Winter 2021 - Volume 25 Number 1



The Quality of Care of Transgender and Gender Nonconforming Patients: The Provider Perspective

Suma Vupputuri, PhD, MPH; Stacie Daugherty, MD, MPH; Kalvin Yu, MD; Christine Truong, MPH; Ayanna Wells, MS, CHES; E W Emanuel, MD

Transgender and gender non-conforming (TGNC) patients have inadequate quality of care. Few studies have examined the issues related to quality of care from the perspective of providers. The purpose of this pilot study was to understand the barriers and facilitators of quality TGNC care and develop recommendations for health systems. Findings were distilled into 3 recommendations to improve the quality of TGNC care: (1) establish a dedicated case-management team; (2) provide access to more in-depth and meaningful training for providers, clinic staff, and administrative staff (and mandate certain basic training); and (3) allocate financial resources and enforce a policy of non-discrimination.

Immune-related Adverse Effects Associated with Programmed Death-1 Inhibitor Therapy in the Treatment of Non-Small Cell Lung Cancer: Incidence, Management, and Effect on Outcomes

Timothy Chiu, PharmD, BCPS; Christopher Yamamoto, PharmD, BCPS; Fang Niu, MS; Helen Moon, MD; Thach-Giao Truong, MD; Robert Cooper, MD; Rita Hui, PharmD, MS

The programmed death 1 (PD-1) inhibitors may improve survival outcomes of non-small-cell lung cancer (NSCLC) patients, but are associated with immune-related adverse effects (IRAEs). IRAEs management may include immunosuppression (i.e., corticosteroids), but there is a concern that this may impact efficacy. This study evaluated the influence of IRAEs and immunosuppression for IRAEs on survival outcomes of NSCLC patients treated with PD-1 inhibitors (pembrolizumab, nivolumab). In a large, real-world cohort from an integrated healthcare system, use of corticosteroids prior to PD-1 inhibitors was associated with worse survival outcomes, whereas concomitant treatment was not.

First Pass Recanalization Rates of Solitaire vs Trevo vs Primary Aspiration: The Kaiser Southern California Experience

Conrad W Liang, MD, PhD; Harjyot J Toor, DO; Evelin Duran Martinez; Sunil A Sheth, MD; Kuo Chao, MD, MPH, MBA; Lei Feng, MD, PhD; Mazen Noufal, MD; Binh V Nguyen, MD; Pankaj J Mowji, MD; Navdeep Sangha, MD

New stroke thrombectomy devices have significantly improved recanalization rates in patients with large vessel occlusion. The first pass effect, or complete or near complete recanalization after a single pass of a device, is associated with better outcome. However, it remains unclear whether one technique is superior to the others at first pass recanalization. In this multi-center cohort, there was no statistical difference in successful first pass recanalization between Solitaire, Trevo, and PA. However, there was a trend towards improved efficacy with the Solitaire device compared to Trevo (OR 1.90, p = 0.09). Additional data are needed to determine the conditions under which design differences may favor one technique over another.

Using the County Health Rankings Framework to Create National Percentile Scores for Health Outcomes and Health Factors

Matthew C Stiefel, MPA, MS; Tasha Straszewski, PhD, MA; Jennifer C Taylor, PhD; Christina Huang, MHSA; Jessica An, MPH; Folasade J Wilson-Anumudu, MPH; Allen Cheadle, PhD

As a means of conceptualizing population health, the County Health Rankings & Roadmaps program developed a methodology to rank counties within each state on Health Outcomes and Health Factors. We built on this framework by introducing an additional application that utilized national percentile scores and population size weighting to compare counties on a national, rather than a state, level. By comparing counties nationally and utilizing population size weighting, community partners can focus on areas that may be of greatest need in moving toward a national Culture of Health.

The Contribution of Patient, Primary Care Physician, and Primary Care Clinic Factors to Good Bone Health Care

Douglas W Roblin, PhD; Peter Cram, MD, MBA; Yiyue Lou, PhD; Stephanie W Edmonds, BSN, MPH, PhD; Sylvie F Hall, PharmD, MPH; Michael P Jones, PhD; Kenneth G Saag, MD, MS; Nicole C Wright, PhD; Lee F Cromwell, MS; Brandi E Robinson, MPH; Fredric D Wolinsky, PhD, ScD; on behalf of the PAADRN Investigators

Patient, provider, and system factors can contribute to chronic care management and outcomes. Few studies have examined these multilevel associations with osteoporosis care and outcomes. We examined how key process and structural factors at the patient, primary care physician (PCP), and primary care clinic (PCC) levels were associated with guideline concordant osteoporosis pharmacotherapy, daily calcium intake, vitamin D supplementation, and weekly exercise sessions at 52 weeks following enrollment in a cluster randomized controlled trial.

