Summer 2019 - Volume 23 Number 3

Original Research and Contributions

Reduced Health Care Utilization among Elderly Patients with Informal Caregivers
Caroline Carlin, PhD; Guy David, PhD
Patients with caregivers were discharged after shorter hospital lengths of stay and were less likely to require postacute emergency care, home health services, or discharge to skilled nursing facilities. Savings were smaller when caregivers were younger, in poor health, or female. We extrapolated the reduced utilization associated with a coresidential caregiver to estimate Medicare savings of $514 million in 2015.

Mastectomy or Breast-Conserving Therapy: Which Factors Influence A Patient’s Decision?
David Moiel, MD; John Thompson, MD; Kenneth D Larsen, MD, PhD
From a cancer registry (2003-2013) of 5258 patients with breast cancer, 2604 patients with invasive breast cancer chose mastectomy or breast-conserving therapy as they met unambiguous criteria for equivalent outcomes with either option. Patients who preferred mastectomy were strongly influenced by tumor size and abnormal physical examination findings of a palpable mass, rather than their age, family history of breast cancer, T category, or surgeon.

CMERapid Implementation of Intraoperative Ultrasonography to Reduce Wire Localization in The Permanente Medical Group
Sharon Chang, MD; Magdalene Brooke, MD; Elizabeth Cureton, MD; Alice Yeh, MD; Rhona Chen, MD; Nicole Mazzetti-Barros, MPH/CHES; Reza Rahbari, MD; Sherry Butler, MD; Nicole Hill, MD; Veronica Shim, MD
A multifacility protocol using intraoperative ultrasonography in 143 patients with breast lesions by 7 surgeons at 4 pilot sites (1/2015-10/2015) decreased preoperative wire localization (WL) procedures and produced no significant difference in margin positivity between the WL and non-WL groups. This technique can be a cost-effective alternative to WL in patients who are candidates for hydrogel clip placement.

Epidemiology of Chemotherapy-Induced Anemia in Patients with Non-Hodgkin Lymphoma
Kim Cannavale, MPH; Hairong Xu, MD, PhD; Lanfang Xu, MS; Olivia Sattayapiwat, MPH; Roberto Rodriguez, MD; Chet Bohac, MD; John Page, MD, ScD; Chun Chao, PhD
Of 699 chemotherapy-treated patients with non-Hodgkin lymphoma (NHL) diagnosed (2010-2012), 36.9% and 11.6% developed moderate (hemoglobin < 10 g/dL) and severe (hemoglobin < 8 g/dL) chemotherapy-induced anemia (CIA) during chemotherapy, respectively. An increasing trend of red blood cell transfusion was observed: 12% in phase 1, 22% in phase 2, and 27% in phase 3. In contrast to previous European reports, we note a higher incidence of CIA in patients with NHL in this US community practice setting.

CMEResident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study
Kristen Ironside, MA; Davida Becker, PhD, MSc; Isabel Chen, MD, MPH; Adegbemisola Daniyan, MD; Ary Kian, MD; Neeta Saheba, MD; Rachel Hollander
The authors conducted 14 focus groups with core faculty and residents in 5 specialties (family medicine, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry) at a large integrated health care system in Southern California. Five themes were contributing or protective factors: 1) having or lacking a sense of meaning at work, 2) fatigue and exhaustion, 3) cultural norms in medicine, 4) the steep learning curve from medical school to residency, and 5) social relationships at and outside of work. Recommended intervention strategies targeted individuals, residents’ social networks, and the learning and work environment.

Hypocalcemia after Total Thyroidectomy in Graves Disease
Malak Al Qubaisi; Philip I Haigh, MD, MSc, FRCSC, FACS
From the 2016 American College of Surgeons National Surgical Quality Improvement Program participant-use data files, of 2143 patients who underwent total thyroidectomy, 222 patients experienced hypocalcemia after surgery (124 had symptomatic hypocalcemia postoperatively), and 16.3% had Graves disease. Women and patients who underwent parathyroid autotransplantation were at greater risk of development of hypocalcemia, but not older patients.

Effect of Helicobacter pylori Treatment on Unexplained Iron Deficiency Anemia
Daniel S Tseng, MD, MS, FACP; Dan Li, MD; Sri M Cholleti, MD; Julia C Wei, MPH; Yves Jodesty, MD; Hung-Viet Pham, MD
A large number of patients with iron deficiency anemia have no known cause of their anemia despite a full evaluation. All adult patients with both unexplained iron deficiency anemia and Helicobactor pylori infection diagnosed 1/1/08-4/30/15 were identified; 408 patients were treated for H pylori. In contrast to the finding of previous studies, we found no evidence that H pylori is involved in causing iron deficiency anemia. Iron deficiency anemia resolved in most subjects regardless of H pylori treatment status.

