Summer 2015 - Volume 19 Number 3

OrigSummer 2015 - Volume 19 Number 3inal Research and Contributions

Characteristics of Newly Enrolled Members of an Integrated Delivery
System after the Affordable Care Act

Elizabeth A Bayliss, MD, MSPH; Jennifer L Ellis, MSPH; Mary Jo Strobel, RN, MBA; Deanna B McQuillan, MA; Irena B Petsche, PhD; Jennifer C Barrow, MSPH; Arne Beck, PhD
Of 89,289 newly enrolled non-Medicare members, 25.3% completed the Brief Health Questionnaire between 1/1/2014, and 8/31/2014. Of these, 3593 respondents were insured through Medicaid, 9434 through the individual health exchange, and 9521 through primarily commercial plans. Of Medicaid, exchange, and commercial members, 19.5%, 7.1%, and 5.3%, respectively, self-reported fair or poor health; 12.9%, 2.0%, and 3.3% of each group self-reported 2 or more Emergency Department visits during the previous year; and 8.1%, 4.3%, and 4.4% self-reported an inpatient admission during the previous year.

A Metrics Taxonomy and Reporting Strategy for Rule-Based Alerts
Michael Krall, MD, MS; Alexander Gerace
An action-oriented alerts taxonomy according to structure, actions, and implicit intended process outcomes using a set of 333 rule-based alerts at Kaiser Permanente Northwest (KPNW) was developed. The authors identified 9 major and 17 overall classes of alerts and developed a specific metric approach for 5 of these classes, including the 3 most numerous ones in KPNW, accounting for 224 (67%) of the alerts.

Summer 2015 - Volume 19 Number 3"Getting off the Bus Closer to Your Destination": Patients' Views about Pharmacogenetic Testing
Susan Brown Trinidad, MA; Tara B Coffin, MEd; Stephanie M Fullerton, DPhil;
James Ralston, MD, MPH; Gail P Jarvik, MD, PhD; Eric B Larson, MD, MPH
The authors conducted focus groups with patients prescribed antidepressants (pilot session plus 2 focus groups, n = 27); patients prescribed carbamazepine (2 focus groups, n = 17); and healthy patients (2 focus groups, n = 17). Although participants understood the potential advantages of pharmacogenetic testing, many felt that the risks (discrimination, stigmatization, physician overreliance on genomic results, and denial of certain medications) may outweigh the benefits. These concerns were shared across groups but were more strongly expressed among participants with chronic mental health diagnoses.

Summer 2015 - Volume 19 Number 3A Community-Based Hip Fracture Registry: Population, Methods, and Outcomes
Maria C S Inacio, PhD; Jennifer M Weiss, MD; Alex Miric, MD; Jessica J Hunt, MA; Gary L Zohman, MD; Elizabeth W Paxton, MA
Cases of hip fracture recorded from 1/2009 to 12/2011 were ascertained using the Kaiser Permanente Hip Fracture Registry. The registry collects information on patient, procedure, surgeon, facility, and surgical outcomes. The population (N = 12,562) was predominantly white, women, and older (≥ 75 years), and 32% had at least 5 comorbidities. The average length of follow-up was 1.1 years. Hemiarthroplasty was the most common procedure (33.1%). Most fractures were treated by medium-volume surgeons at high-volume facilities. The 90-day readmission rate was 22.1%, and the mortality rate was 12.3%.

Utility of the Multinational Association for Supportive Care in Cancer (MASCC) Risk Index Score as a Criterion for Nonadmission in Febrile Neutropenic Patients with Solid Tumors
Roger A Bitar, MD, MPH
Febrile neutropenic episodes in patients with solid tumors were identified electronically from 10/1/2008 to 11/15/2010. Inclusion criteria were met in 198 episodes. Sensitivity, specificity, and positive and negative predictive values of the MASCC risk index score vs complications were, respectively, 94%, 29.6%, 57.7%, and 82.9%. An MASCC risk index score of 21 or greater could not be used as a criterion for "no complication/do not admit." Inability to eat should be an admission criterion.

