Winter 2020 - Volume 24 Number 1

Original Research and Contributions

CMEOutcomes of Robotic Hysterectomy for Treatment of Benign Conditions: Influence of Patient Complexity
Lisa J Herrinton, PhD; Tina Raine-Bennett, MD, MPH; Liyan Liu, MS; Stacey E Alexeeff, PhD; Wilfredo Ramos, MD; Betty Suh-Burgmann, MD
A retrospective cohort study, using the electronic medical records of Kaiser Permanente Northern California (2011-2015), included 560 robotic and 6785 conventional laparoscopic cases with 1836 “complex” patients (25%). The average operative time was 152 minutes (robotic) vs 157 minutes (conventional) laparoscopic hysterectomy. Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications.

Factors Related to Development of Pancreatic Adenocarcinoma in Patients With Chronic Pancreatitis on Long-term Follow-up: A Database Study
Shashank Garg, MBBS, MS; Houssam Mardini, MD, MPH
Chronic pancreatitis (CP) is a risk factor for pancreatic adenocarcinoma (PA). A national insurance database of 120 million US patients was used. Adults with an International Classification of Diseases 9th Revision code for CP (577.1) (1-1-09 to 12-31-14) were identified. PA was diagnosed in 0.72% of the patients with CP at least 2 years after the diagnosis of CP. Increasing age, male sex, smoking, having commercial insurance, absence of diabetes mellitus before CP, and shorter duration of bile duct obstruction were associated with a diagnosis of PA in patients with CP.

Incidence of Metal Hypersensitivity in Orthopedic Surgical Patients Who Self-Report Hypersensitivity History
Mark Schultzel, MD; Christopher M Klein; Marine Demirjian, MD; Colin Blout; John M Itamura, MD
Metallic implants are integral to the practice of orthopedic surgery. Delayed-onset T-cell-mediated metal hypersensitivity (diagnosed by patch testing) is reported in 10% to 17% of the general population. A retrospective chart review of patients from a single surgeon’s practice was conducted during a 1-year period. Of 840 patients, 41 (4.9%) self-reported any metal hypersensitivity. Of these, 34 (83%) were patch-test positive to 1 or more metals. Nonmetal-containing or nonreactive metal implants are an option for patients in whom metal hypersensitivity is suspected or confirmed.

Effectiveness of Best Practice Alerts for Potentially Inappropriate Medication Orders in Older Adults in the Ambulatory Setting
Taylor Ota, PharmD; Rachana J Patel, PharmD; Thomas Delate, PhD, MS
A retrospective cohort study was conducted at an integrated health care delivery system with computerized provider order entry. A total of 2704 patients were included: 1373 (50.8%) and 1331 (49.2%) in the dispensed and nondispensed groups, respectively. There was no difference in the rate of cognitive impairment between the groups. No association was identified between potentially inappropriate medication dispensing, after a prescriber was alerted with a best practice alert, and reduced rates of falls/fractures/injuries and cognitive impairment.

The Relationship Between Hope, Meaning in Work, Secondary Traumatic Stress, and Burnout Among Child Abuse Pediatric Clinicians
Sarah Passmore, DO; Eden Hemming, MA; Heather Chancellor McIntosh, MS, CRA; Chan M Hellman, PhD
Child abuse pediatricians continuously encounter trauma experienced by abused children, putting them at risk of secondary traumatic stress (STS), a syndrome with symptoms similar to those of posttraumatic stress disorder. The survey was completed by 151 participants. Correlational analyses showed strong positive associations between the STS score and burnout. A national sample of child abuse pediatric clinicians shows that STS is associated with burnout. Meaning in work and hope can mitigate these effects.

Reducing Workplace Absenteeism Caused by Work Stress in a Health Maintenance Organization Department of Psychiatry
Teresa E Thomas, PhD; Roy Eyal, MD; Frank Menchavez, MA; TJ Mocci, LMFT; Gayle Goldblatt; Julie Lanoff, PsyD; Myron Hays, PhD; J Jewel Shim, MD; Timothy P Barry, LCSW
A health maintenance organization’s Department of Psychiatry reviewed a new program of group psychotherapy and specialty mental health treatment targeting patients who self-identified as having work stress and who requested medical leave from work. Of those 166 patients who participated in the program, 141 (85%) returned to work and did not have any days off within the 11-month analysis. Involvement in the group also was associated with improvement in self-reported symptom severity about depression and anxiety.

