Spring 2016 - Volume 20 Number 2


Association of Age to Mortality and Repeat Revascularization in End-Stage Renal Disease Patients: Implications for Clinicians and Future Health Policies
Ashok Krishnaswami, MD, MAS; Thomas Alloggiamento, MD; Daniel E Forman, MD;
Thomas K Leong, MPH; Alan S Go, MD; Charles E McCulloch, PhD

The clinical effects of age occur over an age continuum, yet age as a primary predictor is often analyzed using arbitrary age cut-points. This is an observational retrospective cohort study in 1015 Kaiser Permanente Northern California patients with end-stage renal disease after index coronary revascularization. Primary and secondary outcomes were, respectively, all-cause mortality and repeat revascularization. Age dichotomized at 65 years or older and 80 years or older led to loss of information. Categorized age underestimated or overestimated risk at the extremes of age. Only the cubic spline demonstrated the nonlinear relationship between age and repeat revascularization.

Spring 2016 - Volume 20 Number 2Emergency Care of Patients with Acute Ischemic Stroke in the Kaiser Permanente Southern California Integrated Health System
Kori Sauser-Zachrison, MD, MSc; Ernest Shen, PhD; Zahra Ajani, MD; William P Neil, MD;
Navdeep Sangha, MD; Michael K Gould, MD, MS; Adam L Sharp, MD, MS

In a retrospective analysis of all ischemic stroke presentations to 14 Emergency Departments between 2009 and 2013, of the 11,630 patients, 3.9% received tissue plasminogen activator (tPA). The likelihood of tPA receipt increased with presentation in 2012 or 2013, female sex, and ambulance arrival, and decreased with prior stroke and increased age. The rate of intracranial hemorrhage was 4.2% and 0.9% among tPA- and non-tPA-treated patients (p < 0.001). Acute ischemic stroke care improved over time in this integrated health system.

Risk of Delayed Intracerebral Hemorrhage in Anticoagulated Patients after Minor Head Trauma: The Role of Repeat Cranial Computed Tomography
Clifford Swap, MD, MS; Margo Sidell, ScD; Raquel Ogaz; Adam Sharp, MD, MS
This retrospective observational study encompasses adult trauma encounters for anticoagulated patients undergoing head computed tomography (CT) at 1 of 13 Kaiser Permanente Southern California Emergency Departments (ED) between 2007 and 2011. The sample included 443 (260 clopidogrel and 183 warfarin) eligible ED encounters with normal findings of initial head CT. Overall, 11 patients (2.5%) had a delayed intracerebral hemorrhage, and events occurred at similar rates between the clopidogrel groups and warfarin groups.

Using Principles of Complex Adaptive Systems to Implement Secondary Prevention of Coronary Heart Disease in Primary Care
Thomas E Kottke, MD, MSPH; Jacquelyn A Huebsch, RN, PhD; Paul McGinnis, MD; Jolleen M Nichols, RN; Emily D Parker, PhD; Juliana O Tillema, MPA; Michael V Maciosek, PhD
The proportion of patients with coronary heart disease who met the composite goal increased from 40.3% to 59.9% because documented aspirin use increased and attainment of the cholesterol goal increased. Provider satisfaction with preventive services delivery increased significantly. Patient satisfaction improved but not significantly. Principles of complex adaptive systems can be used to implement team-based care systems for patients with coronary heart disease and possibly diabetic patients.

Spring 2016 - Volume 20 Number 2Low Back Imaging When not Indicated: A Descriptive Cross-System Analysis
Rachel Gold, PhD, MPH; Elizabeth Esterberg, MS; Celine Hollombe, MPH; Jill Arkind, MPH; Patricia A Vakarcs; Huong Tran, MS; Tim Burdick, MD, MSc; Jennifer E DeVoe, MD, DPhil; Michael A Horberg, MD, MAS, FACP, FIDSA
The authors extracted data from 2 Kaiser Permanente (KP) Regions and from OCHIN, a community health center network, on imaging performed after index visits for low back pain from 1/1/2011 to 5/31/2012. Among 19,503 KP patients and 2694 OCHIN patients with incident low back pain, ordered imaging was higher among men and whites but did not differ across health care systems. Rates of ordered imaging to evaluate incident low back pain among uninsured OCHIN patients were lower than in KP overall; among insured OCHIN patients, rates were higher than in KP overall.

