Winter 2017 - Volume 21 Number 1

Original Research & Contributions

Fundamental Use of Surgical Energy (FUSE): An Essential Educational Program for Operating Room Safety
Stephanie B Jones, MD; Malcolm G Munro, MD, FACOG, FRCS(c); Liane S Feldman, MD, FACS, FRCS; Thomas N Robinson, MD, MS, FACS; L Michael Brunt, MD, FACS; Steven D Schwaitzberg, MD, FACS; Daniel B Jones, MD, MS, FACS; Pascal R Fuchshuber, MD, FACS
The lack of fundamental understanding of energy device function, design, and application contributes to avoidable injury and harm at a rate of approximately 1 to 2 per 1000 patients in the US. Most injuries are associated with the use of energy-based surgical devices. The Society of American Gastrointestinal and Endoscopic Surgeons developed the Fundamental Use of Surgical Energy (FUSE) program, which fills a void in the curriculum and competency assessment for surgeons and other procedural specialists.

Morbidity in Pregnant Women Associated with Unverified Penicillin Allergies, Antibiotic Use, and Group B Streptococcus Infections
Shilpa H Desai, MD; Michael S Kaplan, MD; Qiaoling Chen, MS; Eric M Macy, MD, MS
In Kaiser Permanente Southern California, there were 170,379 women who had 201,316 pregnancies between 1/1/2009-12/31/2014. Women with a penicillin allergy, with or without group b streptococcus infections, had significantly higher cesarean section rates, days in the hospital after delivery, and higher rates of adverse drug reactions associated with all antibiotic use. Penicillin allergy testing of pregnant women with a history of penicillin allergy may help reduce these unwanted outcomes.

Understanding Preferences for Osteoporosis Information to Develop an Osteoporosis Patient Education Brochure
Stephanie W Edmonds, RN, MPH, PhD(c); Samantha L Solimeo, PhD, MPH; Vu-Thuy Nguyen, MS, PhD(c); Nicole C Wright, PhD, MPH; Douglas W Roblin, PhD; Kenneth G Saag, MSc, MD; Peter Cram, MBA, MD
To develop an educational brochure on bone health for adults aged 50 years and older the authors used a mixed-method, semistructured interview methodology. The authors enrolled 64 participants (most were women, white, and college-educated, with an average age of 66.1 years). Participants restated the basic content of the brochure and preferred Brochure A’s use of photographs. This process can guide others in developing health educational brochures.

Understanding Faculty and Trainee Needs Related to Scholarly Activity in a Large, Nonuniversity Graduate Medical Education Program
Davida Becker, PhD, MS; Hanna Garth, PhD, MPH; Rachel Hollander; Felice Klein, RN, MN; Marc Klau, MD, MBA
Faculty and trainees in primary care and specialties have differing research-related needs that graduate medical education programs should consider when designing curricula to support scholarly activity. Developing research skills of primary care faculty, who reported the lowest skill level, is a priority to support trainees’ scholarly activity. Research barriers that differed across groups included other work roles taking priority; desire for work-life balance; and lack of managerial support, research equipment, administrative support, and funding.

The Evolution of the Medical School Deanship: From Patriarch to CEO to System Dean
Danny A Schieffler, PhD; Philip M Farrell, MD, PhD; Marc J Kahn, MD, MBA; Richard A Culbertson, PhD
An alternative path to the Dean/CEO model has developed—the System Dean, who functions as a team player within a broader health system that determines the mission for the medical school and the related clinical enterprise. In this paper, the authors discuss the evolution of the medical school dean with respect to scope of authority and role within the health care system.

Transcendental Meditation and Reduced Trauma Symptoms in Female Inmates: A Randomized Controlled Study
Sanford Nidich, EdD; Angela Seng; Blaze Compton, MA; Tom O’Connor, PhD; John W Salerno, PhD; Randi Nidich, EdD
Compared with the general population, trauma experiences are higher among incarcerated women. Twenty-two inmates at the Coffee Creek Correctional Facility in Wilsonville, OR, with at least 4 months left of incarceration were enrolled in this randomized controlled pilot study. Significant reductions were found on total trauma, intrusive thoughts, and hyperarousal. These results indicate the feasibility of a Transcendental Meditation (TM) program in a female prison population and that TM may be an effective tool for decreasing trauma symptoms.

