Summer 2012 - Volume 16 Number 3

Original Research and Contributions

Prostate Cancer Screening Trends in a Large, Integrated Health Care System.
Lauren Wallner, PhD, MPH; Stanley Frencher, MD; Jin-Wen Hsu, PhD; Ronald Loo, MD; Joice Huang, PharmD, MBA; Michael Nichol, PhD; Steven Jacobsen, MD, PhD

In a retrospective cohort study (1998-2007) of 2,061,047 men (older than 35 years) within a large integrated health care system, 572,306 (28%) had prostate-specific antigen (PSA) screening. Patterns of screenings varied modestly by age, race, and physician. The lowest frequencies were in men younger than 45 years (19%) and older than 85 years (13%). PSA screening was most common in white men (33.5%) and in men seen by physicians of the same race/ethnicity (32%), compared with men with physicians of disparate race/ethnicity (26%, p < 0.001).

A Colorectal "Care Bundle" to Reduce Surgical Site Infections in Colorectal Surgeries: A Single-Center Experience.
Waleed Lutfiyya, MD, FASCRS; David Parsons, MD, FASCRS; Juliann Breen, RN, CPHQ

In a retrospective analysis of infection rates at Kaiser Sunnyside Medical Center, from the National Surgical Quality Improvement Program (NSQIP) database, the authors reviewed overall, superficial, deep, and organ/space surgical site infections (SSIs). As a baseline there were 430 colorectal cases from January 2006 to December 2009. After a colorectal care bundle of interventions was implemented January 2010 through June 2011, there were 13 infections in 195 cases, a 6.67% overall rate. The overall decrease of 14.49% from baseline, and the decrease of superficial SSI from 15.12% to 3.59%, were both significant (p <0.0001). The rates for deep and organ/space SSIs showed a nonsignificant decrease. The NSQIP observed-to-expected ratio for colorectal SSI decreased from a range of 1.27 to 1.83 before implementation to 0.54 after implementation.

Reductions in Pain Medication Use Associated with Traditional Chinese Medicine for Chronic Pain
Charles Elder, MD, MPH, FACP; Cheryl Ritenbaugh, PhD, MPH; Mikel Aickin, PhD; Richard Hammerschlag, PhD; Samuel Dworkin, DDS, PhD; Scott Mist, PhD, MAcOM; Richard E Harris, PhD

Participants (168) in a randomized trial of traditional Chinese medicine (TCM) for temporomandibular joint dysfunction had a linear decline in pain over 16 TCM visits. This article reports an observational analysis of the average pain outcomes and medication use reported at every TCM visit. Among the heaviest non-steroidal anti-inflammatory drug (NSAID) users, there was a short-term reduction in NSAID use—sustained as visits became less frequent. There was no indication that pain reduction during TCM treatment was influenced by drug use.

Ultrasound Measurements in Hypertrophic Pyloric Stenosis: Don't Let the Numbers Fool You
Meena Said, MD; Donald B Shaul, MD; Michele Fujimoto, MD; Gary Radner, MD; Roman M Sydorak, MD; Harry Applebaum, MD

In a retrospective analysis of 189 patients with hypertrophic pyloric stenosis (means of: 4.6 weeks, 3.9 kg, 0.42 cm muscle thickness, and 1.89 cm muscle length) that were treated at a single institution over a 5-year period (2005-2010), analysis showed a significant relationship between both age and weight and the muscle thickness. No significant relationship existed between pyloric length and age or weight.

Living With Advanced Illness: Longitudinal Study of Patient, Family, and Caregiver Needs
Karen Tallman, PhD; Ruth Greenwald, MS, MA; Alice Reidenouer, SM; Laurel Pantel

Little is known about how the needs of patients with advanced illness and the needs of their families and caregivers evolve, or how effectively those needs are addressed. A video-ethnographic approach was conducted to observe and interview 12 patients and their families before, during, and after an inpatient palliative care consult at 3 urban Medical Centers. This longitudinal approach highlighted areas for improvement, which include clear, integrated communications in the hospital and coordinated, comprehensive postdischarge support for patients not under hospice care and for their caregivers.

Sociodemographic Characteristics of Members of a Large, Integrated Health Care System: Comparison with US Census Bureau Data
Corinna Koebnick, PhD, MS; Annette M Langer-Gould, MD, PhD, MS; Michael K Gould, MD, MS; Chun R Chao, PhD, MS; Rajan L Iyer, MPH; Ning Smith, PhD; Wansu Chen, MS; Steven J Jacobsen, MD, PhD

On review of sociodemographic characteristics of 3,328,579 members of Kaiser Permanente Southern California (KPSC) in 2000 and 3,357,959 members in 2010, compared with those of the underlying population in the coverage area based on US Census Bureau data; similarities included: neighborhood educational levels, household incomes, sex, age, and the proportion of Hispanics/Latinos; however, KPSC members included more blacks. These findings suggest that this setting may provide valid inference for clinical, epidemiologic, and health services research.