Twitter Conversations and English News Media Reports on Poliomyelitis in Five Different Countries, January 2014 to April 2015
Braydon J Schaible, MPH; Kassandra R Snook, MPH; Jingjing Yin, PhD; Ashley M Jackson, MPH; Jennifer O Ahweyevu, MPH; Muhling Chong, MPH; Zion Tsz Ho Tse, PhD; Hai Liang, PhD; King-Wa Fu, PhD; Isaac Chun-Hai Fung, PhD
The authors retrospectively examined a 40% random sample of Twitter data containing the hashtag #polio (1/14-5/15; N = 79,333). The results showed significant differences between the 5 countries in terms of content. English mass media content focused largely on violence/conflicts and cases of polio, whereas social media focused on eradication and vaccination efforts along with celebrations.

Special Reports

The Kaiser Permanente Los Angeles Annual Research Week Abstracts
John J Sim, MD; Kristen Ironside, MA; Gary W Chien, MD

The Kaiser Permanente Los Angeles Annual Research Week Abstract Summaries
Research is a standard for the Kaiser Permanente community and now part of its DNA. The history reflects a changing culture where recognition, emphasis, and support of research increases in the organization and training programs. If physicians are asked to change and improve the ways they practice medicine, the evidence must be there. This has fostered the growth of researchers as well as the recruitment and attraction of talented research-minded physicians.

A Daily Hospital Progress Note that Increases Physician Usability of the Electronic Health Record by Facilitating a Problem-Oriented Approach to the Patient and Reducing Physician Clerical Burden
James M Sutton, MD; Steven R Ash, MD; Akram Al Makki, MD; Rabih Kalakeche, MD
The framework is 3 sections: Subjective, Objective, and an Assessment and Plan section, subdivided by problem titles. The record would: 1) juxtapose to each problem title relevant medications, key durable results, and limitations; 2) enter in the running lists under Assessment and Plan most relevant information for that day; and 3) generate a flow sheet in a problem’s progress note for any key results tracked daily. The physician would enter only the analysis and plan and new information not included.

Imprinting Care and the Loss of Patient Narrative: Creation and Standardization of Medical Records
Kacper Niburski, PhD
Medical records manufacture a representational model of a person. Yet, little has been done to analyze how early patient charts displaced patients’ narratives. From the Archives of 19th Century Canadian psychiatric asylums—Hamilton, London, and Kingston—emerges the advance of physicians’ objective records and the decline of the subjective patient view. This is from index-card inception through design, accreditation, standardization, forms, and quantity, to analysis replacing narration. A tradition of reconfiguring the medical body as a thing dissolving into objectification becomes apparent. This trend continues now through the lack of narrative balancing a person’s health care experience and his/her medical record.

Review Articles

Self-Management of Depression: Beyond the Medical Model
Harpreet S Duggal, MD, FAPA
Self-management is increasingly becoming the standard of care among people with chronic medical conditions. Its application to depression is mostly extrapolated from the paradigms used for nonpsychiatric medical illnesses. Such an approach falls short in addressing strength-based interventions that foster recovery in individuals with depression. This article describes a new paradigm of self-management, which is in line with the recovery model, is patient-centered, and goes beyond amelioration of clinical symptoms.

CMEThe Critical Response Team in Airway Emergencies
John F Damrose, MD, FACS; William Eropkin, RRT, RCP; Serena Ng, MD; Sheik Cale, DO; Subhendra Banerjee, MD, FACS
Successful outcomes of airway emergencies (AEs) in the hospital depend on rapid recognition and intervention before patients become unstable. The authors describe their medical center’s experience with a coordinated rapid response to AEs, including an illustrative case. This approach emphasizes early recognition of impending AEs and instantaneous activation of a team of specialists and operating room personnel to rapidly respond to AEs anywhere in our medical center.

Clinical Practices

How to Determine Whether Our Patients Can Function in the Workplace: A Missed Opportunity in Medical Training Programs
Edward C Alvino, MD; Taha Mansoor Ahmad, MD, MPH
Patients often hand their physicians disability forms, and physicians too often struggle to complete them. Many physicians lack the training to complete these forms. This article aims to provide a clear understanding of impairment, limitations, restrictions, and disability. It explains how physicians can use skills they already possess to appropriately assess limitations, restrictions, and functional capacity, and it explains why accurate determinations are a vital part of good patient care.

