Spring 2021 - Volume 25 Number 2



Trends in Influenza Vaccine Uptake and Severe Influenza-Related Outcomes at Kaiser Permanente Southern California, 2007-2017

In-Lu Amy Liu, MS; Hilary C Tanenbaum, PhD, MS, MPH; Lei Qian, PhD; Lina S Sy, MPH; Wansu Chen, PhD, MS; Steven J Jacobsen, MD, PhD

Major efforts to increase influenza vaccine uptake among Kaiser Permanente Southern California (KPSC) members have been undertaken in recent years. However, whether these improvements translate to a decline in severe influenza-related outcomes has not been examined. We aimed to understand the impact of the influenza vaccination program at KPSC by examining influenza vaccine uptake and three severe influenza-related outcomes.

Ten-year Thyroid Cancer Incidence in an Integrated Healthcare Delivery System

Stephanie J. Kim, MD, MPH; Megan L. Durr, MD; Jeanne A Darbinian, MPH; Lori C. Sakoda, PhD; Charles J. Meltzer, MD; Hasmik Arzumanyan, MD; Kevin H. Wang, MD; Jonathan K. Lin, MD; Deepak Gurushanthaiah, MD; Joan C. Lo, MD

The incidence of papillary thyroid cancer (PTC) has increased in recent decades, but data from community-based settings are limited. This study characterizes PTC trends in a large integrated healthcare system over ten years. Increasing PTC incidence over ten years was most evident for tumors ≤4 cm and Stage I disease. While these findings may be attributable to greater PTC detection, the increase across a range of tumor sizes suggests that PTC burden might also have increased.

Using Real-world Data for Decision Support: Recommendations from a Primary Care Provider Survey

Patricia A Areán, PhD; Emily C Friedman, MID, CPE; Abhishek Pratap, PhD; Ryan Allred, BA; Jaden Duffy, BA; Sara Gille, MPH; Shelley Reetz, BS; Erin Keast, MPH; Gregory Clarke, PhD

The use of data from wearable sensors, smartphones, and apps holds promise as a clinical decision-making tool in health and mental health in primary care medicine. The aim of this study is to determine provider perspectives about the utility of this data for building digitally-based decision-making tools. Primary care providers find value in collecting real-world patient data to assist in clinical decision-making provided such information does not interfere with provider workflow or impose undue burden on patients. Additionally, digital tools will need to demonstrate high accuracy, be able to integrate into current clinical workflows, and maintain privacy and security of patients' data.

Surgeon–Therapist Communication Must Be Improved in Rotator Cuff Repair Rehabilitation: An Electronic Survey of Physical Therapists on Postoperative Rehabilitation Protocols and Communication with Treating Surgeons

Mark Schultzel, MD; Karl B Scheidt, MD; Brian McNeill, DPT; Christopher M Klein, MS; Colin Blout, BS; John M Itamura, MD

There is no consensus on post-operative rotator cuff repair protocols in orthopedic or physical therapy literature. Despite surgical management, the frequency of rotator cuff re-tears continues to be high. Most rehabilitation programs follow protocols developed by surgeons and physical therapists. Tissue quality, size of tear, and repair type are usually documented in the operative report, which are rarely conveyed to the therapist. This study highlights the lack of communication between the physician and the therapist. Improved communication regarding the findings at surgery, open lines of communication, and making alterations to the protocol may improve patient outcomes.

Trends in Endoscopic Sinonasal Debridement in the Medicare Population

Mulin Xiong, BA; Rijul S Kshirsagar, MD; Jonathan Liang, MD, FACS, FARS

Nasal/sinus endoscopy with biopsy/polypectomy/debridement or Current Procedure Terminology (CPT) code 31237 is one of the top 10 most frequent and highest billed otolaryngology procedures among Medicare patients. We analyzed temporal and geographic trends in endoscopic debridement and correlated these with sinus surgery and balloon sinuplasty trends. Otolaryngologists continue to perform increasing numbers of endoscopic debridement and receive increasing payments. There is some geographic variation in these trends. Amongst individual providers, there was a positive correlation between the number of endoscopic debridement procedures and both the number of balloon sinuplasty and sinus surgery procedures.