Graphic Medicine

Use of a Graphic Memoir to Enhance Clinicians’ Understanding of and Empathy for Patients with Parkinson Disease
Kimberly R Myers, PhD, MA; Daniel R George, PhD, MSc; Xeumei Huang, MD, PhD; Michael D F Goldenberg, MA; LJ Van Scoy, MD; Erik Lehman, MS; Michael J Green, MD, MS
After reading a book-length, graphic memoir (an illness story in comic form), a form which engages clinicians in ways different from other mediums, clinicians who read My Degeneration gained insight into the psychosocial effects of Parkinson disease on patients and their loved ones. The book helped facilitate deeper understanding of patients’ experiences living with Parkinson disease and fostered greater empathy and self-reflection.

Narrative Medicine

Health Care Practitioners and Families Writing Together: The Three-Minute Mental Makeover
David G Thoele, MD; Cemile Gunalp; Danielle Baran, PhD; Jamie Harris, MD; Douglas Moss; Ramona Donovan MS, RD, CCRC; Yi Li, MS; Marjorie A Getz, PhD
Eight practitioners led 96 patient/family members in Three-Minute Mental Makeover (3MMM) activities and study surveys. Patients/family members and practitioners reported reduced stress compared with baseline (p < 0.001). A significant improvement in communication was reported by practitioners. Of patients/families using expressive writing, 88% reported that the 3MMM activity was helpful, and reduced stress for practitioners, patients, and families.

Narrative Medicine

Ethics in Narrative Health Interventions
John W Murphy, PhD; Berkeley A Franz, PhD
The thrust of narrative medicine is that patients and communities construct stories that guide their lives and give meaning to both health and illness. The responsibility of health care practitioners, therefore, is to learn how to read these narratives to provide care that is relevant to an individual or community. Listening carefully to patients’ stories is an ethical practice that can be fostered in health care settings. Subjectivity can be embraced by clinicians without jeopardizing ethical or evidence-based patient care.

CMEPractitioner Education and Feedback to Decrease Ciprofloxacin Prescriptions in Patients with Acute Uncomplicated Cystitis
Richard F Guo, MD; Dinh L Nguyen, MD; Steven Park, MD; Kristen Nguyen, MD; Steven Ko, MD; Vicki Y Chiu, MS; Jana Dickter, MD; Davida Becker, PhD MS; Philomena Cho, MD
Primary care practitioners at 3 medical offices participated: 51 in the control group, 65 in the intervention group (educational lecture, emailed antimicrobial guidelines, prescriptions audited with feedback). Intervention group participants (65) had 5262 eligible acute uncomplicated cystitis (AUC) encounters, and control group participants (51) had 5473. At baseline, ciprofloxacin was prescribed at 29.7% (intervention) and 33.7% (control). After intervention, ciprofloxacin was prescribed at 10.8% in the intervention group and 34.3% in the control group. Thus, education, audit, and feedback reduced their prescriptions of ciprofloxacin for AUC therapy.

Adverse Childhood Experiences, Other Psychosocial Sources of Adversity, and Quality of Life in Vulnerable Primary Care Patients
Martina Jelley, MD, MSPH; Frances Wen, PhD; Julie Miller-Cribbs, MSW, PhD; Kim Coon, EdD; Kristin Rodriguez, MPH
Adults who had adverse childhood experiences (ACEs) have increased risk of negative health outcomes. A questionnaire measuring demographics, ACEs, current health status and well-being, sources of support and adversity, and quality of life was completed by 354 patients. Forty-three percent received disability benefits and 71% were unemployed. More than 37% reported 4 or more ACEs. This disadvantaged primary care population had high numbers of ACEs. ACEs correlated with increasing numbers of health problems and worse QOL.

CRcoder: An Interactive Web Application and SAS Macro to Support Personalized Clinical Decisions
Gail J McAvay, PhD; Terrence E Murphy, PhD; George O Agogo, PhD; Heather Allore, PhD
To illustrate the fitting of models, a sample of older adults with comorbid hypertension and chronic obstructive pulmonary disease from the Medical Expenditure Panel Survey was created to examine the association between polypharmacy (use of ≥ 5 medication classes) and limitations in social activities and mobility. Clinical decision making based on electronic health data can be improved using joint modeling to generate an individual’s probability of concurrent risk. This user-friendly software performs the advanced statistical analyses needed to estimate typical and personalized concurrent risks.

