Fall 2010 - Volume 14 Number 3

Fall 2010 - Volume 14 Number 3

Original Research and Contributions

Fall 2010 - Volume 14 Number 3Factors Contributing to Door-to-Balloon Times of ≤90 Minutes in 97% of Patients with ST-Elevation Myocardial Infarction: Our One-Year Experience with a Heart Alert Protocol
Joel T Levis, MD, PhD, FACEP, FAAEM; Mary P Mercer, MD; Mark Thanassi, MD; James Lin, MD
Prompt percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction can significantly reduce mortality and morbidity if not limited by delays in delivery. On a retrospective data and chart review, staff met the recommended door-to-balloon time of ≤90 minutes (mean 57.3 ± 17.6) for 70 of 72 patients (97%). Sixty-five of the 72 patients (90.3%) survived to hospital discharge.

Fall 2010 - Volume 14 Number 3Reasons for Not Meeting Coronary Artery Disease Targets of Care in Ambulatory Practice
Thomas Erling Kottke, MD, MSPH; Zacharia Ogwang, NP; James C Smith, MD
In a retrospective review of patient records in a large multispecialty group practice’s coronary artery disease registry, the most frequent reasons for not meeting all four targets of care— blood pressure, low-density lipoprotein cholesterol level, daily aspirin, and tobacco use—were: 1) the patient was in for a visit and the care team failed to address an unmet target, 2) the patient was asked to return for follow-up care but did not, and 3) the patient declined an intervention that was offered.

The Protective Effect of Family Strengths in Childhood against Adolescent Pregnancy and Its Long-Term Psychosocial Consequences
Susan D Hillis, PhD, MS; Robert F Anda, MD, MS; Shanta R Dube, PhD, MPH; Vincent J Felitti, MD, FACP; Polly A Marchbanks, PhD; Maurizio Macaluso, MD, DrPH; James S Marks, MD, MPH
In this retrospective cohort of 4648 women (3082 participants—66%) ≥18 years (mean 56), teen pregnancy decreased with increased childhood family strengths: family closeness, support, loyalty, protection, love, importance, and responsiveness to health needs. This partly explained progressive delays in initiation of sexual activity and psychosocial problems occurring decades later: job, family, finances, high stress, and uncontrollable anger.

Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index and Its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes
James J Annesi, PhD; Ann M Walsh, MS, RD; Alice E Smith, MS, MBA, RD
Pediatricians seek effective behavioral treatments for referral for 7% of US adolescents who have impaired fasting glucose. Data from 64 pediatrician-referred patients with diabetes risk factors (mean age, 14.1 years; BMI, > 99th percentile) demonstrated nutrition education alone may be insufficient for nutrition behavior change. Behavioral treatment lasting longer than 12 weeks and having a specific weight-loss goal may be useful for BMI improvements, as is attention to participants’ self-concept and mood.

Proactive Office Encounter: A Systematic Approach to Preventive and Chronic Care at Every Patient Encounter

Michael Kanter, MD; Osvaldo Martinez, MPH; Gail Lindsay, RN; Kristen Andrews; Cristine Denver, SM
A systematic program—the Proactive Office Encounter—addresses the preventive care and management of chronic disease. Identification of gaps in care, using information technology, assists physicians to improve consistency. This care was implemented in all outpatient settings in Kaiser Permanente’s Southern California Region’s 13 medical centers and 148 medical office buildings. The program contributed to significant improvements in key clinical quality metrics, including cancer screenings, blood pressure control, and tobacco cessation.

An Alternate Model for Medical Education: Longitudinal Medical Education Within an Integrated Health Care Organization—A Vision of a Model for the Future?
Quentin Eichbaum, MD, PhD, MPH, MFA, FCAP; Tim Grennan, MD, FACP; Howard Young, MD; Myra Hurt, PhD
If one accepts that large health care systems are to remain part of the medical landscape, can their strengths be used in seeking solutions to the country’s health care dilemmas. The authors suggest that situating modular and longitudinal medical education within a progressive integrated health care system such as a large, multispecialty group model, nonprofit health maintenance organization might provide a valid alternate stream of education and training for physicians.

The Northern California Perinatal Research Unit: A Hybrid Model Bridging Research, Quality Improvement and Clinical Practice
Terhilda Garrido, MPH; Rosemarie Barbeau
Now that Kaiser Permanente (KP) HealthConnect, the KP electronic health record, is fully implemented, conducting research is supported by harnessing information systems to leverage internal improvements in outcomes, efficiency, and costs. Research challenges at KP are moving away from data access toward mechanisms through which raw data create meaningful clinical knowledge that is based on rigorous research. This report describes this research model.

Review Articles

Fall 2010 - Volume 14 Number 3Overview of Emerging Concepts in Metabolic Surgery
Michel Murr, MD, FACS; Arash Rafiei, MD; Habib Ajami, MD; Tannous K Fakhry, MD
Obesity is a worldwide health epidemic, and about two-thirds of US adults are overweight or obese. The link between diabetes and obesity is because of induction of insulin resistance by excess adipose tissue and generalized low chronic inflammation. Metabolic or bariatric surgery induces durable and sustainable weight loss, and its role is well established. This review includes: the types of metabolic surgery, preoperative evaluation, postoperative care, follow-up, and the future of metabolic surgery.