Case Reports

Percutaneous Endoscopic Necrosectomy of Complex Walled-Off Lateral Necrosis of the Pancreas with the Aid of Laparoscopic Babcock Forceps: A Case Report of an Endoscopic and Radiologic Team Approach
Andrew K Nguyen, MD, MBA; Andrew J Song; Tanya Swopes, RN; Albert Ko, MD; Brian S Lim, MD, MCR
A 62-year-old woman presented with abdominal pain, nausea, and vomiting. After multiple admissions and repeated abdominal imaging, she was found to have laterally located, infected, walled-off pancreatic necrosis. Initially, a drainage catheter was placed by an interventional radiologist and was eventually upsized to a 28F catheter. Subsequently, a fully covered metal stent was placed in the gastroenterology suite. Laparoscopic Babcock forceps were used under fluoroscopy to remove lodged debris from the midstent.

ECG Diagnosis: Acute Myocardial Infarction in a Ventricular-Paced Rhythm
Ashley S Abraham; David R Vinson, MD, FACEP, FAAFP; Joel T Levis, MD, PhD, FACEP, FAAEM
Acute myocardial infarction is more difficult to diagnose in patients with ventricular-paced rhythms, often leading to delays in treatment and inferior outcomes. The Sgarbossa criteria can help identify ST-elevation myocardial infarction in these patients, many of whom may be candidates for timely reperfusion therapy. Sgarbossa et al further applied their criteria to ventricular paced rhythms, as pacing of the ventricle results in an intraventricular conduction delay similar to that seen with left bundle branch block.

Image Diagnosis: Disappearing Digits: Metabolic Bone Disease in End-Stage Renal Disease
Shitij Arora, MD, FACP; Fathima Jahufar, MD
Metabolic bone disease is a common complication in chronic kidney disease. Low vitamin D levels, resistance of PTH-sensing receptors, and dysregulation of the fibroblast growth factor 23PTH axis can all lead to prolonged excessive synthesis and secretion of PTH, eventually leading to the development of metabolic bone disease. Current treatment options include correcting vitamin D deficiency, controlling dietary phosphorus intake, and prescribing phosphate binders and calcimimetics (cinacalcet).

Unrecognized Value of Carcinoembryonic Antigen in Recurrent Rectal and Sigmoid Colon Cancer: Case Series
Leonid L Yavorkovsky, MD, PhD; Myron S Kwong, MD; Sejal Jhatakia, MD; Pilar Ivanov, MD
The authors report on 11 patients (8 women, 3 men) who, during the postoperative follow-up period, received a diagnosis of recurrent cancer despite their CEA levels exhibiting very subtle increases. Our cohort shared several similar characteristics such as a nonsmoking status, younger age (median, age 52 years at initial diagnosis), and exclusive localization of the cancer to the rectosigmoid region.

Disseminated Herpes Simplex Masquerading as Hemophagocytic Lymphohistiocytosis: A Case Report
Jean W Liew, MD; Brian L Jones, MD, PhD; Alan J Hunter, MD
A 56-year-old man with an indolent undiagnosed brain mass presented with progressive neurologic deficits and was found to have fevers, cytopenias, transaminitis, and hyperferritinemia. Initially, hemophagocytic lymphohistiocytosis was suspected; however, the ultimate diagnosis was Herpes simplex virus hepatitis with dissemination. Although the patient was treated with intravenous acyclovir, multiorgan failure developed, and he died.

Pseudomyxoma Peritonei—An Unusual Cause of Ascites: A Case Report
Puneet Chhabra, MD, DM; Sushant Soni, MD; Hunny Khurana, MD
Pseudomyxoma peritonei is a rare cause of low serum ascitic albumin gradient ascites. It is characterized by the deposition of mucinous material on the peritoneal surfaces. The most common site of origin is the appendix, although it can arise from other intraabdominal organs as well. Excision of the tumor combined with intraperitoneal chemotherapy is the preferred modality of treatment.

Extraskeletal Ewing Sarcoma of the Jejunum: A Case Report
Colby Cantu, MD; Elizabeth Bressler, MD; Josephine Dermawan, MD, PhD; Kristen Paral, MD
A 67-year-old woman presented with acute-onset, right lower quadrant pain. Computed tomography results showed a large mass within the midjejunum with pneumoperitoneum. Surgical excision was performed, and an extraskeletal Ewing sarcoma of the jejunum was suspected histologically. The diagnosis was confirmed with fluorescence in situ hybridization studies.