Special Reports

Haloperidol and Prostate Cancer Prevention: More Epidemiologic Research Needed
Gary D Friedman, MD, MS; Laurel A Habel, PhD; Ninah Achacoso, MS; Christina M Sanders, PhD; Halley M Oyer, PhD; Bruce Fireman, MA; Stephen K Van Den Eeden, PhD; Felix J Kim, PhD
The antipsychotic drug haloperidol has antiproliferative and growth-inhibiting properties on prostate cancer cell lines in vitro by binding the sigma 1 protein. Evidence is needed regarding a possible preventive association in men. The authors’ ambiguous epidemiologic findings should encourage more epidemiologic evaluation of haloperidol use and risk of prostate cancer. Finding a negative association could be a scientific advance in prostate cancer prevention but would not be sufficient basis for recommending the prescription of haloperidol for that purpose.

Disease-Specific Plan Switching Between Traditional Medicare and Medicare Advantage
Sungchul Park, PhD; Paul Fishman, PhD; Lindsay White, PhD; Eric B Larson, MD; Norma B Coe, PhD
Using the 2006 to 2012 Medicare Current Beneficiary Survey, we examined disease-specific switching rates between traditional Medicare and Medicare Advantage (MA) and disease-specific ratios. Beneficiaries with a new diagnosis of Alzheimer disease, hypertension, and psychiatric disorders had relatively high rates of switching into MA plans and low rates of switching out of MA plans. Among those with new diagnoses of psychiatric disorders and diabetes, more costly beneficiaries (those with higher costs) switched into MA plans. For cancer, more costly beneficiaries remained in MA plans.

Public Health Implications of Image-Based Social Media: A Systematic Review of Instagram, Pinterest, Tumblr, and Flickr
Isaac Chun-Hai Fung, PhD; Elizabeth B Blankenship, MPH; Jennifer O Ahweyevu, MPH; Lacey K Cooper, MPH; Carmen H Duke, MPH; Stacy L Carswell, MPH; Ashley M Jackson, MPH; Jimmy C Jenkins III, MPH; Emily A Duncan, MPH; Hai Liang, PhD; King-Wa Fu, PhD; Zion Tsz Ho Tse, PhD
Of 66 research articles, 12 experimental studies used Instagram. Of 54 observational studies, 38 studied Instagram; 12, Pinterest; 7, Tumblr; and 6, Flickr. More than half related to mental health and substance abuse, most investigating questions from public perception of diseases or interventions (vaccination) and undesirable media exposure (“echo chamber,” distorted body image, underage substance use, and pro-suicide messages) to information dissemination and online engagement (likes and comments).

Review Articles

Important Considerations for Design and Implementation of Decision Aids for Shared Medical Decision Making
Sean Koon, MD, MS
A literature search and screening process was employed with a focus on systematic review articles. Patients should be able to select information in a manner that suits them and view it in a way that allows them to evaluate trade-offs. Decision aids should be tested in real settings with iterative improvements. Decision aids can be a valuable tool for shared medical decision making. Their quality and usefulness can be maximized by involving users in their creation, design, implementation, and appraisal.

Clinical Practices

CMERefining the Definition of Polypharmacy and Its Link to Disability in Older Adults: Conceptualizing Necessary Polypharmacy, Unnecessary Polypharmacy, and Polypharmacy of Unclear Benefit
Eric A Lee, MD; Jeffrey W Brettler, MD; Michael H Kanter, MD; Steven G Steinberg, MD; Peter Khang, MD; Christopher C Distasio, MD; John Martin, MD; Mark Dreskin, MD; Nolan H Thompson, MD; Timothy M Cotter, MD; Kim Thai, MD; Lyn Yasumura, MD; Nancy E Gibbs, MD
Because of its link to geriatric syndromes and disability, the avoidance of polypharmacy is usually recommended in older adults as a strategy to optimize functional status. The authors propose that, in the geriatric literature, polypharmacy now be categorized as “necessary polypharmacy,” “unnecessary polypharmacy,” or “polypharmacy of unclear benefit.” In this article, we discuss the 3 categories of polypharmacy and give examples on each polypharmacy regimen and its potential relationship to disability in older adults.

CMEDon’t Fall for That: A Residency Curricular Innovation about Fall Prevention
David R Lee, MD, MBA; Joan C Lo, MD; H Nicole Tran, MD, PhD
Two 20-minute multimodal workshops were created: 1) a classroom session with a video depicting a fall scenario, a team exercise (“Where’s the Fall Risk?”), and review of the American Geriatrics Society Beers Criteria; and 2) a small-group session reviewing a screening algorithm, case study, physical examination maneuvers, and patient resources. Fall prevention remains an important yet undertaught topic for trainees and practicing physicians. These brief multicomponent workshops can be easily implemented and adapted for all clinical learners.

