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On The Cover

China Dr Clarke1


Reed Flute Cave
By David D Clarke, MD


The elaborate natural limestone formations in Reed Flute Cave, in Guilin, Guangxi, China, attract many visitors to the area with their diversity and beauty.

The cover of the first issue of The Permanente Journal, Summer 1997, featured Dr Clarke’s photograph of body pigments for sale in a Kathmandu, Nepal market. Twenty years later, we are proud to be publishing high-quality articles graced by high-quality art.


Numb Chin Syndrome

Image Diagnosis: Numb Chin Syndrome
Rabih Geha, MD; Trevor Jensen, MD


A 58-year-old woman with a history of stage III lung adenocarcinoma presented with good dentition, no oral lesions, and reduced sensation to light touch over the right side of her chin. A scan showed diffuse dural thickening concerning for leptomeningeal carcinomatosis.



Gastrointestinal Bleeding

Image Diagnosis: Unusual Cause of Gastrointestinal Bleeding in a Young Man: Isolated Gastric Angiodysplasias
Sandeep Lamoria, MD; Arka De, MD; Vishal Sharma, MD, DM


Gastric angiodysplasias are an uncommon cause of upper gastrointestinal bleeding and may be associated with underlying predisposing factors like hereditary hemorrhagic telangiectasia syndrome or under-going hemodialysis. They may present with hematemesis, melena, or chronic gastrointestinal blood loss resulting in anemia.



Myocardial Infarction

ECG Diagnosis: Right Ventricular Myocardial Infarction
Manvi R Nagam, MBBS; David R Vinson, MD; Joel T Levis, MD, PhD, FACEP, FAAEM


Approximately 25% to 50% of cases of inferior wall myocardial infarction are associated with a right ventricular myocardial infarction (RVMI).1 In a large meta-analysis, the presence of RVMI was associated with a 2.6-fold increased risk of mortality as well as an increase in ventricular arrhythmias, high-grade atrioventricular block, and mechanical complications.2 The hemodynamic syndrome associated with RVMI includes hypotension, elevated venous pressures, and shock without evidence of congestive heart failure.3




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