Pediatric Hip Fractures in California: Results from a Community-Based Hip Fracture Registry
Heather A Prentice, PhD; Elizabeth W Paxton, MA; Jessica J Hunt, MA; Christopher D Grimsrud, MD; Jennifer M Weiss, MD
In our series of 39 patients using registry data (2009-2012), hip fractures in patients younger than age 21 years were more common in boys and Hispanic people. Intertrochanteric fractures (Delbet Type IV) were the most frequently observed type in our community-based hip fracture registry. Short-term complications were infrequent.

Participation in Activities Associated With Quality of Life for Long-Term Survivors of Rectal Cancer
Carmit McMullen, PhD; Liyan Liu, MD, MS; Joanna E Bulkley, PhD; Mark C Hornbrook, PhD; Christopher Wendel, MS; Marcia Grant, RN, PhD, FAAN; Andrea Altschuler, PhD; Larissa KF Temple, MD, MSc, FACS; Robert S Krouse, MD, FACS; Lisa Herrinton, PhD
Cancer patients’ participation in social, recreational, and civic activities is strongly associated with quality of life (QOL). In an observational study with longitudinal and cross-sectional components, 567 rectal cancer survivors completed a mailed questionnaire. Overall response rate was 61%. The type of operation, receipt of radiation therapy, and bowel function were significantly associated with participation in activities (the strongest predictor of QOL). The authors recommend revising QOL instruments, and interventions addressing preferred activities and adoption of new, fullling activities.

End-Stage Renal Disease Outcomes among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve
John J Sim, MD; Michael Batech, DrPH; Kim N Danforth, ScD; Mark P Rutkowski, MD; Steven J Jacobsen, MD, PhD; Michael H Kanter, MD
In this longitudinal cohort study (2/2010-12/2015) of 12,394 Kaiser Permanente Southern California individuals (in the creatinine safety program), 83 (0.7%) reached End-Stage Renal Disease (ESRD). A higher incidence was found of ESRD among individuals captured into this program than if the Chronic Kidney Disease Epidemiology Collaboration equation were used. The findings demonstrate the importance of a creatinine safety program in an integrated health system.

Physicians’ Perceptions of Volunteer Service at Safety-Net Clinics
Laura McGeehan, PhD; Michael A Takehara, MD; Ellen Daroszewski, PhD, APRN
Physicians belonging to the Southern California Permanente Medical Group conveyed uniformly positive perceptions of their volunteer service, and most were motivated by humanitarian or prosocial desires. Volunteering also provided a protective “escape hatch” from the pressures of the physicians’ regular jobs. Physicians cited few challenges to volunteering. The most common personal barrier was a lack of time. The most common professional barriers were organizational and supply issues at the clinic, along with the patients’ social, transportation, and financial challenges.

Implementation and Evaluation of the Safety Net Specialty Care Program in the Denver Metropolitan Area
Meredith P Fort, PhD, MPH; Lynnette M Namba, MPH; Sarah Dutcher, MIA; Tracy Copeland; Neysa Bermingham; Chris Fellenz, MD; Deborah Lantz, RN; John J Reusch, MD, FACC; Elizabeth A Bayliss, MD, MSPH
This program offers safety-net clinicians the option to electronically consult with specialists. Uninsured patients may be seen by specialists in office visits for a defined set of services. From 5/2013 to 12/2014, safety-net clinicians at 23 clinics made 602 e-consults to specialists, and 81 patients received face-to-face specialist visits. Of 204 primary care clinicians, 103 made e-consults; 65 specialists participated in the program.

