienced. Most patients (69.5%) received dual therapy (sofosbuvir + ribavirin), whereas the remainder (30.5%) received triple therapy (sofosbuvir + ribavirin + interferon). The overall rate of sustained virologic response at 12 weeks posttreatment was 72.9% for genotype 1 infection, 64.7% in the treatment-experienced subgroup, and 66.7% in the cirrhosis subgroup. Rates of sustained virologic response at 12 weeks posttreatment for genotypes 2 and 3 were 90.8% and 55%, respectively.

Patient and Practitioner Perspectives on Culturally Centered Integrated Care to Address Health Disparities in Primary Care
Glenda Wrenn, MD, MSHP; Fatima Kasiah, MD; Allyson Belton, MPH; Sheena Dorvil, MPH; Kristin Roberts, MPH; Brian McGregor, PhD; Kisha Holden, PhD
Thirty-two adult patients of an integrated primary care clinic participated in focus groups, and nine health care practitioners/administrators from five different integrated practice settings in the Atlanta, GA, area participated in interviews. Common themes were the importance of peer support and community engagement as areas of patient interest. Participants had good knowledge in recognizing depressive symptoms but were less knowledgeable about treatment options and expectations of treatment. The administrative and practitioner perspective suggests that patient preferences are valued and perceived as valid.

Effectiveness of Electrostimulation on Whole Salivary Flow Among Patients with Type 2 Diabetes Mellitus
Sujatha Dyasnoor, MDS; Shwetha Kamath, MDS; Nishat Fatima Abdul Khader, MDS


Design and Implementation of a Physician Coaching Pilot to Promote Value-based Referrals to Specialty Care
Leah Tuzzio, MPH; Evette J Ludman, PhD; Eva Chang, PhD, MPH; Lorella Palazzo, PhD; Travis Abbott, MD; Edward H Wagner, MD, MPH; Robert J Reid, MD, PhD

Special Reports

Health Care Systems Support to Enhance Patient-Centered Care: Lessons from a Primary Care-Based Chronic Pain Management Initiative
Charles R Elder, MD, MPH, FACP; Lynn L DeBar, PhD, MPH; Cheryl Ritenbaugh, PhD, MPH, Maureen H Rumptz, PhD; Charlotte Patterson, MBCHB, PhD, MBAcC, MRCGP; Allison Bonifay, MA, LPC; Penney Cowan; Lindsay Lancaster, RN, PhD, CNS; Richard A Deyo, MD, MPH
A qualitative analysis of project minutes, interviews, and focus groups evaluated experiences of stakeholders (patients, caregivers, clinicians, medical office support staff, health plan administrators, an information technology consultant, and a patient advocate). Stakeholders included many patients with no prior experience with research. This approach enriched the applicability of feedback but necessitated extra time for stakeholder training and meeting preparation. More involvement of medical assistants and Information Technology staff was required than originally anticipated.

Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients
Tom Janisse, MD, MBA; Karen Tallman, PhD
Seven different modes of communication transformation were described by seven physicians: a listening tool, an awareness course, finding new meaning in clinical practice, a technologic tool, a sudden insight, a mentor observation, and a physician-as-patient experience. All modes resulted in a change of state of mind. This resulted in a marked change of behavior and a substantial improvement of communication and relationship.

Review Article

Spice-y Kidney Failure: A Case Report and Systematic Review of Acute Kidney Injury Attributable to the Use of Synthetic Cannabis
Ceyda Zarifi, DO; Shuchi Vyas, MD
Spice, a synthetic cannabinoid, is not detectable upon routine drug screening. A 21-year-old man presented with new-onset seizures and then developed uncontrollable hypertension, agitation, respiratory failure requiring intubation, pulmonary hypertension, and acute kidney injury with a maximum blood urea nitrogen/creatinine level of 54/7.90 mg/dL.

Case Reports

Bilateral Basaloid Squamous Cell Carcinoma of the Parotid Gland: A Case Report and Review of the Literature
Alexander Rivero, MD; Christopher G Tang, MD; Barry M Rasgon, MD
Four years after a right total parotidectomy and modified radical neck dissection, the patient presented with an enlarging left parotid mass and received a left total parotidectomy and modified radical neck dissection. Postoperative radiation therapy was performed after each surgical intervention. He remains disease free at four-year follow-up after the second mass was resected.

Leukocytoclastic Vasculitis Secondary to Pyridostigmine (Mestinon): Report of a Possible First Case
Gunveen Singh; Tim Hodgson, MBChB; David E Clarke, MD, FCCP
A 91-year-old man was diagnosed with ocular myasthenia gravis. He was started on pyridostigmine, and 2 weeks later he developed a rash. The rash was biopsied and found to be secondary to leukocytoclastic vasculitis; the pyridostigmine was stopped, loratadine was started, and the rash resolved.


Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Treatment With a Biologic: A Case ReportStevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Treatment With a Biologic: A Case Report
Ian Chong, MD; Alice Chao, MD, MS

An Unlikely Rapid Transformation of Myelodysplastic Syndrome to Acute Leukemia: A Case Report
Andrew Pourmoussa, MD; Karen Kwan, MD


Simultaneous Occurrence of Varicella Zoster Virus-Induced Pancreatitis and Hepatitis in a Renal Transplant Recipient: A Case Report and Review of Literature
Puneet Chhabra, MD, DM; Priyadarshi Ranjan, MS, MCh; Deepak K Bhasin, MD, DM, FASGE, AGAF, FAMS

Clinical Medicine

Focal Segmental Glomerulosclerosis in a Patient with Ambiguous Genitalia: A Diagnostic Dilemma
Oliver E Ross, MD; Dean A Kujubu, MD; John J Sim, MD
This renal condition encompasses and displays a nonspecific histologic appearance on a kidney biopsy specimen. A 34-year-old man, who was born with ambiguous genitalia, now had advanced kidney disease. The literature pertaining to genetic causes of focal segmental glomerulosclerosis is reviewed.

Image Diagnosis: Numb Chin Syndrome
Rabih Geha, MD; Trevor Jensen, MD
A 58-year-old woman with a history of stage III lung adenocarcinoma presented with good dentition, no oral lesions, and reduced sensation to light touch over the right side of her chin. A scan showed diffuse dural thickening concerning for leptomeningeal carcinomatosis.

Image Diagnosis: Unusual Cause of Gastrointestinal Bleeding in a Young Man: Isolated Gastric Angiodysplasias
Sandeep Lamoria, MD; Arka De, MD; Vishal Sharma, MD, DM
Gastric angiodysplasias are an uncommon cause of upper gastrointestinal bleeding and may be associated with underlying predisposing factors like hereditary hemorrhagic telangiectasia syndrome or under-going hemodialysis. They may present with hematemesis, melena, or chronic gastrointestinal blood loss resulting in anemia.

Image Diagnosis: Splenic Infarction Associated with Oral Contraceptive Pills in a Healthy Young Woman
Al-Ola Abdallah, MD; Varinder Kaur, MD; Fade Mahmoud, MD; Pooja Motwani, MD


ECG Diagnosis: Right Ventricular Myocardial Infarction
Manvi R Nagam, MBBS; David R Vinson, MD; Joel T Levis, MD, PhD, FACEP, FAAEM

Narrative Medicine

Dying Is Much More Difficult Than You’d Think: A Death By Dehydration
Phillipa J Malpas, PhD
Then she stopped drinking all fluids. Staff in the retirement village, a palliative care physician friend, her general practitioner, and her friends were supportive of her decision to stop fluids and assured Lieke they would do everything possible to keep her comfortable and at home.

Experiences in an Italian Rehabilitation Hospital—Two Stories
Claudio Crisci, MD; Biagio Arnone, MD
In private rehabilitation centers, physicians often have to deal with overworked nurses and angry, worried patients and relatives. Two stories take place in the same setting, but they are quite divergent and show two very different approaches toward patients and nurses: a thoughtful one and an angry one.

From the Bedside: A Family Physician Experiences Health Care from the Patient Side
Michael Ismail, MD
Getting a terminal diagnosis from a colleague and friend seemed less difficult to me than imagining getting this news from a stranger. Heartfelt concern goes a long way in softening the blow. However, it seemed to be much more difficult for my colleagues in the emergency room and
for the neurologist involved.

Nursing Research and Practice

Patient Preferences for Discussing Childhood Trauma in Primary Care
Ellen Goldstein, MFT, PhD; Ninad Athale, MD; Andrés F Sciolla, MD; Sheryl L Catz, PhD
Of 178 adult patients asked, 83% participated: 37% screened positive for posttraumatic stress disorder, 42% reported ≥ 4 Adverse Childhood Experiences, and 26% had elevated scores on both. Primary Care-posttraumatic stress disorder and Adverse Childhood Experiences scores were strongly positively correlated. Most patients agreed they were comfortable being asked about trauma directly, or through screening questionnaires, and did not oppose the inclusion of trauma-related information in their medical record. In addition, most patients perceived their clinician as comfortable asking questions about childhood trauma and able to address trauma-related problems.


A Qualitative Inquiry into the Complex Features of Strained Interactions: Analysis and Implications for Health Care Personnel
Charlotta Thunborg, PhD; Martin Salzmann-Erikson, RN, PhD

Letters to the Editor


Response to Functional Medicine Case Study and Editorial


Research Letter: Anticholinergic Drugs and the Gallbladder —A Neglected Effect?




An Alternative Paradigm for Evidence-Based Medicine: Revisiting Lawrence Weed, MD’s Systems Approach
Ali Rafik Shukor

Book Reviews


What About Me? Puberty Education for Preteens
Michael E Lynch

Soul of the Healer

Lorenzo Mills, MD

Camel Caravan, Morocco
David Clarke, MD

No One Knows
Danielle Elizabeth Guinan

The Argenteuil Bridge
Rashmi Gupta, PhD

Yosemite Firefall
Michael B Brewer, MD

On the Cover

Irish Fence
Samuel H Glassner, MD


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