Spring 2013 - Volume 17 Number 2

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

Effect of Direct Physician Involvement on Tobacco Abstinence
Rates and Other Variables Affecting Participants of a Freedom
from Tobacco Class

Mohamed H Ismail, MD; Ngoc J Ho, PhD; Nancy Irazu Lara
In a retrospective study, participants in 2008, before direct physician involvement, were compared to those in 2009, after direct physician involvement. The abstinence rate for men improved from 23% to 38% (2008 vs 2009; p = 0.05), whereas for women it was 30% vs 27% (p = 0.7). Attendance of 6 or more classes was associated with higher abstinence rates. There was no significant impact on abstinence rates due to age, body mass index, class teacher, or medications used.

Analysis of Mitral Valve Replacement Outcomes is Enhanced by Meaningful Clinical Use of Electronic Health Records
John C Chen, MD; Thomas Pfeffer, MD; Shelley Johnstone, APRN; Yuexin Chen, MA; Mary-Lou Kiley, MBA; Richard Richter, MD; Hon Lee, MD
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupPatients in the Apollo database (3130) underwent 3180 initial mitral valve procedures: 1160 mechanical valve replacements, 1159 tissue valve replacements, and 861 annuloplasties. Electronic health records were searched to ascertain demographics, comorbidities, and postoperative complications. The study determined risk factors for increased 10-year mortality: tissue valve implantation; advanced age; female sex; nonelective, nonisolated procedure; diabetes; postoperative use of banked blood products; previous cardiovascular intervention; dialysis; and longer perfusion time.

Perforation Following Colorectal Endoscopy: What Happens Beyond the Endoscopy Suite?
Michael S Tam, MD; Maher A Abbas, MD, FACS, FASCRS
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupIn a retrospective review over 16 years at a single tertiary care institution of 132,259 colorectal endoscopies, 26 patients (0.02%) had a perforation. The rectosigmoid colon was the most common site of perforation (65%). Of the perforations, 38% were recognized at the time of procedure, 31% presented within 24 hours, and 31% presented beyond 24 hours. Operative repair was undertaken in 85% of the patients. Perforation following colorectal endoscopy was uncommon in this study but was associated with significant morbidity and mortality.

Predictors of Lung Cancer: Noteworthy Cell Type Differences
H Nicole Tran, MD, PhD; Yan Li, MD, PhD; Stanton Siu, MD; David Baer MD; Gary D Friedman, MD, MS; Natalia Udaltsova, PhD; Arthur L Klatsky, MD
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupIn this cohort study of 126,293 persons with 1852 subjects with incident cancer, smoking 1 or more cigarette packs per day was a powerful predictor (p < 0.0001) of all cell types, with hazard ratios ranging from 5.8 for bronchioloalveolar to 62.7 for squamous cell carcinoma. Other predictors with noteworthy disparities between cell types included men vs women, blacks or Asians vs whites, and heavy alcohol intake vs abstinence. College graduation and increasing body mass index were inversely related to risk of several cell types.

Trends in Influenza Vaccine Coverage in Pregnant Women, 2008 to 2012
Michelle Henninger, PhD; Bradley Crane, MS; Allison Naleway, PhD
This retrospective cohort study of 10,145 pregnant women noted seasonal influenza vaccine coverage increased from 38% to 63% between the 2008-2009 and 2010-2011 seasons and then dropped to 61% in 2011-2012. Vaccine coverage was higher in women considered at high risk of influenza complications, increasing from 43% in 2008-2009 to 71% in 2010-2011, before decreasing to 69% in 2011-2012. H1N1 vaccine coverage was greater than seasonal influenza coverage. The authors observed statistically significant differences in vaccination rates by trimester, gravidity, maternal age, and race/ethnicity.