Inguinal Solitary Fibrous Tumor: A Case Report
Mohamed Ali Essid, MD; Abderrazak Bouzouita, MD; Ahlem Blel, MD; Ahmed Saadi, MD
A 59-year-old man, with an unremarkable medical history, presented with a slow-growing painless mass in the left side of the inguinal region, which he had ignored for 3 years. On clinical examination, there was an indurated, irreducible, mobile, and painless mass in the left side of the inguinal area. Magnetic resonance imaging and computed tomography results revealed a 15-cm mass made up of soft tissue and with nonspecific radiologic aspect. The tumor was totally excised. This was a rare extrapleural localization of an SFT.

Agranulocytosis from Outpatient Antimicrobial Treatment with Ceftriaxone: A Case Report
Yevgeniy Genchanok, MD; Seda S Tolu, MD; Heidy Wang; Shitij Arora, MD, FACP
A 72-year-old woman, on ceftriaxone for left knee septic arthritis 3 weeks before presentation, was found to be neutropenic on outpatient laboratory analysis. Once this cause of agranulocytosis is identified, ceftriaxone therapy should be stopped; if the patient is febrile, an infectious disease workup should be performed and antibiotics should be started; and granulocyte colony-stimulating factor should be administered with daily monitoring of the absolute neutrophil count.

Image Diagnosis

Image Diagnosis: Boxers Ear
Satvinder Singh Bakshi, MS, DNB
On examination, the right pinna was swollen and red. The swelling was tender, warm, and soft on palpation. A diagnosis of pinna hematoma was made, and the hematoma was drained immediately. Postdrainage, the patient was started on parenteral antibiotics, and compression bandages were applied for a week.

Image Diagnosis: Frontoethmoidal Mucocele
Satvinder Singh Bakshi, MS, DNB
A mucocele is an epithelial-lined cystic lesion of the paranasal sinuses, containing thick mucus and characterized by its slow growth and expansile nature. Its etiology is unclear but may be secondary to obstruction of the affected sinus by chronic processes such as rhinosinusitis, nasal polyposis, previous surgery, or craniofacial trauma. Mucoceles occur most frequently in the frontal and ethmoid sinuses, and the majority of mucoceles present in patients age 40 to 60 years.

Nursing Research and Practice

Are Perceived Stress and Cytokine Genotypes Clinically Feasible as Predictors of Psychoneuroimmune Symptoms in Advanced Cancer?
Stephanie Gilbertson-White, PhD, APRN-BC; Ariana Shahnazi, MA; Catherine Cherwin, PhD, RN
Forty-two participants were recruited (21 with cancer and 21 cancer-free controls). Cancer-affected patients reported higher perceived stress and psychoneuroimmune (PNI) symptom severity. Associations were found between several single-nucleotide polymorphisms and PNI symptoms, with no clear pattern. Perceived stress was associated with PNI symptom severity for memory problems and fatigue at all 6 time points. Assessing perceived stress is an easy and low-cost approach that can be used to identify patients at high risk of PNI symptom development.

Health Care Communication

Help Your Patients Stay Healthy on Their Cruise Vacation: Suggestions for Primary Care Physicians from a Cruise Ship Physician
Lee Jacobs, MD
During the author’s 12 years of experience in caring for critically ill patients on cruise ships, he has learned that good advice and preparation by primary care physicians before sailing can prevent life-threatening situations from occurring when their patients are at sea. Good health is a major prerequisite, especially with the realization that most serious illnesses encountered on ships may be preventable.


CMELegal Perspectives on Telemedicine Part 1: Legal and Regulatory Issues
Christian D Becker, MD, PhD; Katherine Dandy, Esq; Max Gaujean, Esq; Mario Fusaro, MD; Corey Scurlock, MD
In critical care approximately 20% of nonfederal adult intensive care unit (ICU) beds in the US today are supported by some form of tele-ICU coverage. The literature has shown with increasing clarity that correct tele-ICU implementation improves outcomes and has the potential to significantly improve the financial performance of health care systems. Part 1 of this series discusses legal and regulatory challenges of telemedicine in general, with a focus on tele-ICU. The second part will discuss the effects of telemedicine implementation.

Why I Treat Obesity
Adam Gilden Tsai, MD, MSCE, FACP
In this narrative, the author describes a patient who has lost 25% of her starting body weight and the behaviors that she practices to maintain this weight loss. Patients who have lost weight have reductions in metabolism that are out of proportion to their amount of weight loss. They also have increases in appetite. Physicians have to understand the physiologic and behavioral barriers to long-term weight loss, treat obesity as a chronic disease, and also be open to using medications to treat obesity.