Reducing Unnecessary Postoperative Complete Blood Count Testing in the Pediatric Intensive Care Unit
Maya Dewan, MD, MPH; Jorge Galvez, MD; Tracey Polsky, MD, PhD; Genna Kreher, MPH; Blair Kraus, RN, MSN; Luis Ahumada, MS; John McCloskey, MD; Heather Wolfe, MD
The authors identified a cohort of patients for whom routine postoperative complete blood count (CBC) testing is unnecessary. They saw sustained decreases below their 50% goal. There were no hemoglobin results below 8 mg/dL, or surgery-related blood transfusions in this cohort within 7 days of surgery. Estimated hospital charges related to routine postoperative CBCs decreased by 87% during 6 postintervention months.

Comprehensive Description of Comorbidity for Autism Spectrum Disorder in a General Population
David Cawthorpe, PhD
Direct physician billing data for the city of Calgary, Alberta, Canada, for the treatment of any presenting concern in the Calgary Health Zone (n = 763,449) from 1994 to 2009 were extracted. Annual rates of autism spectrum disorder (ASD) increased 3.9-fold for males and 1.4-fold for females. Males with ASD had overall higher odds ratios (ORs) in 11 main ICD-9 classes, and females with ASD had higher ORs in 12 main ICD-9 classes. Patients with ASD have significant comorbidity of physical disorders.

Collaborative Management of Neurocognitive Disorders in Primary Care: Explorations of an Attempt at Culture Change
Lewis Mehl-Madrona, MD, PhD, MPhil; Barbara Mainguy, MA
Two group programs were implemented offering exercise, diet, cognitive enhancement, and socialization for patients with minor neurocognitive disorder (MiND): one at a hospital and one at a skilled nursing facility. Thirty-two different patients attended the groups for at least six sessions. Participants enthusiastically reported positive change on qualitative interviews and showed improvement in cognition, balance, and self-esteem. Family medicine residents and practicing physicians both shifted toward lifestyle medicine and significantly changed their views on the efficacy of treatments.

Special Report

The Grateful Aging Program: A Naturalistic Model of Transformation and Healing into the Second Half of Life
Marilyn Schlitz, PhD
This article applies an empirically derived naturalistic model of transformation to aging. Nine steps are identified: 1) answer the call to transformation, 2) cultivate curiosity, 3) formalize a practice, 4) set intention, 5) pay attention to the gifts of aging, 6) build habits, 7) find guidance, 8) move to acceptance, and 9) transform self and society. Educational programs are described, and are designed to expand awareness of healthy, mindful, and meaningful aging; to promote individual and social well-being; and to facilitate a supportive atmosphere for personal enrichment and shared learning.

Review Articles

Use of Improving Palliative Care in the ICU (Intensive Care Unit) Guidelines for a Palliative Care Initiative in an ICU
Eluned Mun, MS, MSN, DNP, APRN-Rx, AGNP-BC, CCRN; Craig Nakatsuka, MD; Lillian Umbarger, MD; Ruth Ruta, MSN, RN; Tracy McCarty, RN; Cynthia Machado, RN; Clementina Ceria-Ulep, PhD, RN
A systematic method was developed to create a new program compatible with the authors’ specific intensive care unit (ICU) environment and patient population. A literature review revealed an extensive array of reports and numerous clinical practice guidelines, assessed for information and strategies appropriate for their unit. Recommendations provided by the Center to Advance Palliative Care from its Improving Palliative Care in the ICU project were used to successfully implement a new palliative care initiative in their ICU.

Sjögren Syndrome and Pregnancy: A Literature Review
Suruchi Gupta, MS, MBBS; Nikhil Gupta, MD, MBBS

Case Reports

Consideration of Personal Adverse Childhood Experiences during Implementation of Trauma-Informed Care Curriculum in Graduate Health Programs
Joshua Strait; Tiffany Bolman, MAT
Scientific findings of adverse childhood experiences (ACEs) and their lifelong graded relationship with leading causes of death are well established. Many health care practitioners, however, have yet to implement ACEs screening in clinical practice. Furthermore, ACEs screening and trauma-informed care (TIC) are not part of standard graduate-level training. Among 967 graduate students from 9 health professions programs, who voluntarily completed an ACE questionnaire, there was statistical significance in familiarity with clinical and scientific findings of the ACE Study and familiarity with TIC.