Parent Activation and Child Mental Health Service use in African American Families in a Large Cross-Sectional Study

Kathleen C Thomas, PhD, MPH; Izabela Annis, MS; Alan R Ellis, PhD, MSW; Leslie B Adams, MPH; Scott A Davis, PhD; Tywanda Lightfoot, PhD; Twyla Perryman, PhD; Madeline Wheeley, RN; Linmarie Sikich, MD, MA; Joseph P Morrissey, PhD

Data from African American parents in North Carolina 2010-2011 raising a child with mental health needs (n=325) were used to identify child mental health service use from a medical provider, counselor, therapist, any of the above or if the child had ever been hospitalized. Logistic regression was used to model the association between parent activation and child mental health service use controlling for predisposing, enabling and need characteristics of the family and child.

Mitigating the Youth Vaping Epidemic through Increasing Screening Rates for Youth Vaping/E-Cigarette Use in Pediatrics

Wynnyee Tom, MD; Brooke Harris, PhD; Arthur Shen, MPH; Lizeth Rivas, BS; Denise Williams, MA; Seham El-diwany, MD; Edan Wernik, MD; Andrew Nguyen; Gabriella Jones; Chynna Bantug, MD

E-cigarette/Vaping use in adolescents has increased 77.8% among high schoolers and 48.5% among middle schoolers in 2017-2018. As such, there is need for an effective workflow for screening for vaping. We aimed to increase screening rates of e-cigarette/vaping users from less than 1% to at least 50% in 6 months. It is important to find ways in which providers can mitigate this epidemic given the alarming increase in e-cigarette/vaping use among adolescents. This study furthers the effort to develop a screening method that is simple and brief, allowing physicians to intervene if necessary.

The Application of Community-Based Information from the American Community Survey in a Large Integrated Health Care Organization

Zhi Liang, PhD; Claudia Nau, PhD; Fagen Xie, PhD; Ralph Vogel, PhD; Wansu Chen, PhD

The American Community Survey (ACS) is the largest household survey conducted by the U.S. Census Bureau. We sought to describe the community-level characteristics derived from ACS among enrollees of Kaiser Permanente Southern California (KPSC), evaluate the associations between ACS estimates and selective individual-level health outcomes, explore how using different scales of the census geography and the linearity assumption affect the associations.

The Vancouver Community Analytics Tool (VCAT): Software Enabling Operationalization of the Building Blocks of High-Performing Primary Care at Community Health Centers in British Columbia, Canada

Ronald Joe, MBChB, MSc; Gabriela Sincraian, BSc(Eng), PhD(Eng), MBA; Ali Rafik Shukor, MBiotech, MSc

Community Health Centres (CHCs) in British Columbia, Canada are using a data-driven approach to enable functions related to the design, organization, management, delivery and evaluation of primary health care services for complex populations. VCAT models, analyzes and visualizes the complexity profiles and service utilization patterns of complex populations, thereby enabling system administrators and clinicians to improve system performance and quality of care. The software represents a significant advance for health services research and is transforming the organization, delivery and evaluation of primary health care services.

Digital Communication Technology: Does Offering a Choice of Modality Improve Medication Adherence and Outcomes in a Persistent Asthma Population?

PJ Cvietusa, MD; NM Wagner, PhD; JA Shoup, PhD; GK Goodrich, MS; SM Shetterly, MS; DK King, PhD; MA Raebel, PharmD; CS Riggs, PharmD; B Bender, PhD

Use of digital communication technology has shown potential to improve asthma adherence and outcomes. Few studies have looked at patient preference around mode of medication reminders used to improve and maintain asthma medication adherence. In a patient population already used to receiving medication reminders, offering a choice about what type of technology-enabled asthma medication reminder patients wanted did not improve outcomes, but did enable a sub-group to better maintain their medication adherence.