Engaging Patients in Managing Their Health Care: Patient Perceptions of the Effect of a Total Joint Replacement Presurgical Class
Mary-Louise Lane-Carlson, EdD, MPH, RD, CDE; John Kumar, MD

Most research studies on presurgical education are quantitative in nature, preventing patients' voices from being heard. Using a success-case, narrative design, 24 patients (from the Kaiser Permanente Downey Medical Center) were interviewed regarding their pre- and postsurgical experiences. Patient education, in the form of classes, with recognition of the participants' physical needs, social needs, concrete supports, and psychological needs, as well as the willingness of the participants to work with their health care team, can promote patient engagement and improved quality of life.

A Framework for Making Patient-Centered Care Front and Center
Sarah M Greene, MPH; Leah Tuzzio MPH; Dan Cherkin, PhD

The concept of patient-centered care is now considered an essential aspiration of high-quality health care systems. 
Historically, those advocating patientcentered care have focused on the relationship between the patient and the physician or care team. Changes to  the health care system suggest that a multidimensional conceptualization of patient-centered care illustrates how clinical, structural, and interpersonal attributes can collectively influence the patient's experience.

Review Article

Women in Surgery: Bright, Sharp, Brave, and Temperate
Elisabeth C McLemore, MD; Sonia Ramamoorthy, MD; Carrie Y Peterson, MD; Barbara L Bass, MD

In drastic contrast to the 1970s, nearly half of first-time applicants to medical schools in 2011 were women. Less than 20% of full professor, tenured faculty, and departmental head positions are currently held by women. The aim of this article is to review the history of women in surgery and to highlight individual and institutional creative modifications that can promote the advancement of women in surgery.

Case Studies

Lymphoepithelial Carcinoma: A Case of a Rare Parotid Gland Tumor
Christopher G Tang, MD; Thomas M Schmidtknecht, MD; Grace Y Tang; Luke J Schloegel, MD; Barry Rasgon, MD

A 29-year-old woman presented with a 10-month history of an enlarging left-sided facial mass. The patient received a total left parotidectomy and a selective neck dissection. A lymphoepithelial carcinoma of the parotid is a rare salivary gland tumor accounting for less than 1% of all salivary gland tumors. Complete resection of this poorly differentiated carcinoma followed by postoperative radiation is essential for local control.

Neurothekeoma in the Posterior Fossa: Case Report and Literature Review
Daniela Alexandru, MD; Radha Satyadev, MD; William So, MD

Neurothekeoma is a benign nerve sheath tumor (myxoma), though intracranial neurothekeoma is an extremely rare entity (only 3 cases reported in the literature): A case is presented of a 40-year-old man with a very large neurothekeoma present in the posterior fossa who had no neurologic deficit on presentation.

Clinical Medicine

Nailing the Diagnosis: Koilonychia
Vivek Kumar, MD; Sourabh Aggarwal, MD; Alka Sharma, MD; Vishal Sharma, MD

Koilonychia is an abnormality of the nails that is also called spoon-shaped (concave) nails. It is primarily recognized as a manifestation of chronic iron deficiency, resulting from malnutrition, gastrointestinal blood loss, worms, gastrointestinal malignancy, and celiac disease. Other causes of koilonychia are high altitude, trauma, exposure to petroleum products, and heredity.

Image Diagnosis: Foot Pain and Fever
William C Krauss, MD, FACEP

Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and fascia (as evidenced by air on this patient's plain films). Typical sites for this infection are the lower extremities, abdomen and perineum. The incidence of such infections, in the US, is estimated at 500 to 1500 cases per year, with a case-fatality rate of 24% and is more commonly associated with injection drug use, diabetes mellitus, immunosuppression, and obesity.

Development of a Computerized Intravenous Insulin Application (AutoCal) at Kaiser Permanente Northwest, Integrated into Kaiser Permanente HealthConnect: Impact on Safety and Nursing Workload
Christine Olinghouse, MPH/MSN, FNP-BC, BC-ADM, CDE

A review of 35 patient charts using a computerized insulin infusion tool indicated 100% accuracy in computations with a reduction of nursing workload from 2 minutes to 30 seconds per calculation. Development and operationalization of an integrated intravenous insulin calculator into HealthConnect was successfully completed at the Kaiser Sunnyside Medical Center, with 97% nursing satisfaction scores, and a promise to generate data on intravenous insulin therapy to refine the protocol.

Commentary

Solving the Emergency Care Crisis in America: The Power of the Law and Storytelling
John Maa, MD

An Emergency Department visit that ended tragically prompted a yearlong journey to Washington, DC, to explore the current crisis in emergency room care. A three-part solution includes 1) nationally standardizing and coordinating care, 2) prioritizing resources and incentives in the delivery of emergency care, and 3) inspiring young clinicians to careers in emergency care. Physicians across America should now harness the power of storytelling to strengthen both the delivery of patient care and health care reform efforts on Capitol Hill.

Narrative Medicine

Trifecta: Running on Hope.
Carol Redding, MA

With excerpts from physicians' notes, a patient-author recounts the physical and emotional history of personal illness that began in 1983.

Book Review

Ace Study DVD
David L Corwin, MD
Review by David L Chadwick, PhD

Soul of the Healer

Original Visual Art 

"Kayaks on the Suwannee"
Mark M Cohen, MD 

"The Healing Touch"
Mohamed Osman, MD 

"The Virgin River"
Fred M Freedman, MD 

"Star Ferry, Hong Kong, 1961"
J Richard Gaskill, MD

On the Cover

"Lower Falls"
Gary Larsen, MS