Physician Professional Satisfaction and Area of Clinical Practice: Evidence from an Integrated Health Care Delivery System
John P Caloyeras, MPhil; Michael Kanter, MD; Nicole Ives, MHA; Chong Y Kim, PhD; Hemal K Kanzaria, MD, MSHPM; Sandra H Berry, MA; Robert H Brook, MD, ScD
Evidence suggests that primary care physicians are less satisfied than those in other medical specialties. However, of the 636 physicians responding to the cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) physicians (61.5%), on average 8 in 10 physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide, and 8 in 10 physicians reported satisfaction with their income. It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.

Impact of a Care Directives Activity Tab in the Electronic Health Record on Documentation of Advance Care Planning
Marianne Turley, PhD; Susan Wang, MD; Di Meng, PhD; Michael Kanter, MD; Terhilda Garrido, MPH 
A retrospective pre- and postimplementation analysis was conducted in 2012 and 2013 at Kaiser Permanente Southern California among 113,309 patients aged 65 years and older with advance care planning (ACP) opportunities during outpatient or inpatient encounters. Statistically significant differences in documentation rates between patients with and without Care Directives Activity tab use suggest the potential of a standardized location in the electronic health record to improve ACP documentation.

Spring 2016 - Volume 20 Number 2Treatment of Alcohol Withdrawal Syndrome with and without Dexmedetomidine
Muna Beg, MD; Sara Fisher, PharmD; Dana Siu, PharmD, BCPS; Sudhir Rajan, MD; Lawrence Troxell, PharmD; Vincent X Liu, MD, MS
A retrospective, cohort study looked at 77 patients admitted to the adult medical intensive care unit with severe alcohol withdrawal between 1/1/2009 to 10/31/2013. The frequency of dexmedetomidine use (an intravenous central-acting a2 adrenergic agonist that effectively reduces anxiety among critically ill patients) increased dramatically between 2009 and 2013 (16.7% vs 82.4%). Initiation of dexmedetomidine therapy was associated with significant improvements in Clinical Institute Withdrawal Assessment for Alcohol scores during corresponding 24-hour intervals (14.5 vs 8.5). Benzodiazepine use also decreased. Dexmedetomidine was well tolerated, requiring discontinuation of therapy in only 4 patients (10.5%). Dexmedetomidine use was also associated with significantly longer hospitalizations.

Family Characteristics Associated with Likelihood of Varicella Vaccination
Sheila Weinmann, PhD, MPH; John P Mullooly, PhD; Lois Drew; Colleen S Chun, MD
The authors identified 88,646 children (between 6/95-12/99) under age 13 years without a history of varicella; 22% were vaccinated during the study period. Varicella vaccination was more likely among children who were born after 1995, were not Medicaid recipients, or had pediatricians as primary clinicians. In the survey-linked cohort, positively associated family characteristics included smaller family size; higher socioeconomic status; and parents who were older, were college graduates, reported excellent health, and received influenza vaccination.

Spring 2016 - Volume 20 Number 2Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care
Lee D Jacobs, MD; Thomas M Judd, MS; Zulfiqar A Bhutta, MD, PhD
The neonatal, infant, child, and maternal mortality rates in Haiti are the highest in the Western Hemisphere. To create a major change in Haiti’s health care infrastructure, we are implementing two strategies that are unique for low-income countries: development of a countrywide network of geographic “community care grids” to facilitate implementation of frontline interventions, and construction of a centrally located referral and teaching hospital to provide specialty care for communities through the country. This hospital strategy will leverage the proximity of Haiti by mobilizing large numbers of North American medical volunteers to provide one-on-one mentoring for the Haitian medical staff.


Lactation Ketoacidosis: An Unusual Entity and a Review of the Literature
Sarah Gleeson, MB, BCh, BAO; Eoin Mulroy, MB, BCh, BAO; David E Clarke, MD, FCCP
A 31-year-old woman presented to the hospital with symptoms of nausea, malaise, and emesis. She was breastfeeding her 10-month-old infant. She was found to have severe ketoacidosis. A general review of all causes of ketoacidosis is presented with special emphasis on lactation ketoacidosis.


