Summer 2010 - Volume 14 Number 2

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupOriginal Research and Contributions

Comparisons of Health Education, Group Medical Care, and Collaborative Health Care for Controlling Diabetes
Lewis Mehl-Madrona, MD, PhD, MPhil

This early phase clinical investigation focuses on improving outpatient care for Native Americans with diabetes mellitus through "shared collaborative care"—simultaneous medical, psychological, and spiritual care, compared to diabetic health education, or group medical care. All of the multiple measures of glucose control were statistically significantly better for shared, collaborative care.  Potential explanations offered include: stress reduction, increased social support, producing more positive health beliefs, and acting as a naturalistic biofeedback.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupRisk of Proximal Colonic Neoplasms in Asymptomatic Adults Older Than 50 Years Found to Have Distal Hyperplastic Polyps on Routine Colorectal Cancer Screening
Bradley D Collins, PhD, MHS, PA-C

A retrospective case-control study of medical charts and colonoscopy reports compiled during a ten-year period found that distal hyperplastic polyps (HP) in the lower 50 cm of colon were not significantly associated with synchronous proximal neoplasm's when patients with HPs were compared with those without any distal polyps at all (odds ratio = 0.94; interval = 0.73-1.22).

Primary Care DirectConnect: How the Marriage of Call Center Technology and the EMR Brought Dramatic Results—A Service Quality Improvement Study
Brent Bowman, MBA; Scott Smith, MD

DirectConnect is a system that automatically routes medical advice calls directly to the Primary Care Physician (PCP) or staff to manage their panel's requests in real time with "one-number" convenience. DirectConnect resulted in statistically significant improvement in: patient satisfaction; percentage of all Primary Care calls handled by the home medical office team; the centralized Call Center's speed of answering calls; and estimated savings of cumulative hours per week in unnecessary telephone work regionwide.

The Limits of Tolerance: Convicted Alcohol-Impaired Drivers Share Experiences Driving Under the Influence
Sandra C Lapham, MD, MPH, FASAM

Most people are aware that regular alcohol drinkers can become tolerant to the effects of alcohol. Tolerance can lessen the outward manifestations of intoxication, and this poses challenges for the drinker and other observers, including law enforcement officers. This article presents commentary regarding this phenomenon in offenders convicted of driving under the influence and the implications for traffic safety, from a National Institutes of Health-funded longitudinal study.

Conflicts of Interest in Research — Towards a Greater Transparency
Jeffrey P Braff, DrPH, CIP

Recently, substantial undisclosed financial Conflicts of Interest (COI) by researchers at academic medical centers have been discovered and reported in US Senate investigations, prompting large research institutions to take a close look at policies and procedures associated with the reporting and management of researcher COI. This article defines COI, reviews the background, describes the problems that arise, and offers solutions.

Review Article

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupClostridium difficile Infections: What Every Clinician Should Know
James Yoo, MD; Amy Lee Lightner, MD

The leading cause of nosocomial enteric infections in the US is a potentially lethal condition that influences the daily care of medical and surgical patients across all specialties. The incidence is increasing because of the emergence of a new virulent strain, the development of antibiotic resistance, and an increase in infection rates within populations once believed to be at low risk. Current strategies for the prevention, diagnosis, and treatment are cited.

Case Studies

Late Presenting Complications After Splenic Trauma
Sandra Freiwald, MD, FACS

The management of blunt splenic trauma has evolved from almost exclusive surgical management to selective nonsurgical management in hemodynamically stable patients. Understanding the spleen's immunologic importance in protection against overwhelming postsplenectomy infection led to surgical splenic salvage and later to nonsurgical management (60% of adults). This article describes a pancreatic pseudocyst, a delayed complication of nonsurgical management.

Echinococcus of the Liver Treated with Laparoscopic Hepatectomy
Erina N Foster, MD; Gabor Hertz, MD

Echinococcosis or hydatid disease is endemic to many countries where livestock, mainly sheep and cattle, are raised with dogs that act as the definitive hosts for the adult phase of the echinococcal tapeworm. We report a case of a man, age 22 years, who emigrated from Kyrgyzstan as an adult, presenting with abdominal fullness and nausea. A 9 cm echinococcal cyst of the liver was successfully treated with laparoscopic hepatectomy.