Evidence-Based Referral: Effects of the Revised "Youth Fit 4 Life" Protocol on Physical Activity Outputs
James J Annesi, PhD, FAAHB, FTOS, FAPA; Linda L Vaughn, MS, MBA
The authors contrasted 2 physical activity/nutrition treatments on the basis of social cognitive and self-efficacy theory, and a comparison condition, on time in moderate-to-vigorous physical activity (MVPA) during the 45-min/day physical activity segment of elementary after-school care. The Revised Youth Fit 4 Life protocol that sought to maximize participants' cardiovascular physical activity appeared to improve upon the Original Youth Fit For Life treatment on time in MVPA. Thus, pediatricians might have confidence in referring their patients to such evidence-based approaches.

Summer 2015 - Volume 19 Number 3Relationship between Participation in Patient- and Family-Centered Care Training and Communication Adaptability among Medical Students: Changing Hearts, Changing Minds
Lisa Rossignol, MA
A census of 43 third-year medical students at the University of New Mexico School of Medicine participated in Parents Reaching Out: Families as Faculty program during their pediatric rotation. Analysis of variance revealed statistical significance for the factor "appropriate disclosure" (meaning students have become more sensitive to the level of intimacy that the other person is seeking and the student is willing to offer more information). There was a positive correlation between pretest and posttests in social experience, wit, and social confirmation.

A Ten-Year Case-Control Study of Passive Smoke Exposure as a Risk Factor for Pertussis in Children
Mark A Schmidt, PhD, MPH; Samantha K Kurosky, MS; John P Mullooly, PhD; Colleen Chun, MD; Sheila Weinmann, PhD
The authors conducted a matched case-control study of laboratory-confirmed pertussis cases, occurring from 1/1/1996 to 12/31/2005, in children up to 12 years of age who were members of a large managed care organization. Sixty-five laboratory-confirmed cases of pertussis were identified. Using multivariable conditional logistic regression analysis, the authors did not detect a statistically significant association between pertussis and household passive exposure to cigarette smoking.

Special Report

Summer 2015 - Volume 19 Number 32014 Hypertension Guideline: Recommendation for a Change in Goal Systolic Blood Pressure
Joel Handler, MD
The 2014 Kaiser Permanente Care Management Institute National Hypertension Guideline was developed to assist primary care physicians and other health care professionals in the outpatient treatment of uncomplicated hypertension in adult men and nonpregnant women aged 18 years and older. A major practice change is the recommendation for goal systolic blood pressure less than 150 mmHg in patients aged 60 years and older who are treated for hypertension in the absence of diabetes or chronic kidney disease. This article describes the reasons for, evidence for, and consequences of the change, and includes the guideline.

CASE REPORTS

Beer Potomania—An Unusual Cause of Hyponatremia
Dean A Kujubu, MD; Ardeshir Khosraviani, MD
The first case of severe hyponatremia, since referred to as beer potomania, in a heavy beer drinker patient was reported in 1972. Excessive consumption of beer in particular, which has a low solute content, may result in severe hyponatremia. We report a case of severe hyponatremia that occurred in a patient who, owing to his underlying colon cancer, was drinking beer and ingesting little food.

Pneumomediastinum Diagnosed on Ultrasound in the Emergency Department: A Case Report
Hilary FH Beason, MD; Joshua E Markowitz, MD, RDMS, FACEP
An emergency ultrasound performed at bedside helped to confirm and to expedite the diagnosis of esophageal perforation in a 23-year-old man. To our knowledge, this is the first published report of using ultrasound as an aid in the diagnosis of Boerhaave syndrome by diagnosing pneumomediastinum in an adult male.

Case Report: Pulmonary Papillomatosis in a Patient Presenting with Cough and Hemoptysis
Zhou Zhang, MD; Melisa Chang, MD; Luis M Moreta-Sainz, MD
A previously healthy patient was seen in the Emergency Department for evaluation of a one-month history of cough and one-day history of hemoptysis. This case report, from a pulmonologist's perspective, includes a comprehensive review of the patient's clinical presentation and outcome, as well as a discussion of recurrent respiratory papillomatosis.

