Volume 26, Number 1



A Few Final Words. Stephen Tarnoff, MD

Incoming Remarks. G. Richard Holt, MD

Voices From The Permanente Journal: Examining the Past While Embracing the Future. Cuong Le, MA, MAT; Paul Bernstein, MD, FACS; Kirk Fernandes, MS


Clinical Decision Support to Address Racial Disparities in Hypertension Control in an Integrated Delivery System: Evaluation of a Natural Experiment. Cassondra Marshall, DrPH, MPH; Alyce S Adams, PhD; Lin Ma, MA; Andrea Altschuler, PhD; Mark W Lin, MD, MPH; Nailah A Thompson, DO, MPH; Joseph D Young, MD

The authors evaluated the impact of a clinical decision support tool to improve evidence-based thiazide diuretic prescribing among Black patients to address racial disparities in hypertension control. They observed no change in thiazide use or blood pressure control following the implementation of the tool.

Evaluating the Implementation of Digital and In-Person Diabetes Prevention Program in a Large, Integrated Health System: Natural Experiment Study Design. Stephanie L Fitzpatrick, PhD; Meghan Mayhew, MPH; Chris L Catlin, BS; Alison Firemark, MA; Inga Gruß, PhD; Denis B Nyongesa, MS; Maureen O’Keeffe-Rosetti, MS; Andreea M Rawlings, PhD, MS; David H Smith, PhD, RPh; Ning Smith, PhD; Victor J Stevens, PhD; William M Vollmer, PhD; Stephen P Fortmann, MD

Kaiser Permanente Northwest patients who were 19 to 75 years old with prediabetes and obesity were invited to participate in the digital and in-person Diabetes Prevention Program during 2016 through 2018. The mixed-methods, natural experiment design the authors used contributes new knowledge related to best practices for implementing and sustaining the Diabetes Prevention Program within large health systems over the long term.

Computed Tomography Use in Children With Minor Head Trauma Presenting to 21 Community Emergency Departments Within an Integrated Health-Care System. Judy Shan, BS; E Margaret Warton, MPH; Mary E Reed, DrPH; David R Vinson, MD; Nathan Kuppermann, MD, MPH; Peter S Dayan, MD; Stuart R Dalziel, MD; Adina S Rauchwerger, MPH; Dustin W Ballard, MD, MBE

This study evaluated computed tomography use in children with minor blunt head trauma in 21 community emergency departments within an integrated health care system. Use was low and stable across facilities from 2016 through 2018. This may be indicative of the safe stewardship of resources in the system.

Impact of COVID-19 on the Incidence and Severity of Obstetric and Gynecologic Emergency Department Visits in an Integrated Health Care System. Cassidy E Tierney, MD; Mary Kathryn Abel, AB; Mubarika M Alavi, MS; Miranda Ritterman Weintraub, PhD, MPH; Andrew Avins, MD, MPH; Eve Zaritsky, MD

The aim of this study was to assess changes in incidence of OB/GYN emergency department visits and disease severity at time of presentation during the COVID-19 pandemic. The incidence of OB/GYN emergency department visits declined substantially between March and August 2020 but then returned to pre-pandemic levels by fall/winter 2020.

Downstream Acute Care Utilization Following Initial Prescription of an Opioid Pain Reliever Among Emergency Department Patients With Low-Severity Conditions. Nathan Juergens, MD, MPH; Julia Wei, MPH; Esme Cullen, MD, MPH; Moses Graubard, MD; Vibha K Gupta, MD; Miranda Ritterman Weintraub, PhD, MPH; Dana Sax, MD, MPH

Authors investigated the association between receipt of an opioid pain reliever in the emergency department and downstream acute health care utilization. Patients who received an opioid pain reliever at their index encounter had substantially increased odds of a subsequent emergency department, urgent care, or inpatient visit.

Variation in Positivity Rates of Computed Tomography Pulmonary Angiograms for the Evaluation of Acute Pulmonary Embolism Among Emergency Department Physicians. Kori Higashiya, MD; James Ford, MD; Hyo-Chun Yoon, MD, PhD

Computed tomography pulmonary angiography is an imaging study for which there is substantial evidence for its overuse in the evaluation of acute pulmonary embolism. This study was based in a single emergency department that is part of a geographically isolated integrated health care system.

Pragmatic Randomized Study of Targeted Text Message Reminders to Reduce Missed Clinic Visits. Ernesto Ulloa-Pérez, MS; Paula R Blasi, MPH; Emily O Westbrook, MHA; Paula Lozano, MD, MPH; Katie F Coleman, MSPH; R Yates Coley, PhD

Missed clinic appointments waste health system resources, decrease physician availability, and may worsen patient outcomes. Study findings indicate that using a prediction model to target reminders may reduce missed appointments and allow for more efficient use of health care resources.

The Effect of Elexacaftor/Tezacaftor/Ivacaftor on Hospitalizations and Intravenous Antibiotic Use. Eric Walter, MD, MSc; Jennifer L Bass, MD

Elexacaftor/tezacaftor/ivacaftor is a highly effective cystic fibrosis transmembrane conductance regulator modulator. The authors performed a single-institution, retrospective review comparing hospitalization and intravenous antibiotic rates before and after the initiation of elexacaftor/tezacaftor/ivacaftor.