A Quality Improvement Initiative Targeting Chronic Kidney Disease Metrics Through Increased Urinary Albumin Testing

Ken J Park, MD; Robert S Unitan, MD; Micah L Thorp, MPH, DO

Achievement of quality metrics in chronic kidney disease (CKD), specifically urinary albumin testing and angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use remained lower in Kaiser Permanente Northwest compared to other Kaiser Permanente regions. The authors were interested if more frequent testing of urine albumin (ACR) improved CKD quality metrics. In patients with stage 3 CKD, increased ACR testing via automated testing linked with EHR alert did not result in an improvement in CKD quality metrics.

Effectiveness at 24 Months of Single-Source Generic Carbamazepine, Lamotrigine, or Levetiracetam in Newly Diagnosed Focal Epilepsy

Suresh Gurbani, MD, PhD; Sirichai Chayasirisobhon, MD; Aditya Gurbani, BA; Stephanie Tovar, MS; Erika Pietzsch, MD; Benjamin Spurgeon, DO

This is a retrospective data analysis of 646 consecutive AED naïve patients aged 1-88 years treated with CBZ, LTG or LEV between 2006 and 2012 with dosing adjustments permitted during the first 6 months. Chi-square test with p-value at < 0.05 was used to calculate seizure-freedom and tolerability rates. At the 24-month study period, in head to head comparison of single-source bioequivalent generic formulations, when compared to CBZ and to LTG, superior seizure-freedom rate, and comparable tolerability and retention rates for LEV were observed.

Implementation of a Post-Surgical, Multimodal Analgesia Pain Management Order Set in Opioid-Naive Patients

Faith Brown, PharmD; Maggie Guinta, PharmD, BCPS, BCCCP; Jenna Swindler, PharmD, BCPS-AQID; Denise Allison, MSNEd, RN; Craig Selander, MD; Brenda Raynor, BSN, RN

Perioperative pain management guidelines recommend using multimodal analgesia (MMA) to improve pain control while reducing opioids administered. The primary objective assessed whether implementing MMA on general surgery post-operative pain management order sets would reduce opioid quantities postoperatively. Utilizing perioperative MMA reduces opioid consumption without increasing pain scores.

Effectiveness of a Family-Centered Pediatric Weight Management Program Integrated in Primary Care

Veronica Else, RN, NP, MSN; Qiaoling Chen, MS; Alan B Cortez, MD; Corinna Koebnick, PhD

The evidence supporting the effectiveness of weight loss interventions with low to medium intensity is limited. Electronic medical record data of pediatric patients in Kaiser Permanente Orange County, California, who were enrolled in weight management between 04/2014 and 12/2018 (FB-WMG, n=162) and compared to patients who were referred but did not enroll (Ref-CG, n=203) and controls matched by sex, age, zip code and BMI (Area-CG, n=287). BMI was measured at the first visit (or index date) and after 6 months.

Development and Validation of Machine Learning Models: Electronic Health Record Data To Predict Visual Acuity After Cataract Surgery

Stacey E Alexeeff, PhD; Stephen Uong, MPH; Liyan Liu, MSc; Neal H Shorstein, MD; James Carolan, MD; Laura B Amsden, MSW, MPH; Lisa J Herrinton, PhD

To develop predictive models of final corrected distance visual acuity (CDVA) following cataract surgery using machine learning algorithms and electronic health record data. In this predictive modeling study we used decision tree, random forest, and gradient boosting. We included the first surgical eye of 64,768 members of Kaiser Permanente Northern California who underwent cataract surgery June 1, 2010, through May 31, 2015. We measured discrimination and calibration of machine learning models for predicting post-operative CDVA 20/50 or worse vs 20/40 or better.


Mechanisms of Action and Pharmacokinetics of Cannabis

Sirichai Chayasirisobhon, MD, FAAN

At least 100 of cannabis species are compounds known as cannabinoids, a molecule with 21-carbon terpenophenolic skeleton. Cannabinoids produce over 100 naturally occurring chemicals, the most abundant of which are delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD), terpenes and flavonoids. THC and CBD bind with cannabinoid receptors (CB1 and CB2), which are present in many organs of the body including the brain.

