Winter 2009 - Volume 13 Number 1
Improving D-dimer Positive Predictive Value for Outpatients with Suspected Deep Vein Thrombosis
In a retrospective review, 1015 continuous patients with suspected deep vein thrombosis (DVT) were clinically evaluated in a laboratory with a D-dimer assay: 503 with a bioMérieux system and 512 with a Trinity Biotech system. With the Trinity Biotech assay, specificity increased from 41.3% to 66.9%, positive predictive value increased 2.3 times from 8.8% to 20.0%, and the probability of DVT increased from 25% to 38%. A significant number of unneeded compression ultrasounds were saved.
From Our Lips To Whose Ears? Consumer Reaction to Our Current Health Care Dialect
Every profession spawns a dialect, however, this qualitative study, conducted with consumers from Boston, New York City, St Paul, Billings, and San Diego, revealed a tremendous gap between what health care professionals say and what health care consumers hear. Negative language associations for consumers include: "medical decision support," "guidelines," "integrated care," "evidence-based medicine," and "best practices." Positive language associations include: "communication," "treatment," and "coordination."
Blood-Management Programs: A Clinical and Administrative Model with Program Implementation Strategies
Blood-management programs ensure that patients can access treatment without having to forfeit their beliefs, through an enlightened approach to medical and surgical treatment that can be used to benefit the Jehovah's witness population and the general population. The authors review a comprehensive approach to blood conservation, including acute normovolemic hemodilution simultaneous removal of the patient's blood and its replacement with a nonblood product.
Medical, Surgical, and Endoscopic Management of Gastroesophageal Reflux Disease
This article reviews the pathophysiology, presentation, workup, treat-ment, and emerging therapies for GERD with an emphasis on surgical management and outcomes to help primary care physicians have a better understanding of the role of surgery in this complex disease.
National Practice Recommendations for Hematuria: How to Evaluate in the Absence of Strong Evidence?
Hematuria is one of the most common conditions confronting clinical urologists, and generalists, however the existing lack of scientific evidence has created variations in clinical practice. Consequently, many patients with microscopic or gross hematuria undergo low-yield workups that include invasive testing and imaging with radiation. As a response, a national group of KP urology chiefs developed national practice recommendations.
Laparoscopic Surgery for Rectal Cancer
Because of the confined space within the pelvis, laparoscopic surgery for rectal cancer is much more challenging than that for colon cancer, particularly maintenance of resection margins. Nonrandomized studies have shown both that it produces short-term outcomes equivalent to open surgery, performed safely from an oncologic perspective. This review summarizes the technical considerations, early outcomes, late outcomes, costs, and complications.
A Case of Large Pericardial and Pleural Effusions Associated With Pulmonary Emboli in a User of Crack Cocaine
Hien Nguyen, MD; Connie Le, MD; Hanh Nguyen, MD
This is an unusual case of a user, age 56 years, of crack cocaine who presented with progressive dyspnea of subacute duration. One prior case report describes the development of a pleural effusion via an eosinophilic process. In contrast, in this patient the most probable mechanism is that crack cocaine induced a prothrombotic state that promoted formation of pulmonary emboli
Recognition of Kawasaki Disease
Janelle R Cox, MD; Robert E Sallis, MD
One of the most common vasculidities of childhood is the leading cause of acquired heart disease in children in the US. Though it should be included in the differential diagnosis for any child with prolonged fever that is unresponsive to antibiotics, the diagnosis is often difficult in that the symptoms tend to present at different times, and require multiple examinations on different days.
The B-SMART Appropriate Medication-Use Process: A Guide for Clinicians to Help Patients—Part 1: Barriers, Solutions, and Motivation.
Elizabeth Oyekan, PharmD, FCSHP; Ananda Nimalasuriya, MD; John Martin, MD; Ron Scott, MD; R James Dudl, MD; Kelley Green, RN, PhD
This multifaceted approach used before, during, and after any patient-clinician interaction creates a consistent method to help patients more effectively use their medications. Elements include: involving patients in the decision-making, simplifying dosage regimens, education about the medication, self-management training, ongoing reinforcement and motivation, and positive relationships. Concrete solutions are provided to nine common practice challenges, including: forgetfulness, literacy, denial, financial, depression, and lack of knowledge.
Image Diagnosis: Foot Fractures
Gus M Garmel, MD, FACEP, FAAEM
Although it may be difficult to see a Lisfranc foot fracture, significant force is needed to disrupt and dislocate this strong joint which stabilizes the midfoot. Calcaneus fractures, also the result of significant force can be associated with vertebral body fractures of the spine.
Evaluation of Hypertension with Hypokalemia
Antoine C Abcar, MD; Dean A Kujubu, MD
Hypertension that remains in poor control despite the use of many medications is a difficult problem that every primary care physician has faced. This article focuses on those less common causes of hypertension with hypokalemia—essential hypertension with diuretic use, primary aldosteronism, Cushing's syndrome, pheochromocytoma, renal vascular disease, and malignant hypertension.
SCPMG University: Helping New Physicians Adapt and Succeed
Jeffrey Weisz, MD; Nancy H Spiegel, MS
An individual's first few months with an organization are crucial. During that period, professionals develop a sense of what is important, what the organization expects from them, and what they can expect in return. Mean scores, from first-year, pre- to postprogram surveys, improved significantly on 11 of 14 items demonstrating the success of the University program in helping physicians adapt to their new positions, thus laying the foundation for a successful career within the medical group
At a Decade: Centers of Excellence in Culturally Competent Care
Rapidly increasing national racial and ethnic diversity calls for interventions that are culturally specific to improve patients' health outcomes and to eliminate health disparities. Kaiser Permanente developed nine innovative Centers of Excellence in Culturally Competent Care that are population-based, data-driven research projects that unravel and explain the dynamic processes by which culture, race, and ethnicity interact in health care delivery settings
Narrative-Based Medicine: Potential, Pitfalls, and Practice
With the evolution of "modern" medicine, narratives were increasingly neglected in favor of "facts and findings," regarded as more scientific and objective. Now—through understanding the narrative structure of medical knowledge, and narrative-oriented, physician-patient relations—narratives from social science research and medical practice and patient encounters are a source of knowledge for evidence, beyond the gold standard of randomized controlled trials of evidence-based medicine. This is a systematic overview of narrative-based medicine—background, narrative genres, and application in theory, research, and medical practice.
The Desert Doctor
This is the first chapter from the new book published by The Permanente Press—The Story of Dr Sidney R Garfield: The Visionary Who Turned Sick Care into Health Care—documenting the creation of Kaiser Permanente by cofounders Sidney Garfield and Henry J Kaiser. This biography, focuses, for the first time, on Sidney Garfield's story and vision.
Period. A Girl's Guide
Original Visual Art
"Child is the Father of the Man"
"Household Saints of Dubious Virtue"
Tribute to Robert Hippen, MD
Old Man Waiting at a Bus Stop
On The Cover