CLINICAL MEDICINE

Dermatologic Diagnosis: Leukocytoclastic Vasculitis
Joseph Einhorn, MD; Joel T Levis, MD, PhD, FACEP, FAAEM
Leukocytoclastic vasculitis (LCV), also termed hypersensitivity vasculitis, is a small-vessel vasculitis. The skin is the organ most commonly involved in LCV. Typical presentation is a painful, burning rash predominantly in the lower extremities. The most common skin manifestation is palpable purpura. Other skin manifestations include maculopapular rash, bullae, papules, plaques, nodules, ulcers, and livedo reticularis.

ECG Diagnosis: Hyperacute T Waves
Joel T Levis, MD, PhD, FACEP, FAAEM
After QT prolongation, hyperacute T waves are the earliest-described electrocardiographic sign of acute ischemia, preceding ST-segment elevation. The principle entity to exclude is hyperkalemia—this T-wave morphology may be confused with the hyperacute T wave of early transmural myocardial infarction.

Image Diagnosis: Inferior Mesenteric Vein Thrombosis
Avin Aggarwal, MBBS; Shashank Garg, MBBS
A 59-year-old man presented to the gastroenterology clinic with 2 weeks of worsening lower back pain. There was associated poor appetite, fatigue, night sweats, and chills. The patient's medical history was significant for well-controlled hypertension and sigmoid diverticulosis. The thrombosis probably resulted from inflammation in the adjacent diverticulum.

COMMENTARY

Does Consuming Sugar and Artificial Sweeteners Change Taste Preferences?
Carole Bartolotto, MA, RD
Americans consume 22.3 teaspoons of added caloric sweeteners a day. Sweeteners range from 180 to 13,000 times sweeter than sugar. In summer 2014, 20 people from Kaiser Permanente California facilities cut out all added sugars and artificial sweeteners for 2 weeks: 95% of participants found that sweet foods and drinks tasted sweeter or too sweet, 75% found that other foods tasted sweeter, and 95% said moving forward they would use less or even no sugar. Additionally, 86.6% of participants stopped craving sugar after 6 days.

Special Report

New Kid on the Block Turns Ten! The Brief, Remarkable History of the National Physicians Alliance
Jean Silver-Isenstadt, MD, PhD
Founded in 2005 by General Surgeon Lydia J Vaias, MD, MPH, the National Physicians Alliance is a 501c3 public charity with a mission to create research and education programs that promote health and foster active engagement of physicians with their communities to achieve high-quality, affordable health care for all. The National Physicians Alliance offers a professional home to physicians across medical specialties who share a commitment to professional integrity and health justice. As the organization celebrates its tenth birthday, the history and scope of this mission-aligned group is described.

NARRATIVE MEDICINE

Suicide is a Baobab Tree: A Narrative Medicine Case Study
Adriano Machado Facioli, PhD; Fábio Ferreira Amorim, MD, PhD; Karlo Jozefo Quadros de Almeida, MD; Eliana Mendonça Vilar Trindade, PhD
Like the baobab, when suicide or a suicide attempt occurs, suicidal ideations are well cultivated and have often already been repeatedly planted. Consequently, suicide is often difficult to prevent: once the death seed is planted; it is difficult to recreate life. Every year, more than 800,000 people die by suicide worldwide.

Why a Hanging Man Dances
Gurpreet Kaur Padam, MD
"Do you know why a hanging man dances?" asked Mr B. He was once an intensely independent man, now 80 years old and afflicted with end-stage lung disease. He appeared tired, repositioning himself with great effort to sitting at the edge of the bed, tightly holding onto the bed sheets as if clenching to a life that was slowly escaping him. "No. I don't want anything that will make me live longer."

BOOK REVIEW

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma
Review by Albert Ray, MD
This book explores the ways that patients and healers can develop the skills to appropriately evaluate historic traumatic events and how to successfully begin treating them. From the scientifically oriented physician, the biochemical, physiologic, and anatomic effects of trauma on the body are well explored in this detailed exposé. What is more important though is the invisible mark that is embedded permanently on the mind and body by past traumatic events

Soul of the Healer

Pinnacle
Brad Christian McDowell, MD

Seville
Samuel H Glassner, MD

Dorothy's View
Bridget Bourgon, PA-C

So Much Sky
Sharon Lee Hostler, MD

On The Cover

Rocky Perspective
David L Shenson, MD