“Headache” Online Information: An Evaluation of Readability, Quality, Credibility, and Content

Abdulrahman Bukhari, MBBS; Saad Alshihri, MBBS; Mohammed Abualenain, MBBS; Jordan Barton, BA; Genevieve Kupsky, BS; Jesse M Pines, MD; Ali Pourmand, MD, MPH, RDMS

Headache is experienced by more than half of the world population each year. In this study, we evaluate the content, quality, and health literacy required to understand online information for patients with headaches. We found variable content and quality in online headache websites for patients. Many of these websites failed to disclose information about authorship, conflicts of interest, and details on the prognosis or prevention of headaches. Readability, credibility, completeness, and quality of information were lacking in the most websites.

The Utility of Brain Magnetic Resonance Imaging/Angiography and Neck Magnetic Resonance Angiography in Patients with Suspected Acute Stroke

Mark Harris; Alyssa Finger; Emily Nishimura; Blake Watabe; Hyo-Chun Yoon, MD, PhD

In our health maintenance organization, we have seen a trend among our referring physicians to order a simultaneous brain MRI, head MRA, and neck MRA in the evaluation of patients for acute stroke. However, there is little data to demonstrate any improvement in patient care resulting from ordering this triple study. The objective of this study was to analyze the utility of this triple study for patients who experience stroke-like symptoms.

The ATTAIN Solution Tested: Initial Pilot Results of an Automated, Web-based Screening Tool for Unhealthy Drinking Behaviors

Jiseung Yoon, MD; Emma Fredua, MPH, CHES; Shahriar B Davari, MD; Mohamed H Ismail, MD, DrPH

AuTomaTed Alcohol misuse Interventions (ATTAIN) is an automated, computer-based tool that screens people for unhealthy alcohol use and offers web-based counseling with minimal involvement of healthcare personnel. ATTAIN was well accepted by eligible adults, appeared non-inferior to office-based screening, and added several potential advantages in terms of screening for alcohol use disorders and readiness to change.

Insurance Barriers, Gendering, and Access: Interviews with Central North Carolinian Women About Their Health Care Experiences

Lena JP Cardoso, MPP; Anna Gassman-Pines, PhD; Nathan A Boucher, DrPH, PA, MS, MPA, CPHQ

Women face unique logistical and financial barriers to healthcare access. They also have higher healthcare expenditures and higher rates of morbidity. Women's experiences while utilizing healthcare is historically less well researched and warrants exploration. Future clinical and research efforts should include 1) increasing awareness of and facilitating access to affordable post-partum care; 2) easing burdens around scheduling appointments and improved care coordination; and 3) more research exploring women's experiences during in-person healthcare encounters. Concerns and barriers that women described may be due to systems-level requirements and constraints.

Does a Recumbent Lateral Stability Trainer Improve Balance Scores Among Older Adults Within 4 Weeks?

Andrew Shim, EdD; Samantha Prichard, MHS; David Newman, PhD; Carly Lara, Mike Waller, PhD; Maureen Hoppe, EdD, OTR/L

Past literature has shown balance and strength are important in preventing falls, but few studies have focused on developing strength and power in a lateral plane. A recumbent lateral stability device can improve balance scores among older adults within 4 weeks of training.

Better Together: Long-term Behaviors and Perspectives after a Practitioner–Family Writing Intervention in Clinical Practice

Madelaine Schaufel, MS, RD; Douglas Moss, BS; Ramona Donovan, MS, RD, CCRC; Yi Li, MS; David G Thoele, MD

Excessive stress has been shown to be detrimental to human health in many ways. Therefore, interventions that either reduce stress or improve coping are of considerable interest. One method used to help cope with stress is expressive writing (EW), defined as therapeutic writing that involves disclosure of personal information, thoughts, or feelings. EW has been associated with reduced stress, improved health, increased disease-related quality of life scores, and reductions in physical symptoms in a variety of patient populations. EW interventions also have the potential to be low-cost, low-risk, and generally well-accepted by patients.

Multistage Adolescent Depression Screening: A Comparison of 11-Year-Olds to 12-Year-Olds

Alan B Cortez, MD; Julia Wilkins, BS; Eric Handler, MD; Marc A Lerner, MD; Raoul Burchette, MS; Lawrence S Wissow, MD

Adolescent depression screening is recommended starting at age 12-years, but younger children experience depression as well. Our objective was to determine if screening for depression at age 11-years yields similar results to screening at age 12-years. Multi-stage depression screening in 11-year-olds can be successfully applied in clinical practice with most cases identifying youth without a prior mental health diagnosis.