Special Report

Novel Use of Apple Watch 4 to Obtain 3-Lead Electrocardiogram and Detect Cardiac Ischemia
Cesar O Avila, MD
Two male patients in the Emergency Department had ST-elevation myocardial infarction (STEMI) apparent on their electrocardiograms (ECGs). The patients’ real-time, Apple Watch 4-based, 3-lead ECG tracings matched the traditional ECGs demonstrating STEMI, confirming the potential ability of this device to uncover myocardial ischemia. In each patient, cardiac catheterization revealed severe, 100% occlusion of the right coronary artery. The Apple Watch 4 could lead to earlier detection of acute coronary artery disease, but sensitivity and specificity remain unknown.


We Can Save a Million Hearts
Thomas E Kottke, MD, MSPH; Sarah Horst, MA
The authors identify 3 barriers that are hard stops for many medical groups participating in the Million Hearts initiative: 1) the inability of many physicians to access and visualize their patient panel electronic medical record data for patient and quality management, 2) a lack of compensation for the cost of team-based primary care, and 3) external support for single-condition registries rather than a single registry that contains the information that is necessary to manage all conditions of interest. These barriers have been overcome by high-performing medical groups.

Graphic Medicine

Giving Bad News
Toney Welborn, MD, MPH, MS
This graphic medicine piece is a commentary on communication in medicine, health literacy, and how far we sometimes are from our patients in oral communication. This story is loosely based on the physician-author’s own experience of being diagnosed with bone cancer at age 15. At a writing retreat, she was encouraged to draw her story: Pairing words with images.

Narrative Medicine

Before and After
Cecilia Runkle, PhD, MPH
I mentored Permanente Medical Group and Group Health physicians in teaching their colleagues how to have conversations about death and dying. In 2016, my partner of 36 years unexpectedly died. During this time I wrote the following haiku about my experience.

D is for Donna
Laurie Cruz, MD
I think of you when I text or email funny things to the kids, fondly remembering the newspaper and magazine clippings you sent me with notes in your beautiful handwriting. I never could forget your “D.” I have always been envious and proud of that distinct cursive.

Her Heart, Her Flowers
Sumam Abraham, MD
Her tiny, frail body lay in the middle of the room. The EMTs were busy trying to save her. I had never been in my neighbor’s house and didn’t know much about her apart from the fact that she was a second-generation Japanese woman who had been married to an African-American man who had passed away. Her children were around. Every spring she would gather daisies from my garden to honor the dead. As she grew weaker she asked me to cut the daisies for her.

Caring for Youth in Juvenile Detention Centers: A Story of Hope
Tim Lubben, MA
During the past 3 years the author has visited youth-detention facilities to provide instruction on basic life skills. Struck by the discouragement and hopelessness of each youth, two events discussed here encouraged him to get involved. He encourages them not to feel sorry for themselves, tell them they are not alone, and people want to help them. Their lives can change, that they can have hope.

Poetic Science: Bidirectional Reflection in Science and Medicine
Sherry-Ann Brown, MD, PhD
Integrating creative expression—poetry and other visual and performing arts—can help clinicians, scientists, and others use familiar social constructs to embody science and medicine, in what may be termed poetic science. Poetic science imbues bidirectional reflections of science and medicine on the clinician or scientist or other inquisitor, creatively engaging the learner’s brain cells as mirrors. This ultimately leads to a subjective perspective on the understanding or the proposition of underlying principles.

Book Reviews

Writing to Improve Healthcare: An Author’s Guide to Scholarly Publication
H Nicole Tran, MD, PhD; T Stephanie Tran
If you are looking for advice on how to introduce your findings and interventions to your departments or publish them, look no further than this book. The dissemination of quality improvement research and analysis helps the medical community stay current in knowledge of innovation, provide positive health outcomes, and decrease waste in health services. In Writing to Improve Healthcare, Stevens proclaims that health care improvement is incomplete until it is published, and he provides a unique guide to publication for this new category of writers.

Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions
Review by Igor Sapozhnikov, MD
Up to 40% of patients in my obesity clinic were victims of child abuse or neglect, and up to 57% of those had depression. Indeed, the section in Lost Connections detailing the effects of trauma on depression reinforced my findings. The rest of the book proved to be just as revelatory and important for primary care providers, who are responsible for psychotropic medications in the US.

Soul of the Healer

Oneonta Gorge
Tyler Kern, MD

Hillary Mullan

A Storm Is Coming
Tonya Lippert, PhD, LCSW

Kilauea Volcano Lava Flow—View from the Ocean
Lee D Jacobs, MD

End of KP Workday
Tonya Lippert, PhD, LCSW

On the Cover

The Milky Way
Jorge A Ramirez, MD


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