Adult Epiglottitis: A Case Series
Benjamin Lindquist, MD; Sybil Zachariah, MD; Anita Kulkarni, MD


Image Diagnosis: Endobronchial Tuberculosis Masquerading as an Endobronchial Tumor with Presentation as Middle Lobe Syndrome
Kamal Gera, MD; Nevin Kishore, MRCP(UK)

Primary Upper Limb Lymphedema: Case Report of a Rare Pathology
Michael EC McFarlane, DM, FRCS, FACS


Why Branding Permanente Matters
Deb Friesen, MD
Brands are the composite experiences that consumers have with a company. A brand promises relevant differentiated benefits. This knowledge then turns brands into assets that drive strategy. Brand isn’t just what we think of ourselves; it’s the totality of the perceptions of everyone around us. Customers, patients, and the market are often confused about who is Permanente. When people choose KP they are buying a healthier, better version of themselves.


Mind-Body Training for At-Risk Populations: Preventive Medicine at its Best
Charles Elder, MD, MPH, FACP
This article is a companion to, and offers editorial commentary in support of, “Transcendental meditation and reduced trauma symptoms in female inmates: A randomized controlled pilot study,” in this Winter 2017 issue, and “Reduced trauma symptoms and perceived stress in male prison inmates through the Transcendental Meditation program: A randomized controlled trial,” in the Fall 2016 issue of The Permanente Journal.

Narrative Medicine

On The Shoulders of Giants
Tom Paluch, MD
A mentor is defined in Webster’s Dictionary as a trusted counselor or guide. Irwin was, and ever will be, my dearest and most influential mentor. He is the man who taught me how to operate, what it meant to be a surgeon, and, most importantly, how it felt to be a surgeon; for without the feeling, a surgeon is a mere technician: a manipulator of human flesh. With feeling, a surgeon can find transcendence, a special, powerful intimacy with another human being in this most unique of human relations.

Practicing Healing—Cleaning the Back of an Elderly Tibetan Woman
James Lake, MD
While the author volunteered at a Tibetan hospital, he encountered an elderly woman who has become an icon of Tibetan stoicism in the face of suffering. He felt deeply humbled by the realization that he had participated in a sacred space with a patient—and he felt awake. He found himself contemplating how many “exchanges” of spirit he had missed during the weeks in Tibet, how many encounters between one sentient being and another might have taken place had he paid closer attention and taken more time to be present with an open heart while doing the hard work of healing.

Clinical Medicine

Image Diagnosis: A Striking Bleomycin-Induced Skin Toxicity: Flagellate Hyperpigmentation
Lin Hao, MD; Fade Mahmoud, MD, FACP


ECG Diagnosis: Deep T Wave Inversions Associated with Intracranial Hemorrhage
Joel T Levis, MD, PhD, FACEP, FAAEM


Image Diagnosis: Zinc-Induced Copper Deficiency Causing Pancytopenia Recognized on Bone Marrow Examination
Joyce Johnsrud, MD; Al-Ola Abdallah, MD; Steven A Schichman, MD, PhD; Zhifu Xiang, MD, PhD

Book Review

Childhood Disrupted: How Your Biography Becomes Your Biology, and How You Can Heal
David D Clarke, MD

Soul of the Healer

Bogenfels Rock, Namibia
Quentin Eichbaum, MD, PhD, MPH, MFA, MMHC, FCAP

Tom Sawyer Syndrome
Phillip La Borie

Autumn Dream
Sapna Reddy, MD

Haleakala Sunrise
Jae Lim, MD, PhD

On the Cover

Where Time Stands Still
Sapna Reddy, MD


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