COVID-19 Pandemic and the Burden of Acute Kidney Injury: The Known and the Unknown

Talha H Imam, MD

The present pandemic of severe acute respiratory syndrome (SARS) is caused by the coronavirus (2019-nCoV), commonly called COVID-19. Starting from China, it has spread worldwide causing major morbidity and mortality. It primarily involves pulmonary system, but other organ systems are not spared. Treatment is still elusive and evolving. Exact pathogenesis of renal damage from COVID-19 virus, as well as the magnitude of renal failure in this infection is not very clear. This review looks at the burden and influence of the COVID-19 pandemic on the kidneys, and what implications it will have on public health planning.


Pyomyositis as an Unusual Presentation of Colonic Adenocarcinoma

Osama Mosalem, MD; Fawzi Abu Rous, MD; Abdullah Al-Abcha, MD; Shouq Kherallah, MD; Jacob Burch, DO

Pyomyositis has been described in association with hematological malignancies. It is rarely associated with solid cancers, particularly colorectal carcinoma (CRC). CRC can present with local or systemic abscesses by causing perforation of the colonic mucosa, followed by local or hematogenous spread of infection. Colorectal cancer (CRC) can be associated with local or systemic abscess formation. When cultures from an abscess show enteric pathogens, it's essential to look to gastrointestinal or genitourinary tracts for the source of infection. Although rare, the diagnosis of pyomyositis should warrant further investigations to unmask the possible underlying cause.

Concurrent Delusions of Ocular Parasitosis and Complex Visual Hallucinations from Charles Bonnet Syndrome Treated Successfully with Aripiprazole in an Elderly Male: A Case Report

Nakiya T Whitfield, Pharm D; Anne E Krasniak, Pharm D; Hien T Nguyen, MD

Delusional parasitosis (DP) has been described as among the most challenging diagnosis to manage in dermatology and psychiatry literature. Patients with this perplexing and enigmatic condition present potentially to a wide range of specialties including primary or emergency care, dermatology, infectious diseases, neurology and psychiatry. DP is probably underdiagnosed from patients’ underreporting of symptoms of being infested with parasites, due to the associated social stigma. In addition, specialists who most often encounter these patients often possess low familiarity and comfort level in the diagnosis and therapy of this disorder.

Ipsilateral Vocal Cord Paralysis After Acute Anterior Ischemic Stroke

Khalid Sawalha, MD; Ahmed Abd Elazim, MD; Omar Hussein, MD

The vocal cord is innervated by the recurrent laryngeal nerve and the superior laryngeal nerve which are branches of the vagus nerve. The nucleus ambiguous is a motor nucleus of the vagus nerve and it is located in the medulla. It receives supratentorial upper motor regulatory fibers. Commonly, this regulation is bilaterally represented in the brain. Less commonly, it is contralaterally represented. We present a female patient in her early sixties with a past medical history significant for hypertension who presented with acute right-sided weakness and expressive aphasia (NIHSS= 20).

Case Report: From Irregular Hiccups to Acute Myocardial Infarction

Kamiar Kersten Rueckert, MD; Adrian Willersinn, MD

The ECG is the key player in the diagnosis of an acute coronary syndrome (ACS). In the light of normal ECG findings, the diagnosis can be missed. The high-sensitive troponin is a necessary laboratory value for patients with uncommon symptoms. The troponin algorithm helps to identify this patient group, especially in the setting of elevated CK and LDH. Awareness of these symptoms can help lead to a timely reperfusion therapy and thus improved outcomes. The 2015 ESC-algorithm (European Society of Cardiology) for troponin may not only help for the initial diagnosis, but rather, should be regarded as crucial.

Complete Regression of Rhabdomyosarcoma in an Adult Secondary to Postoperative Wound Infection Following Limb Salvage Surgery: A Case Report

Andrew S Fang, MD; Lee Jae Morse, MD; Rosanna Wustrack, MD; Ryan Huber, MD; Minggui Pan, MD

A 33-year old male presented with a 25-centimeter lower extremity embryonal rhabdomyosarcoma with presumed extensive nodal metastasis on positron emission topography (PET) scan. Neoadjuvant chemotherapy and radiation provided minimal response. Following limb salvage resection and flap coverage, a prolonged postoperative infection occurred requiring intravenous antibiotics and wound care over five months. Given the infection, no postoperative radiation or chemotherapy was administered. Eight months following surgery, PET scan showed complete regression of local and nodal disease. Patient has remained in complete remission for more than four years.