Epidemiology of Diabetic Foot Infections in an Eastern Caribbean Population: A Prospective Study
Shariful Islam, MBBS; Patrick Harnarayan, FRCS; Shamir O Cawich, DM; Steve Budhooram, FRCS; Vinoo Bheem, MBBS; Vijai Mahabir, MBBS; Shiva Ramsewak, MBBS; Imran Aziz, MBBS; Vijay Naraynsingh, FRCS
Of all patients with diabetic foot infections who were admitted to tertiary care hospitals (446) from July 2011 to June 2012, most had Type 2 diabetes (93.3%). Despite most patients claiming compliance with treatment, 75% had glycosylated hemoglobin levels above 7.1%, and 49.3% continued unhealthy lifestyles. Only 57.4% of patients reported ever being counseled or taught about foot care by medical personnel.

Preoperative Pain Intensity and Chronicity and Postoperative Analgesia Markers of Length of Stay in Patients Undergoing Spinal Fusion
Kevin Douglas Waits; Mohammed Sami Walid, MD, PhD; Joe Sam Robinson, MD
The authors studied preoperative pain intensity and chronicity and the amount of postoperative analgesia as a marker of length of stay (LOS) in patients undergoing spinal fusion, cervical or lumbar. Regression analysis revealed statistical significance only between LOS and surgical site. It showed no significance between LOS as the dependent variable and preoperative pain parameter, postoperative morphine per kilogram, sex, or age as predictors.

Adverse Childhood Experiences and Adult Criminality: How Long Must We Live before We Possess
Our Own Lives?

James A Reavis, PsyD; Jan Looman, PhD; Kristina A Franco; Briana Rojas
Subjects (151) from 4 different offender groups (nonsexual child abusers, domestic violence offenders, sexual offenders, and stalkers) referred for treatment at an outpatient clinic in San Diego, CA, after conviction in criminal court, completed the ACE Questionnaire. The offender group reported nearly 4 times as many adverse events in childhood than an adult male normative sample. In addition, convicted sexual offenders and child abusers were more likely to report experiencing sexual abuse in childhood than other offender types.

A Novel Population-Based Health Index for Mental Disorder
David Cawthorpe, MSc, PhD
Randomly selected individuals (685,684 and 45.8% male), with physician-billing visit and cost data from 1994 to 2009 were grouped on the basis of presence or absence of a psychiatric disorder (53% over 16 fiscal years). The median cost of physical (biomedical/somatic) disorders was 2.9 times higher for the group with any International Classification of Diseases psychiatric disorder. This is a novel population health index that holds the potential to directly measure the impact of promotion and prevention programs associated with psychiatric disorders.

Weight-Loss Study in African-American Women: Lessons Learned from Project Take HEED and Future, Technologically Enhanced Directions
Pamala J Murphy, MD; Roger L Williams, MEd
Begun in 2005, an 18-month randomized clinical trial, culturally adapted an evidence-based dietary approach and exercise program to fit the female African-American population. The study included 223 African-American women (120 in the experimental group). That group received education and instruction at 24 group sessions and recorded their daily food intake and physical activity. Controls received usual care (referral to a dietitian). After 18 months, the treatment group consisted of 12 women (attrition rate of 87%) who had begun the study low in self-efficacy.

Nutritional Update for Physicians: Plant-Based Diets
Philip J Tuso, MD; Mohamed H Ismail, MD; Benjamin P Ha, MD; Carole Bartolotto, MA, RD
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupPhysicians are becoming more involved in helping their patients adopt healthier lifestyles. Healthy eating may be best achieved with a plant-based diet (which encourages whole, plant-based foods and discourages meats, dairy products, and eggs as well as all refined and processed foods). Research shows that these diets are cost-effective, low-risk interventions that may lower body mass index, blood pressure, HbA1C, and cholesterol levels, and may also reduce the number of medications needed to treat chronic diseases

Understanding the Social Factors That Contribute to Diabetes: A Means to Informing Health Care and Social Policies for the Chronically Ill
Jacqueline Hill, MPH; Marcia Nielsen, PhD, MPH; Michael H Fox, ScD
Social determinants of health are increasingly being recognized for their relationship to the soaring incidence of Type 2 diabetes in the US. Interventions focus on biologic and behavioral factors, such as symptoms, diet, and physical activity. It is equally important to address the influence of physical and social environments on health outcomes: low income, employment insecurity, low educational attainment, and poor living conditions. The Patient Protection and Affordable Care Act of 2010 offers an opportunity to improve data collection and policy development.

