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On the Cover


The Wheel of Life
by Daniela Alexandru Abrams, MD

The Wheel of Life is an acrylic on canvas painting (40” x 40”) by Daniela Alexandru Abrams, MD. Dr Alexandru Abrams is a Neurosurgeon in the Department of Neurological Surgery at the University of California, Irvine School of Medicine in Orange, CA. She has created numerous pieces of art over the years, including medical illustrations, some of which can be seen in The Permanente Journal.

Soul of the Healer


Scarlet Macaws at a Mineral Lick,
Tambopata National Reserve, Peru

Stuart Hahn, MD



Île d’Orléans, Quebec
Gerald Levy, MD, MBA


Umbrellas for Sale
Stuart Hahn, MD


Heading Home
Cathleen VanBergen

Online Only

Case Report


An Unusual Presentation of Dengue Fever: Association with Longitudinal Extensive Transverse Myelitis

The authors describe a middle-aged man who presented with dengue fever and in whom weakness of his bilateral lower limbs and urinary incontinence developed on the third day of fever. Magnetic resonance imaging confirmed the diagnosis of longitudinally extensive transverse myelitis. Over a four-week course of corticosteroids with supportive management, the patient recovered without any residual neurologic deficit.

Clinical Medicine

MyocardialInfarction ECG Diagnosis: Isolated Posterior Wall Myocardial Infarction

The ECG diagnosis of posterior wall myocardial infarction (MI) is difficult because no specific leads of the standard ECG directly represent this area. In addition, the lack of ST-segment elevation (as seen in typical ST-elevation MI) combined with misinterpreting the anterior ST-segment depressions as indicating ischemia rather than posterior infarction frequently lead to missing the diagnosis of posterior wall MI.

Book Review

The Lost Art of Retinal Drawing

Most physicians are familiar with direct ophthalmoscopy, which produces an upright, unreversed, and virtual image of approximately 15 times magnification. Binocular indirect ophthalmoscopy produces a stereoscopic inverted, reversed, and aerial image of 2 to 5 times magnification (depending on the power of the field lens) between the patient and examiner. The advantages of the direct ophthalmoscope are its relative portability and the ease of learning its use. Its disadvantages are a flat image and an inability to view the anterior fundus.


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