Psychological Effect of the COVID-19 Pandemic Among Facial Feminization Surgery Patients. Nikolas R Block-Wheeler, MD, MS; David W Chou, MD; Kathleyn Brandstetter, MD; Andrew Kleinberger, MD; Charles Shih, MD

The COVID-19 pandemic has had a disproportionately negative impact on mental health among the lesbian, gay, bisexual, transgender, queer community, with the delay of medical services as a factor. This study revealed greater perceived facial femininity and a lower desire for surgery among facial feminization surgery patients during the pandemic.

Identifying Suicidal Ideation and Attempt From Clinical Notes Within a Large Integrated Health Care System. Fagen Xie, PhD; Deborah S Ling Grant, PhD, MPH, MBA; John Chang, MPH; Britta I Amundsen, LMFT; Rulin C Hechter, MD, PhD

Suicide can be a devastating outcome of psychiatric illness is a critical public health problem worldwide. The purpose of this study was to develop a natural language processing algorithm to identify suicidal ideation/attempt from free-text clinical notes.

Providing Rapid Access to Care for Underserved Patients During the COVID-19 Pandemic. Aleece Caron, PhD; Kim Bauchens, MSN; David Margolius, MD; Kathryn Teng, MD, MBA

COVID-19 is altering the health care delivery landscape at a rapid pace. This commentary describes our hospital system’s response to the COVID-19 pandemic and how we managed to rapidly transition to telehealth and provide seamless access for underserved patients.


Assessing the Role of High-Dose β-Agonists Use in Triggering Takotsubo Syndrome During Asthma Exacerbation. Danish Abbasi, MD; Saif Faiek, MD; Waqas J Siddiqui, MD; Angel Lopez-Candales, MD

A surge in catecholamine levels has been postulated as a potential mechanism causing cardiomyopathy, particularly Takotsubo Syndrome. We conducted a PubMed search for published case reports, experimental studies, animal studies, and review articles examining Takotsubo Syndrome documentation among patients with asthma.


High-Dose Pulse Steroids for the Treatment of Acute Hypoxemic Respiratory Failure in COVID-19 Pneumonia: A Simple Case Series. Gholmieh Ghassan, MD, PhD

Pulse steroids therapy is widely used to treat flare-ups of autoimmune diseases, such as systemic lupus erythematosus. The author presents a series of 9 cases that explore the use of high-dose pulse steroids in hypoxemic respiratory failure.

Case Report of Novel, Automatic Shocking Vector Adjustment Algorithm: A Life-Saving Feature of a Modern Defibrillator. Mark R Heckle, MD; Sunil K Jha, MD, MRCP, FACC, FHRS

Failed delivery of appropriate shocks against fatal dysrhythmias can be the result of low impedance on high-voltage leads. We describe the case of a 66-year-old man with a high-voltage lead short circuit who was successfully rescued with the use of an overcurrent detection and automatic shocking vector adjustment algorithm.

Effect of Immunosuppressive Diseases and Rituximab Infusions on Allowing COVID-19 Infection to Relapse. Rohan M Prasad, DO; Shaurya Srivastava, DO; Enhua Wang, MD; Jason Z Liu, DO; Rakesh Gami, MD; Ayat Abdelgadir, MD; Akhil Sharma, DO; Sumugdha Rayamajhi, MD; Richa Tikaria, MD

Relapsing COVID-19 infections have been reported, but their etiology and severity are still unknown. This case series illustrates 2 patients who developed a relapsed infection.

Rare Case of Mixed Phenotype Acute Leukemia Presenting as a Myeloid Sarcoma Without Leukemic Involvement. Jeffrey Means, DO; David Feldman, MD; Allison Shaw, MD; Khoan Vu, MD

Mixed phenotype acute leukemia is a rare type of acute leukemia with immunophenotypic features of both myeloid-derived and lymphoid-derived lineages. We present an atypical case of a 32-year-old woman presenting with an anterior mediastinal mass and pericardial/pleural involvement.

Efficacy and Cost of Maxillary Patient-Specific Implants in Orthognathic Surgery: A Review of Three Patient Cases. Ho-Hyun (Brian) Sun, DMD, MS; Heshaam Fallah, MD, DDS

Patient-specific implants are accurate, efficient alternatives to traditional plate fixation. We explored the departmental protocol for Lefort 1 patient-specific implant orthognathic surgery at a high-volume, tertiary referral center.

Gangrene of the Foot After Coronary Artery Bypass Graft Surgery. Julia L Boland, MD; Kristine Cueva, MD; Jessica Pawly, MD; Darius Shahbazi; Maximillian Lee, MD; Shahin Shahbazi, MD

Coronary artery bypass grafting is the most common surgery performed by cardiothoracic surgeons worldwide. The aim of this case report is to present a rare complication of coronary artery bypass grafting with perioperative intra-aortic balloon pump use and to highlight the need for prompt diagnosis and treatment of dry gangrene.


Personal Protective Equipment for COVID-19 and Beyond: Occupational and Environmental Exposure Considerations in Primary Care. Onyemaechi Nwanaji-Enwerem, MS, MPP; Jamaji C Nwanaji-Enwerem, MD, PhD, MPP; Brian Antono, MD, MPH

In this reflection piece, the authors describe a hypertension follow-up visit and draw attention to an often overlooked aspect of a patient’s health: their occupational and environmental history. This article specifically addresses the critical question of how primary care physicians and clinicians can think about, and address, occupational and environmental health hazards in their assessment and treatment of chronic disease in patients.

2021 Reviewer Acknowledgment


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