Digging for the Deeper Diagnoses in Dermatology
David J Elpern, MD
In a small private dermatology practice, I became aware that knowledge of some patients’ adverse childhood experiences, traumatic experiences, and social determinants of health was essential to establish a successful therapeutic relationship. I discuss how these factors play important and lifelong roles in the disorders that dermatologists see, but these factors have not been addressed in the dermatology literature.

Case Reports

Postvasectomy Scrotal Pain and Hematospermia, a Possible Harbinger for Vasectomy Failure and Recanalization: A Case Report
Tyler Kern, MD; Daniel Artenstein, MD; Charles Shapiro, MD
To our knowledge, there is no symptom complex that has been identified and described that is predictive of early recanalization and vasectomy failure. Delayed postvasectomy scrotal pain associated with hematospermia may be a sign of vasal recanalization. We propose that this symptom complex should prompt an investigation for vasal recanalization, during which the patient should be instructed to refrain from intercourse without the use of an additional method of contraception.

Confusion vs Broca Aphasia: A Case Report
Regina Wang, MD, MPH; Christi Wiley, MD
Broca aphasia presents with impaired expression of spoken and/or written language and is often caused by infarction in the Broca area in the frontal lobe. A 76-year-old woman was brought to the Emergency Department with confusion and slurred speech that began in the morning. Magnetic resonance imaging confirmed recent infarct involving left frontal and occipital lobes, coinciding with the Broca area. The patient was able to communicate via writing and eventually made an uneventful recovery of speech.

Health and Wellness Coaching and Psychiatric Care Collaboration in a Multimodal Intervention for Attention-Deficit/Hyperactivity Disorder: A Case Report
Elizabeth Ahmann, ScD, RN, PCC, NBC-HWC; Katherine Smith, MPH, ACC, NBC-HWC; Laurie Ellington, MA, LPC, RCC, PCC, HMCT; Rebecca O Pille, PhD, MS, CHWC, CWP
Using the CARE guidelines designed to improve transparency and accuracy in health research reporting, this case report was based on a systematic review of data collected from the point of care, during an 8-week collaboration between a psychiatrist and a health and wellness coach. This is the first case report that illustrates beneficial outcomes and the promising role of health and wellness coaching in assisting individuals with attention-deficit hyperactivity disorder in achieving successful behavior change.

A Tale of Two Immunodeficiencies: A Case of Multiple Myeloma Associated with Profound Immune Defect Mimicking Common Variable Immunodeficiency Syndrome
Leonid L Yavorkovsky, MD, PhD; Andrew Hope, MD
Besides a defective immune system and susceptibility to infections, common variable immunodeficiency (CVID) is associated with autoimmune disorders, gastrointestinal tract inflammation, granulomatous disease, and malignancies. Although multiple myeloma and CVID both manifest an abnormal immune system homeostasis, the pathogenesis of the immune defect is different: Quantitative deficiency of the normal plasma cells in the former and qualitative defect in plasma cell maturation in the latter.

Intravascular Large B-cell Lymphoma Associated with Systemic and Central Nervous System Hemophagocytic Lymphohistiocytosis: A Case Report
Aradhana Verma; Akanksha Sharma, MD; Ryan Robetorye, MD; Alyx Porter, MD; Talal Hilal, MD
The patient was treated with the hemophagocytic lymphohistiocytosis (HLH)-2004 protocol but relapsed 3 months later. A repeated liver biopsy confirmed the initially missed diagnosis of intravascular large B-cell lymphoma, a known driver of HLH in patients of Asian origin. After treatment with lymphoma-directed therapy her fever and neurologic symptoms resolved with normalization of blood cell counts and ferritin level.

Ceftriaxone-Induced Hemolytic Anemia: A Rare Case Report
Sandeep Kumar, MD; Rohit Bansal, MD; Priya Bansal, MD; Rajinder Kumar Dhamija, MD, DNB Neurology
A review of the literature highlights the salient features of drug-induced immune hemolytic anemia (DIIHA) and underscores high suspicion of DIIHA in the relevant clinical settings because ceftriaxone has been associated with particularly severe outcomes of DIIHA, and the physician must meticulously look for the possible culprit drugs. Treatment with suspected drugs must be stopped promptly to prevent severe complications and fatal outcomes.

