Summer 2013 - Volume 17 Number 3

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

Accuracy and Implications of Percutaneous Renal Biopsy in the Management of Renal Masses
Diana C Londoño, MD; Melanie C Wuerstle, MD; Anil A Thomas, MD; Luis E Salazar, MD; Jin-Wen Y Hsu;
Tarek Danial, MD; Gary W Chien, MD

This is a retrospective review of 126 patients who underwent computed tomography or ultrasound-guided percutaneous renal biopsy of a solid renal mass from 1/2005 to 12/2009. Initial diagnostic biopsies revealed 87 (66%) malignant, 38 (29%) benign, and 7 (5%) nondiagnostic lesions. Sixty- three patients (50%) ultimately underwent extirpative surgery. Of these patients, the diagnostic accuracy of the initial biopsy was 76%- sensitivity (75.4%) and specificity (100%)-and the biopsy concordance to final histologic tumor subtype was 93%.

Elimination of Admission Hypothermia in Preterm Very Low-Birth-Weight Infants by Standardization of Delivery Room Management
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupMadhu Manani, RNC; Priya Jegatheesan, MD; Glenn DeSandre, MD; Dongli Song, MD, PhD; Lynn Showalter, RNC; Balaji Govindaswami, MBBS, MP

Preterm infants, < 33 weeks' gestation with very low- birth-weight < 1500 g, born at a Regional Level III Neonatal Intensive Care Unit (NICU) received an intervention involving standardizing the management of thermoregulation from predelivery through admission to the NICU. The hypothermia rate was reduced from 44% in early 2006 to 0% by 2009. After a rise to 6% in 2010, with further feedback, the unit sustained 0% hypothermia through 2011-substantially lower than state and national hypothermia benchmarks.

Mental Health Practice and Attitudes of Family Physicians Can Be Changed
Dan MacCarthy, MB, BCh, BAO; Rivian Weinerman, MD, FRCPC; Liza Kallstrom, MSc; Helena Kadlec, MA, PhD; Marcus J Hollander, MA, MSc, PhD; Scott Patten, MD, FRCPC, PhD

The British Columbia Practice Support Program delivered an adult mental health module to enhance family physician skills, comfort, and confidence in diagnosing and treating mental health patients using the lens of depression. More than 1400 of the province's 3300 full-service family physicians have completed or started training, and reported high to very high success implementing self-management tools with an overall positive impact on patients.

Use of Portable Ultrasound Machine for Outpatient Orthopedic Diagnosis: An Implementation Study
Sean Adelman, MD; Paul Fishman, PhD

A portable ultrasound machine was introduced at an orthopedic clinic in an integrated group practice by an orthopedic surgeon, primarily treating shoulder disorders, who administered 146 ultrasound examinations. Compared with patients who did not undergo ultrasonography, patients who received ultrasonography had significantly higher comorbidity. However, they were significantly less likely to have magnetic resonance imaging (MRI) (9.7% with ultrasonography vs 14.4% without; p = 0.03), although equally likely to undergo surgery. For patients receiving ultrasonography, an estimated 35 MRIs were avoided.

Nonbeneficial Treatment and Conflict Resolution: Building Consensus
Craig M Nelson, PhD, CLS; Blanca Arriola Nazareth, MSW

After establishing a nonbeneficial treatment (withholding or withdrawing) and conflict resolution policy, retrospective evaluation of all bioethics consultations from 11/2009 to 8/2012 identified 146 (39.4%) cases with a treatment-level conflict between patients/surrogates and the treatment teams. In 54 (37.0%) of the cases, resolution occurred. In 87 (94.6%) of the cases where treatment was withheld or withdrawn, the treatment teams and patients/surrogates reached consensus.

Ambulatory Treatment Gaps in Patients with Ischemic Stroke or Transient Ischemic Attack
Kari L Olson, BSc(Pharm), PharmD; Lisa J Lash, PharmD; Thomas Delate, PhD, MSc; Michele Wood, PharmD; Jon Rasmussen, PharmD; Anne M Denham, PharmD; John A Merenich, MD

This cross-sectional study evaluated goal attainment for patients aged 18 to 85 years with a history of noncardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA). Of 1731 patients evaluated (mean 73.6 years; 58% women), stroke type was NCIS in 51.9% and TIA in 48.1%. Men and patients younger than age 65 years were significantly more likely to have blood pressure (BP) measured. Men and patients age 65 years or older more likely attained LDL-C goals and BP < 140/90 mm Hg.

Identification of Internal and External Stressors in Parents of Newborns in Intensive Care
Cindy Grosik, MSN, RNC, CNL; Denise Snyder, MSN, NNP-BC; Gerard M Cleary, DO; Diane M Breckenridge, PhD, RN; Barbara Tidwell

To identify parents' self-reported stressors, 119 parents of neonatal infants, 24 weeks to full term, were surveyed in a 28-bed level 3 NICU of an 665-bed acute care hospital. Parents deal with fear and uncertainty, are unprepared, and so feel overwhelmed, hopeless, and despair. Highest stressors include: "seeing my baby stop breathing," "being separated from my baby," "being discharged from the hospital before my baby," and "seeing my baby suddenly change color." Establishing strong, trusting, therapeutic relationships is essential.