Humanizing Patients through Narrative Approaches: The Case of Murphy, the "Motor-Mouth."
Lewis Mehl-Madrona, MD, PhD, MPhil

Some psychiatric patients are presented as hopeless, burned out, and devoid of social graces. A narrative perspective allows anyone to emerge as a richly complex human being. Murphy in story emerges as a more interesting, worthy of knowing, and  richly complex human being than the clinical Murphy constructed by medical staff.  This approach fosters a more therapeutic and effective relationship between patients and staff.

Clinical Medicine

ECG Diagnosis: Wolff-Parkinson-White Syndrome
Joel T Levis, MD, FACEP, FAAEM

Wolff-Parkinson-White Syndrome—the presence of an accessory pathway and a predisposition to the development of supraventricular tachydysrhythmias—results in conduction that circumvents delay within the atrioventricular node, leading to early eccentric activation of the ventricles and fusion complexes. Unstable patients should receive immediate electrical cardioversion. Stable patients can be chemically cardioverted with IV procainamide.

Image Diagnosis: Ankle Fractures and Dislocations
Sundeep R Bhat, MD; Gus M Garmel, MD, FACEP, FAAEM

Standard radiographs for suspected ankle injury include anterior-posterior, lateral, and mortise views. This series features:  a subtle fracture of the distal fibula; a bimalleolar ankle fracture, a trimalleolar ankle fracture, and a talar neck fracture-dislocation.

Pressure Ulcers: What Clinicians Need to Know
William T Wake, MD, FAAFP

Pressure ulcer treatment is one of many aspects of patient care in which nursing care interfaces directly with clinician-provided medical services. Although traditionally the treatment of pressure ulcers has been left to nurses, physicians have become more engaged in the prevention, identification, and treatment of pressure ulcers. Patients who are ambulatory can also develop pressure ulcers.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupHyponatremia—What Is Cerebral Salt Wasting?
Jasminder Momi, MD; Christopher M Tang, MD; Antoine C Abcar, MD; Dean A Kujubu, MD; John J Sim, MD

Hyponatremia, a common electrolyte imbalance in hospitalized patients, is associated with significant morbidity and mortality, if the underlying cause is incorrectly diagnosed. The hospitalist is faced with a clinical dilemma when there is hyponatremia of unclear etiology and uncertain volume status. The syndrome of inappropriate antidiuretic hormone is frequently diagnosed in this clinical setting, but cerebral salt wasting is an important diagnosis to consider.

Commentary

On Being a Time–Space Copilot: 35 Years of Practicing Psychotherapy
William J Cook, MSW, LCSW

A mental health therapist shares personal triumphs and frustrations, exploring the integration of mental and physical health and the joys and challenges of caring for patients.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupThe Case for Unit-Based Teams: A Model for Frontline Engagement and Performance Improvement
Paul M Cohen; Mark Ptaskiewicz, MD; Debra Mipos

Unit-based teams (UBTs)—defined as natural work groups of physicians, managers, and frontline staff who work collaboratively—are designed to deliver measurable benefits in clinical outcomes and operations, patient-experience enhancements, and physician-team performance or work life. This article presents case examples of successful UBTs' outcomes, and physicians' comments on their experience working with teams.

Book Reviews

Waiting for Wings: A Woman's Metamorphosis through Cancer
Heidi Marble
Review by Valerie Ozsu, NP, MSN, CNM

The Healing Of America: A Global Quest for Better, Cheaper, and Fairer Health Care
TR Reid
Review by KM Tan, MD

Soul of the Healer

Original Visual Art

"Hibiscus"
Ira J Levy, MD

"The Medusa of Alcoholism"
Lorenzo Mills, MD

"Evening in the Foothills"
Gary Larsen, MS

"Mendocino"
Nandini Bakshi, MD

Original Literary Art

Mammogram

Teri Bordenave, MHSA

Chocolates
Lynette Vialet, MD

On The Cover

"Yosemite Falls, Yosemite National Park, California"

Circulation

25,000 print readers per quarter, 6900 eTOC readers, and in 2015, 1.4 million page views on TPJ articles in PubMed from a broad international readership

Subscriptions

The Permanente Journal (ISSN 1552-5767) is published quarterly by The Permanente Press. The Permanente Journal is available online (ISSN 1552-5775) at www.thepermanentejournal.org.

Letters

Articles, editorials, letters to the editor, and other material represent the opinion of the authors. Send your comments to permanente.journal@kp.org.


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