Importance of Assessing Compliance with Conservative Treatment of Primary Hyperoxaluria Type 1: A Case Report of a Patient with I244T/c.969-3C>G Mutation
Paloma Gutiérrez Medina, MD; Laura Espinosa Román, PhD
Primary hyperoxaluria type 1 (PH1) is an autosomal recessive inherited disorder that progresses to end-stage renal disease. Patients experience excessive urinary oxalate excretion, which causes nephrocalcinosis and recurrent urolithiasis. Laboratory and genetic findings confirmed PH1. Physicians need a high level of suspicion to diagnose this rare disease. It has been previously demonstrated that early conservative treatment improves long-term outcomes, averting preemptive transplant during childhood.

Image Diagnosis

Image Diagnosis: An Uncommon Cause of Painful Trigeminal Neuropathy
Rita Raimundo, MD; Inês Rego, MD; Andreia Veiga, MD
Neoplastic perineural spread occurs through the movement of neoplastic cells into the neural space, affecting predominantly the trigeminal and facial nerves. Given the anatomic proximity to these nerve terminations, it is typically associated with cutaneous and salivary glands tumors. The perineural spread can be detected by magnetic resonance imaging as an obliteration of the fat planes around the nerve branches and an enhancement and/or enlargement of the nerve.


Learning in Humans versus Hierarchies
Mihal Emberton, MD, MPH, MS
We first need to connect the patterns of how humans learn and solve problems and the patterns of leadership in hierarchies to find the pathways that drive organizational learning vs conformity. With this operationalized framework, we can now teach supervisors how to recognize the clues and evidence that result from our belief-behavior systems to subsequently convert conformity processes into learning processes, generating organizational innovation and growth as well as employee engagement, loyalty, and trust.

Narrative Medicine

A Patient’s View of the Challenges and Blessings of Her Dissociative Disorder
Bonnie Armstrong, MA, ACC
People who live with dissociative disorders and a history of childhood trauma are less rare than commonly thought and can be challenging for unfamiliar medical practitioners. On the basis of my own experiences, I offer in this article some instructive anecdotes and tips for health care practitioners on how to work with patients with a trauma-related diagnosis such as a dissociative disorder.

The Sword of Damocles: Living with Neurofibromatosis Type 1
Juan Sebastián Botero-Meneses, MD
Both as a physician and as a patient, having neurofibromatosis type 1 has been an important part of my life. In my practice as a physician and a professor, I have tried to reflect on the reality of living with a genetic condition and how it affects the way I live and practice medicine.

Initiating Narrative Medicine at a Medical College in Pakistan: Achievements, Challenges, and Opportunities
Huma Baqir, MD; Kanwal Nayani, MD; Ayesha Mian, MD; Asad I Mian, MD, PhD
In this brief report, we discuss Narrative Medicine (NM) in the context of low- to middle-income regions like ours, describing how a workshop on NM-based reflective writing was developed and executed at Aga Khan University, Karachi, Pakistan. This development includes creating a digital library of narratives, releasing an annual NM newsletter, incorporating NM into the undergraduate curriculum, and conducting studies to assess the impact of our intervention.

Wilderness Meeting
Christine Walden, MD

Graphic Medicine

Comics as Reflection: In Opposition to Formulaic Recipes for Reflective Processes
Jack Whiting, MSc
The importance of reflection in the continued learning and professional development of health care professionals is imparted to medical students soon after they begin their training. However, in both undergraduate and postgraduate medical training, reflection is most commonly “assessed” in extended pieces of formal writing—something that can inhibit natural approaches to reflective practice. In opposition to formal, standardized approaches to reflection, it is argued that comics can mesh congruously with multiple approaches to reflection and, as such, can promote legitimate natural reflective processes, which may appeal to health care professionals

Letter to Editor

Lifestyle Medicine: The Role of the Physical Therapist

Book Review

Dissident Doctor: Catching Babies and Challenging the Medical Status Quo
The book reveals Dr Klein’s unconventional life from childhood to the present. Growing up in the US with politically active parents and family, he learned at an early age to speak his mind when things were not to his liking. As he matured, he discovered that a career in medicine would best combine his quest for independence of thought with his desire to help others.

On The Cover

Polar Bear and Cubs
Richard Mittleman, MD

Soul of Healer

Polar Bear and Two Cubs
Richard Mittleman, MD

Golden Light
Michael House, LCSW

Out of the Cave
Jorge Ramirez, MD

Med School Valentines
Lucy Chisler


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