Acute Uterine Bleeding Unrelated to Pregnancy: A Southern California Permanente Medical Group Practice Guideline
Malcolm G Munro, MD, FRCS(c), FACOG; The Southern California Permanente Medical Group's Abnormal Uterine Bleeding Working Group

Guidelines for the management of acute uterine bleeding are based on the best available evidence, as identified in a systemic review of the available literature. Given the paucity of studies evaluating this condition, the guidelines, by necessity, include recommendations largely based on expert opinion or other sources such as case studies. More high-quality studies are needed to better define the appropriate drugs, dose, and administrative scheduling.

2012 Transfer Projects Lawrence Patient Safety Award
The Readmission Reduction Program of Kaiser Permanente Southern California—Knowledge Transfer and Performance Improvement
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupPhillip Tuso, MD, FACP; Dan Ngoc Huynh, MD, FACP; Lynn Garofalo, DPPD, MHA; Gail Lindsay, RN, MA; Heather L Watson, MBA, CHM; Douglas L Lenaburg, MSN, RN; Helen Lau, RN, MHROD, BSN, BMus; Brandy Florence, MHA; Jason Jones, PhD; Patti Harvey, RN, MPH, CPHQ; Michael Kanter, M

A large Region successfully implemented a "transitional care" bundle consisting of 8 bundle elements-risk stratification, standardized discharge summary, medication reconciliation, a postdischarge phone call, timely follow-up with a primary care physician, a special transition phone number on discharge instructions, a palliative care consult, and a complex- case conference. The observed-over-expected ratio of readmissions and readmission rates, from 12/2010 to 11/2012, decreased from approximately 1.0 to 0.80 and 12.8% to 11%, respectively.

Infection Control Practice in the Operating Room: Staff Adherence to Existing Policies in a Developing Country
Shamir O Cawich, DM; Ingrid A Tennant, DM; Clarence D McGaw, DM; Hyacinth Harding, DM; Christine A Walters, BSc; Ivor W Crandon, DM

Infection control interventions are important for containing surgery-related infections. A sample of 132 participants (90 physicians and 42 nurses), with a mean age of 36 years completed a questionnaire. Overall, 40.1% were adherent to existing protocols, and 19% felt their knowledge of infection control practices was inadequate, attained through informal communication (80.4%) and self-directed research (62.6%).

Special Report
Leadership in Surgery for Public Sector Hospitals in Jamaica: Strategies for the Operating Room
Shamir O Cawich, MBBS, DM; Hyacinth E Harding, MBBS, DM; Ivor W Crandon, MBBS, FRCS; Clarence D McGaw, MBBS, DM; Alan T Barnett, MBBS, DM; Ingrid Tennant, MBBS, DM; Necia R Evans, BSc; Allie C Martin, MBBS, DM; Lindberg K Simpson, MBBS, DM; Peter Johnson, MBBS, DM

Effective leadership must adapt to the environment. Delivery of operating room services in Jamaica may be improved by addressing: leadership training, workplace safety, interpersonal communication, work environment, and revision of existing policies. Additionally, there should be regular practice audits and quality control surveys.

Review Articles

Current Management of Fecal Incontinence
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupJennifer Y Wang, MD; Maher A Abbas, MD, FACS, FASCRS

The medical literature from 1980 to 2012 was reviewed. A comprehensive history and physical examination are required to understand the severity and type of symptoms and the cause of incontinence. Treatment options range from medical therapy and minimally invasive interventions to more invasive procedures and must be individualized. For patients in whom biofeedback has failed, other options include injectable medications, radiofrequency ablation, or sacral nerve stimulation. Many patients can have substantial improvement in symptoms with dietary management and biofeedback therapy.

Preventing Type 2 Diabetes Mellitus: A Call for Personalized Intervention
Harry Glauber, MD; Eddy Karnieli, MD

With the dramatic increase in the incidence and prevalence of metabolic consequences of obesity, in particular prediabetes and type 2 diabetes mellitus, it is not clear who will benefit from lifestyle change or medication interventions. The authors review the many risk factors and summarize treatment trials. With the potential to analyze massive amounts of routinely gathered data from large populations, they call for the development of tools to more precisely estimate individual risk of type 2 diabetes mellitus.