Disclosing Medical Mistakes: A Communication Management Plan for Physicians
Sandra Petronio, PhD; Alexia Torke, MD, MS; Gabriel Bosslet, MD, MA; Steven Isenberg, MD; Lucia Wocial, RN, PhD; Paul R Helft, MD
There is a growing consensus that disclosure of medical mistakes is ethically and legally appropriate. This discussion proposes a theoretically based, streamlined, two-step plan that physicians can use as an initial guide for conversations with patients about medical mistakes: 1) physician preparation, such as talking about the physician's emotions and seeking information about the mistake, and 2) use of mistake disclosure strategies that protect the physician-patient relationship. These include optimal timing, context of disclosure delivery, the content of mistake messages, sequencing, and apology.

Review Articles

A Clinician's Guide to the Diagnosis and Management of Gallbladder Volvulus
Brian J Pottorf, MD; Leonardo Alfaro, MD; Harris W Hollis, MD
Gallbladder volvulus (GV), or torsion of the gallbladder, is an uncommon surgical emergency. This article reviews the world literature related to GV. Lists of typical symptoms and clinical presentations are provided to allow clinicians to establish an accurate preoperative diagnosis. GV is frequently undiagnosed before surgical intervention. When the diagnosis has been established before operative intervention, expeditious laparoscopic cholecystectomy can be performed safely. Delays in diagnosis may mandate open cholecystectomy.

Clinical Medicine

ECG Diagnosis: Apical Hypertrophic Cardiomyopathy
Joel T Levis, MD, PhD, FACEP, FAAEM
Apical hypertrophic cardiomyopathy (HCM) is an atypical phenotype of nonobstructive HCM with an indistinguishable histology. In Japan this apical variant constitutes approximately 25% of patients with HCM. Electrocardiogram typically shows repolarization changes and giant (>10 mm), inverted T waves in the anterolateral leads.Transthoracic echocardiography is the initial test of choice in making the diagnosis.

Case Studies

Allergic Bronchopulmonary Aspergillosis Presenting as Chronic Cough in an Elderly Woman Without Previously Documented Asthma
Richard Roth, MD; Michael Schatz, MD
This is a case report from a specialist point of view that includes a comprehensive review of the clinical course pre- and postconsultation along with a brief but pertinent review of the literature as it relates to this particular unusual and protracted case, which was ultimately successfully diagnosed and treated.

Propofol-Related Infusion Syndrome: Role of Propofol in Medical Complications of Sedated Critical Care Patients
Talha Imam, MD
Use of propofol has increased manifold over the last decade, most commonly in intensive care settings, in patients critically ill or injured requiring prolonged sedation. Most of the deaths reported were at propofol levels greater than 4 mg/kg/hour, and many of these for greater than 48 hours. Metabolic acidosis is among the earliest signs and can occur within hours. Adequate carbohydrate intake will prevent the body from switching to fat metabolism.

Book Reviews

Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy
Review by Susan Brown, LCSW, BCD

Soul of the Healer

A Father's Letter to His Graduating Daughter: Advice to the Medical School Class of 2013 as They Go Forth Into Uncharted Waters
Lee Jacobs, MD

Fourteener
Brad Christian McDowell, MD

Medicine Man
Mas Yamanaka, MD

Propofol Dreams
Kyle T Amber

Pangong Tso
Nandini Bakshi, MD

On The Cover

Door to the Forest
Samuel H Glassner, MD