Fall 2010 - Volume 14 Number 3Thiazolidinediones: A 2010 Perspective
Ashok Krishnaswami, MD, FACC; Shalini Ravi-Kumar, MD; John M Lewis, MD
As the incidence of cardiovascular complications related to diabetes mellitus increases, there is a sense of urgency to produce antidiabetic medications that achieve not only nontoxic glycemic control but also improved cardiovascular outcomes, including lowering mortality. The goal of this review is to shed light on the current understanding of, and the debate surrounding, thiazolidinedione use.

Clinical Medicine

ECG Diagnosis: Hypothermia
Joel T Levis, MD, PhD, FACEP, FAAEM
An Osborn wave (J wave) is a characteristic electrocardiogram finding for hypothermia consisting of an extra deflection at the terminal junction of the QRS complex and the ST segment takeoff, and usually occurs when the core body temperature falls below 90°F (32°C). This is believed to result from an exaggerated outward potassium current leading to repolarization abnormality.

Image Diagnosis: Interesting Chest Radiographs from the Emergency Department
L Paige Sokolsky, MD; Gus M Garmel, MD, FACEP, FAAEM
Five chest x-rays represent left upper lobe pneumonia, right upper lobe pneumonia, right third and fourth lateral rib fractures, large pneumothorax, and pneumomediastinum with pneumopericardium and subcutaneous emphysema.

Commentary

HAITI: The Kaiser Permanente Experience—Part 1
Introduction.
Sarah Beekley, MD
Our cause is health, our passion is service, and we are here to make lives better. This is the social mission of Kaiser Permanente (KP), and the personal mission of the staff whose stories are shared in this collection of essays. Each volunteered their time, sacrificed their personal safety and comfort, and challenged themselves to extend well beyond their normal limits both personally and professionally. And each of them would say that they gained more than they gave.

Tribute
Robert Pearl, MD

From Tragedy, Opportunity—A New Beginning for Haiti and the Dominican Republic

John Freedman, MD
An important epiphenomenon created a new inflection point between Haiti and Dominican Republic, neighboring nations with a long history of violent relations. The Dominican authorities allowed thousands of Haitian refugees to cross the border to seek care in our emergency relief hospital.

Haiti—Forgotten Already?
Lee Jacobs, MD
The story yet to be written of the massive rebuilding and relocation that must be supported by people and finances from around the world is a challenge just too great to meet the basic living needs of displaced peoples. The Haitians wonder have you already forgotten them?

Mes Quatre Fils (My Four Sons)
Mason Spain Turner, MD
In his late 30s, to restore the author’s balance and perspective realigning his life with his personal moral values, a watershed moment occurs within the unique family that was built with four young interpreters who had lost their parents, siblings and many friends.

Disaster Medical Relief—Haiti Earthquake January 12, 2010
Hernando Garzon, MD
Kaiser Permanente’s Global Health and volunteer programs support physician volunteerism, relationships with multiple medical relief organizations, created a KP National Volunteerism Web site, and developed and delivered CME courses.

Mentoring About Vector-borne Disease Control

D Scott Smith, MD, MSc, DTM&H
One million displaced people increased the risks of insect-borne diseases, amplified by exposure—densely populated tent camps with little between them and the elements; migration—large-scale movement to areas where disease rates are high; and the disruption of public health systems. The Kaiser MENTOR initiative focuses on clinical trainings, vector assessments, and control using indoor residual spraying and larviciding.

First Responders: The DMAT Team

Judy O’Young, MD
The Disaster Medical Assistance Team, cocooned inside the surgical field hospital where they had arrived in darkness, isolated within and guarded by the 82nd Airborne, they heard the hymns of prayer and gratitude from the people in the adjacent tent city rise above the generator’s drone and float back through the warm heavy air.

Disaster Readiness Tips Steeped in My Time in Haiti

Vivian Reyes, MD
The people around you during a disaster are the critical component to whether you survive it. The more times you run through scenarios in your mind or in a drill, the better you will react in a real event. “Crisis Care Guidelines” help medical professionals navigate through these difficult times.

Letters to the Editor

Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index and Its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes
Congratulations to Dr Felitti and colleagues for publication of the article “Obesity: Problem, Solution, or Both”1 in the Spring 2010 issue of The Permanente Journal (TPJ) as well as continued success for their weight loss program in San Diego. I believe that readers of TPJ and individuals contemplating participation in similar programs might appreciate a different perspective, evidence, and context regarding the use of Very Low Calorie Diets (VLCD) for weight management.

Book Reviews

Obese from the Heart: A Fat Psychiatrist Discloses
by Sara L Stein, MD

Grandparenting a Child with Special Needs
by Charlotte E Thompson, MD

Soul of the Healer

Original Visual Art

“Dance with Heart”

Shenshen Dou

“Slot Canyon Lower Antelope Valley, Page, Arizona”
Gerald Levy, MD, MBA

“Scripps Pier, La Jolla, CA”
Gevork Mosesi, MD

“HA 260 #3”
Josh Schechtel, MD

Original Literary Art

And The Beat Goes On

Pattie Palmer-Baker

On the Cover

“River Bottom Fall”
Susan Guy, MD

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