Clinical Outcome of Adult Spinal Muscular Atrophy Patients Treated with Nusinersen: A Case Series Review

Keng Lam, MD; Abel Wu, MD

Nusinersen is an antisense oligonucleotide drug that was developed for treatment of spinal muscular atrophy (SMA). Its effectiveness for adults is limited, thus more clinical data is needed to guide adult SMA patients who are considering this treatment. Through case series review, we retrospectively reviewed charts of Kaiser Permanente Southern California members who were already receiving nusinersen treatment that was available since August 2017. They were evaluated by physical therapy using Hammersmith Functional Motor Scale (out of highest possible score of 40). Based on this small study, some adult SMA patients may benefit from treatment of nusinersen.

Telehealth in Pediatric Gastroenterology Can Be a Sustainable Long-Term Option: A Single-Center Experience

Kristina Leinwand, DO; Nicole Blodgett, RN; Ramya Ramraj, MD

In this report, we aim to present our single center experience from the past year where virtual care was already an integral part of our clinical practice in pediatric gastroenterology, and aim to review satisfaction data and quality measures from the COVID-19 era where our existing telehealth system expanded to nearly exclusive virtual care.

Durable Complete Remission of PD-L1 Positive NUT Carcinoma Treated With Concurrent Chemotherapy and Radiation

Minggui Pan, MD, PhD; James S Chang, MD

NUT carcinoma is an extremely rare disease and yet extremely aggressive with two-year survival of only approximately 19% and median survival of 6 to 9 months. We report here two successfully treated patients with durable complete remission (CR) after concurrent chemotherapy and radiation using two completely different chemotherapy regimens. One patient had extremely high tumor burden and obtained CR with ifosfomide and etoposide concurrently with radiation. One patient with low tumor burden and obtained CR with carboplatin and paclitaxel concurrently with radiation. Interestingly, both patients had high PD-L1 expression in the tumor that may be associated with the favorable outcome. Our experiences with these two successfully treated patients offer insight for the management of NUT carcinoma.

Case Report: Lactation Ketoacidosis Can Complicate the Ketogenic Diet

Michelle C Liu, RD, BS; Ruth Ann Bertsch, MD, PhD, FACP

We report the case of a mother, who lactating and losing weight on a ketogenic diet, developed a pneumonia and then went into ketoacidosis. Physicians should be aware that patients on the ketogenic diet are at risk for life threatening acidosis, especially if they develop a second and/or third stressor or energy requirement on top of the low carbohydrate diet. This case and those reviewed in the literature indicate that ketogenic diets may not be safe during lactation and could be associated with increased morbidity.


Interfaith Dialogue and Sir William Osler

Jonathan Kopel, BS; Mark Webb, PhD; Carmine Gorga, PhD

In recent years, the United States (US) has become extensively polarized across social, political, and religious divides. As the cultural, political, and social divides continue to grow, the medical establishment has shown similar divisions between clinicians and patients. However, an inclusive dialogue that recognizes the intellectual and interpersonal boundaries of opposing groups and traditions would provide an avenue towards mutual understanding and further collaboration towards a common goal and solution. One such method for building bridges between opposing groups can be found in interfaith dialogue.

Converting to Laparoscopic Inguinal Hernia Repair in Children: A Tale of a Dilemma

Sani Z Yamout, MD, FACS

Inguinal hernia repair is the most common elective operation performed by pediatric surgeons. Unlike the adult version of the operation, pediatric inguinal hernia repair does not involve the use of mesh to reinforce weak tissue. The goal is simply to close a hole in the abdominal wall (the internal inguinal ring), that did not close as intended prior to birth. While performing the operation in boys, the surgeon’s biggest concern is not injuring the vas deferens or blood supply to the testicle.

"Call Me Your Clinical Reader-Witness"

Alexandria Yap, BA

A recently graduated, pre-med, English major reflects on the benfits of her perspective.


Re: Dutheil et al. Prostate Cancer and Asbestos: A Systematic Review and Meta-Analysis

Paolo Boffetta, MD, MPH; Nicolò Franco, MD; Attilia Gullino, MD, PHD; Enrico Pira, MD

Letter regarding the systematic review meta-analysis by Dutheil et al. on occupational and residential exposure to asbestos and prostate cancer risk includingn the authors' response.


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