Validation Study of Kids Hearing Game: A Self-Administered Pediatric Audiology Application

Brian Kung, MD; Larisa Kunda, MD; Sarah Groff, AuD; Erica Miele, AuD; Marion Loyd, AuD; Diane M. Carpenter, MPH

Conduct a comparison study between conventional audiometry and a tablet-based hearing screening application, Kids Hearing Game (KHG). If KHG measures hearing at levels comparable with conventional audiometry, it could be used to screen hearing in children. KHG is comparable to conventional audiometry and may be used as a screening tool for children.

Effects of Implementing a Higher Threshold for Recommending Thyroid Biopsies on Malignancy Rates

Kori Higashiya, BS; Liam Delgesso, BS; Hyo-Chun Yoon, MD, PhD

We implemented a new thyroid nodule classification system where biopsy was recommended for thyroid lesions ≥1 cm with at least two or more suspicious features. In a community setting performing less than 200 biopsies per year, the utilization of more stringent requirements for thyroid biopsy are necessary to achieve malignancy rates comparable to the published literature.

Changes in Emergency Department Patient Volume and Acuity Associated with Early Stages of the COVID-19 Pandemic in a Unique Environment

Brent Lorenzen, MD; Adam Schwartz, MD, MS

Hospitals and emergency departments faced profound uncertainty during the COVID-19 pandemic. Early concerns regarding demand far exceeding capacity were balanced by anecdotal reports of decreased patient visits, including those for specific high acuity conditions. This study seeks to identify changes in Emergency Department (ED) volume and acuity, within a specific managed care environment, associated with the onset of the pandemic

Colorectal Cancer and Return to Work: A Pilot Study of Recruiting Cancer Survivors and Their Employers

Inga Gruß, PhD; Cathy J Bradley, PhD, MPA; Matthew P Banegas, PhD, MPH

In this study we assessed the feasibility of recruiting colorectal cancer survivors and their employers to participate in research on return-to-work (RTW) after cancer diagnosis.

Time-varying Reproduction Numbers of COVID-19 in Georgia, USA, March 2, 2020 to November 20, 2020

Kamalich Muniz-Rodriguez, DrPH; Gerardo Chowell, PhD; Jessica S Schwind, PhD; Randall Ford, DDS; Sylvia K Ofori, MPH; Chigozie A Ogwara, BS; Margaret R Davies, BS; Terrence Jacobs, BS; Chi-Hin Cheung, MS; Logan T Cowan, PhD; Andrew R Hansen, DrPH; Isaac Chun-Hai Fung, PhD

In 2020 SARS-CoV-2 impacted Georgia, USA. Georgia announced state-wide shelter-in-place on April 2 and partially lifted restrictions on April 27. We estimated the time-varying reproduction numbers, Rt, of COVID-19 in Georgia, Metro Atlanta, and Dougherty County and environs, from March 2 through November 20, 2020.

Adverse Events of Sodium–Glucose Cotransporter-2 Inhibitors in Chronic Kidney Disease: A Retrospective Chart Review

Hanul Choi, PharmD; Leigh-Anh Nguyen, PharmD; Jenny Wan, PharmD, BCPS; Hooman Milani, PharmD, MBA; Kristine McGill, PharmD, BCPS; Jong Park, MD

The renal benefits of SGLT2 inhibitors are now well-established, and these agents are recommended by the ADA and KDIGO guidelines for patients with type 2 diabetes and CKD. However, the safety profile of SGLT2 inhibitors in CKD is not as clear. This study describes the adverse event rates of SGLT2 inhibitors, primarily empagliflozin, in KP SCAL members with diabetic kidney disease.

Visit Content Analysis: Doctor-Patient Communication in Patients with Type 2 Diabetes

Dana A Abdelgadir, BA; Laurie M Rodriguez, BS; Maruta A Blatchins, BS; Pranita Mishra, MPP; Anjali Gopalan, MD, MS; Richard W Grant, MD, MPH

The primary care visit is an important opportunity to discuss and modify diabetes management. Our results highlight two potential strategies (preparing patients for their visits through identifying priorities and learning how to ask more questions during visits) for improving diabetes primary care.