Telepsychiatry in Correctional Facilities: Using Technology to Improve Access and Decrease Costs of Mental Health Care in Underserved Populations
Stacie Anne Deslich, MA, MS; Timothy Thistlethwaite, MD; Alberto Coustasse, DrPH, MD, MBA, MPH

A literature review examined implementation of telepsychiatry in correctional facilities in Arizona, California, Georgia, Kansas, Ohio, Texas, and West Virginia. Telepsychiatry provided improved access for inmates through the continuum of mental health care and saved correctional facilities from $12,000 to more than $1 million. Telepsychiatry may improve living conditions and safety inside correctional facilities.

Case Studies

Mixed Cryoglobulinemia: An Unusual Presentation of Hepatitis C
Donald Mebust, MD

A 50-year-old man with a history of hepatitis C presented with recurrent episodes of abdominal pain, arthralgia, and weakness. A purpuric rash of the lower extremities was the final clue to diagnosis then confirmed by histopathologic and serologic testing.

Reversal of Acute Complex Regional Pain Syndrome Using the Practical Application of Neurodiagnostic Evaluation Process: A Case Study
Karen E Anderson, DPM

After bunion surgery, a patient developed complex regional pain syndrome type 1 (CRPS 1), which is a dysfunctional state of the autonomic regulatory control of pain. A positive reflex at the posterior tibial nerve was elicited. The Practical Application of Neurodiagnostic Evaluation process was shown to be diagnostic for the cause of acute CRPS 1 and to allow its reversal.

Clinical Medicine

Image Diagnosis: Headache and an Isolated Oculomotor Nerve Palsy
Donald Mebust, MD

A 55-year-old woman had complaints of headache, diplopia, and double vision, and on examination demonstrated right-sided ptosis, a dilated pupil with a sluggish light response, and a downward and lateral deviation of the right eye. After a stat unenhanced computed tomography scan, diagnostic cerebral angiogram confirmed a posterior communicating artery aneurysm.

Image Diagnosis: A Curious Case of Causeless Clubbing
Vishal Sharma, MD; Alka Sharma, MD; Vivek Kumar, MD, DM; Sourabh Aggarwal, MBBS

A 22-year-old woman had protuberance of terminal parts of all her fingers, apparent since childhood. The causes may include: pulmonary disorders; cardiovascular disease, and gastrointestinal disorders, however after exploring these, a diagnosis of idiopathic clubbing was made.

Commentary

What Does Professionalism Mean to the Physician?
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupMichael H Kanter, MD; Miki Nguyen, MPH; Marc H Klau, MD, MBA; Nancy H Spiegel, MS; Virginia L Ambrosini, MD

Professionalism consists of four principles: excellence, humanism, accountability, and altruism. Current programs and initiatives of the Southern California Permanente Medical Group are described throughout this article. The authors' and organization's experience validates professionalism as a core physician competency comprising a set of behaviors that are continually refined.

Editorial

Simple Rules That Reduce Hospital Readmission
Thomas E Kottke, MD, MSPH

To address hospital readmissions, the author describes a program design that meets the principles of complex adaptive systems and enumerates five rules: 1) mutual, measurable goals; 2) public reporting; 3) resources must be available; 4) incentives, imperatives, and sanctions must align; and 5) leaders must endorse and promote the health system goals.

Narrative Medicine

Death Wish of a Cardiac Transplant Patient
Joseph Gascho, MD

Unraveling the Devil in Disguise: How I Dodged a Bullet and Turned the Worst Possible Patient Experience into the Greatest Achievement of My Medical Career
Martin Gilboa, MD

Nursing Research and Commentary

Research
Adverse Childhood Experiences and Psychosocial Well-Being of Women Who Were in Foster Care as Children
Delilah Bruskas, PhD, RN; Dale H Tessin, MS

Of 101 women (age 18 to 71 years) who completed an anonymous online survey based on the 10-item ACE Questionnaire, the Sense of Coherence questionnaire, and the General Health Questionnaire, more than 56% were experiencing current psychological distress. Adverse Childhood Experiences (ACEs) reported to occur before foster care were associated with lower levels of sense of coherence (8%) and higher levels of psychological distress (6%). Children entering the foster care system are already vulnerable and at risk of experiencing ACEs during foster care and psychological distress during adulthood.

Commentary
Training Patient and Family Storytellers and Patient and Family Faculty
Lisa Morrise, MArts; Katy Jo Stevens, MSW, LCSW

Narrative medicine has become a prominent method of developing more empathetic relationships between medical clinician and patient on the basis of a deeper understanding of the patient experience. Patient and family storytelling is a key component of the collaboration that is ideal. Providing patients and families with training will make the narratives they share more powerful. This article provides instruction for teaching patients and families how to tell stories with purpose and offers advice about how to support patients, families, and clinicians participating in this effort.

Soul of the Healer

Scavenger Type
Adrianne Carol DiBernardo, MA

Torres del Paine
David Clarke, MD

Tahquamenon River
Stephen Henry, MD

Beauty of the Sahara Over Mali, West Africa
Timothy Allyn Munzing, MD

Death Valley Dunes
Abdalla Mallouk, MD