Regionalization of Acute Myeloid Leukemia Treatment in a Community-Based Population: Implementation and Early Results

Lisa Y Law, MD; Stephen P Uong, MS; Hyma T Vempaty, MD; Vu H Nguyen, MD; David Baer, MD; Vincent X Liu, MD; Lisa J Herrinton, PhD

Regionalization of care for acute myeloid leukemia (AML) has not been described for community-based settings. In 2015, we shifted AML induction from 21 local centers to three regional centers.

Unhealthy Drinking Behavior and the ATTAIN Solution: Web-based Automated Alcohol Misuse Interventions

Jennifer Chevinsky, MD, MPH; Emma Fredua, MPH, CHES; Ebonie M Vazquez, MD; Mohamed H Ismail, MD, DrPH

Context: Up to 30% of American adults may have unhealthy drinking behavior, but only 17% get screened. There is promise in improving screening via technology, but a lack of published evidence supporting these efforts. Objective: To describe the development of ATTAIN, an automated, web-based process to screen for and manage adults with unhealthy drinking behavior with minimal involvement of healthcare personnel.


The Role of Cannabidiol in Neurological Disorders

Sirichai Chayasirisobhon, MD, FAAN

CBD is a non-psychotropic chemical and therefore has become a compound of interest for clinical researchers to study its therapeutic potential. This article is intended to review the efficacy and safety of CBD in various neurological disorders in humans.

What Is Genitourinary Syndrome of Menopause and Why Should We Care?

Kelly Jo Peters, DO

Genitourinary syndrome of menopause (previously known as vulvovaginal atrophy or atrophic vaginitis) involves symptoms of vaginal dryness, burning, itching as well as dyspareunia, dysuria, urinary urgency and recurrent urinary tract infections. This article is intended to address the signs, symptoms and significant impact this condition can have for women and help healthcare providers be more comfortable knowing how to ask about this, diagnosis it and review various treatment options that are available about this condition.


Bringing Down the Door-to-needle Time: Patient Thrombolysed in 6 Minutes—A Case Report

Ankur Verma, MBBS, MEM; Sanjay Jaiswal, MBBS, MEM

It has been clearly established that thrombolysis using recombinant tissue plasminogen activator (rTPA) is strongly beneficial for acute stroke patients. The sensitivity of brain tissue to ischemia causes this time dependence of the effectiveness of rTPA. Early recognition and activation of a stroke alert/code becomes imperative to effectively treat acute stroke patients and have positive outcomes. Here we describe the case and our rapid thrombolysis protocol which helped us achieve this door to needle time. A structured protocol is recommended to reduce the door to needle times for thrombolysis in acute ischemic strokes.

Utilization of Nivolumab in Adenoid Cystic Carcinoma After Progression on Platinum-Based Chemotherapy

Diana V Maslov, MD, MS; Katharine Thomas, MD, MS; Marc Matrana, MD, MS, FACP

Immunotherapy has clinical activity for those with metastatic head and neck cancers (HNC) who progress on proton therapy. This case reviews the use of immunotherapy in a patient with ACC. Immunotherapy has been utilized for HNC patients that have progressed. No study has evaluated the efficacy of immunotherapy in ACC. Our patient survived three months following administration of Nivolumab. Nivolumab and other PD-L1 inhibitors may be considered in patients with ACC.

Deadly Neuroinvasive Mosquito-Borne Virus: A Case of Eastern Equine Encephalitis

Natalie Millet, DO; Saif Faiek, MD; Daniel Gurrieri, DO; Karanvir Kals, DO; William Adams, DO; Edward Hamaty, DO; Manish Trivedi, MD; David Zeidwerg, DO

In this report, we describe a 42 years old man who worked primarily in wooded areas, presented to a hospital in southern New Jersey with an intractable headache and global facial paraesthesia. He reported multiple tick bites in the weeks prior to his presentation. Based on high clinical suspicion, cerebrospinal samples were sent to the CDC, which confirmed the diagnosis of eastern equine encephalitis.

Jejunal Gastrointestinal Stromal Tumor as a Source of Small Bowel Bleeding: A Case Report

Jacob Burch, DO; Iftiker Ahmad, MD

We present the case of a 76-year-old male who presented with 2 weeks of melena which began after starting dual antiplatelet therapy with aspirin and clopidogrel after undergoing coronary artery stenting. After EGD and colonoscopy failed to identify the culprit, the patient underwent VCE which identified a suspicious area concerning for intussusception. Computed tomography enterography (CTE) was then performed and showed a short segment of bowel wall thickening. The patient underwent laparoscopic small bowel resection and was found to have a GIST.

Rapid Response of a BRCA2/TP53/PTEN-Deleted Metastatic Uterine Leiomyosarcoma to Olaparib: A Case Report

Minggui Pan, MD, PhD; Kristen Ganjoo, MD; Amer Karam, MD

Here we report a patient whose metastatic ‘uterine leiomyosarcoma (uLMS)’ contains a BRCA2 deep deletion, as well as TP53 and PTEN deep deletion, responded rapidly to olaparib, a poly (ADP-ribose) polymerase (PARP) inhibitor, after progressing on gemcitabine-docetaxel, doxorubicin, and temozolomide regimens. This case report shall be helpful to the treatment of other patients with metastatic uLMS that harbors a BRCA2 mutation or deletion.

A Case Report of Leptomeningeal Carcinomatosis Secondary to Recurrent Merkel Cell Carcinoma after Avelumab

Pedro Mendoza, MD; Kathy Lin Chuang, MD

Merkel cell carcinoma is a rare and aggressive neuroendocrine cancer with a high mortality rate of ('33%-46%'). 1 Merkel cell is a type of epidermis cell receptor responsible for contact sensitivity and is known to have neuroendocrine properties. Treatment of Merkel cell carcinoma with avelumab has been promising, but its rarity and poor prognosis necessitates close follow up.


Unconscious Bias Is a Human Condition

Mihal Emberton, MD, MPH, MS

The unconscious bias that plagues our police departments is the same unconscious bias that plagues business in the form of employee oppression and burnout, that plagues academia in the form of social promotion and fixed mindsets, that plagues law in the form of poetic injustice and that plagues politics in the form of disenfranchisement and voter suppression. Each industry has also attempted to correct the negative effects of unconscious bias with leadership development in business, Montessori method and active learning in academia, restorative justice in law, and voter participation and town halls in politics. The reason that each of these efforts is still in its infancy is that our understanding of the rules of unconscious bias and the behaviors that stem from that unconscious bias have been incompletely understood until now. Good people like yourself and like me have unconscious bias; having unconscious bias is a human condition. But those of us who learn to recognize and overcome our unconscious bias become more impactful and powerful stewards of society.

The Ally Book Club: A Tool for Challenging Racism

Jeffrey B Ritterman, MD; Miranda Ritterman Weintraub, PhD, MPH

The Black Lives Matter movement has encouraged many of us to challenge our personal racism and to uproot the racism within our institutions. This is a national project, long overdue. While we have watched with interest the toppling of Confederate statues, we were surprised to learn that we, in medicine, have statues of our own that need removal. The marble statue of Dr. James Marion Sims that once graced New York City's Central Park no longer stands. For years, it proudly faced the New York Academy of Medicine. Other statues of Dr. Sims can be found at South Carolina's Statehouse and on the Alabama State Capitol grounds.

Etiology of Belief–behavior Systems and Hierarchies

Mihal Emberton, MD, MPH, MS

In order to understand the well documented patterns of mental health, human learning, human behavior, and the mechanics of hierarchies such as academic institutions, political systems, and business organizations, one must discover the rules and pathways that cause those patterns. My Belief-Behavior Systems archetype is the first of its kind to reconcile the theories and insights from social sciences, political science, psychiatry, and evolutionary biology into a unifying paradigm which explains how socialization and human interactions evolved into the patterns we recognize today. More importantly is that this new contribution to our understanding of human behavior within hierarchies provides the key insights to guide the restoration and repair of our dysfunctional hierarchies which, unfortunately, all too often oppress, manipulate and exploit our humanity.

  1. ‘uterine leiomyosarcoma (uLMS)’?


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