PEITC in End-Stage B-Cell Prolymphocytic Leukemia: Case Report of Possible Sensitization to Salvage R-CHOP
Arian Nachat, MD; Sam Turoff-Ortmeyer; Chunnan Liu, MD; Michael McCulloch, LAc, MPH, PhD
A 53-year-old man whose chronic lymphocytic leukemia transformed to end-stage B-cell prolymphocytic leukemia, disqualifying him for allogenic stem cell transplantation, was treated with PEITC (a natural compound from horseradish), followed by salvage R-CHOP chemotherapy, which led to normalized white blood cell count and disease stabilization that requalified him for allogenic peripheral stem-cell transplant therapy. The authors conducted a systematic review to analyze and interpret the potential contribution of PEITC to his unexpectedly favorable R-CHOP response. Following sequential 8 weeks of PEITC/pentostatin and 6 cycles of R-CHOP, the patient received allogenic peripheral blood stem cell transplant on an outpatient basis and remains well at the time of publication with no evidence of CD20+ small B-cells.

Spring 2016 - Volume 20 Number 2Sclerosing Polycystic Adenosis: A Rare Tumor of the Salivary Glands
Christopher G Tang, MD; Justin B Fong; Karen L Axelsson, MD; Deepak Gurushanthaiah, MD


Spring 2016 - Volume 20 Number 2Onset of Ulcerative Colitis after Helicobacter pylori Eradication Therapy: A Case Report
Mitsuro Chiba, MD, PhD; Tsuyotoshi Tsuji, MD, PhD; Kenichi Takahashi, MD; Masafumi Komatsu, MD, PhD; Takeshi Sugawara, MD; Iwao Ono, MD, PhD


Spring 2016 - Volume 20 Number 2Wilms Tumor: An Uncommon Entity in the Adult Patient
Fade Mahmoud, MD, FACP; M Brandon Allen, MD; Roni Cox, MD; Rodney Davis, MD



Image Diagnosis: Worm-Induced Biliary Obstruction
Andrew W Phillips, MD, MEd; Joanna Ready, MD; Gus M Garmel, MD, FACEP, FAAEM
A 57-year-old woman, who was born in the Philippines, presented to the Emergency Department with 6 hours of epigastric and right upper quadrant abdominal pain radiating to her back. She denied fever, nausea, and vomiting. An endoscopic retrograde cholangiopancreatography showed the presence of a worm, extending from the ampulla into the bowel lumen.

Image Diagnosis: Capitellar Fracture
Ganesh Nagaraj, MD; Justin P Mitchelson, MD; Cameron M McFarland, MD; Matthew A Silver, MD
A healthy 35-year-old man presented with left elbow pain and swelling after a ground-level fall onto his outstretched left hand. Greatest pain and swelling was over the distal humerus. On x-ray, disruption of the radiocapitellar joint was noted along with presence of a raised anterior fat pad and the resulting sail sign.

Spring 2016 - Volume 20 Number 2Image Diagnosis: Bronchioloalveolar Carcinoma Presenting as Unilateral “Crazy-Paving” Pattern on High-Resolution Computed Tomography
Vikas Pilaniya, MD; Shekhar Kunal, MBBS; Sudhir Jain, MD; Ashok Shah, MD


Learning to “Swim” with the Experts: Experiences of Two Patient Co-Investigators for a Project Funded by the Patient-Centered Outcomes Research Institute
Michele Robbins; Janice Tufte; Clarissa Hsu, PhD
Written from the perspective of two PCORI patient co-investigators, this commentary provides lessons learned and recommendations about incorporating nonscientists into research teams. Specifically, the authors suggest recruiting people with a record of relevant volunteer experience and commitment; establishing a formal application process that provides candidates with details about expectations and responsibilities; and providing comprehensive orientation with ongoing training, encouragement, and support. It is hoped the points in this commentary help research teams that are incorporating patient co-investigators toward a positive and productive experience.

The Language of Engagement: "Aha!" Moments from Engaging Patients and Community Partners in Two Pilot Projects of the Patient-Centered Outcomes Research Institute
Ming Tai-Seale, PhD, MPH; Greer Sullivan, MD, MSPH; Ann Cheney, PhD; Kathleen Thomas, PhD; Dominick Frosch, PhD
Compared with people living in the community, researchers often have different frameworks or paradigms for thinking about health and wellness. These differing frameworks are often accompanied by differences in terminology or language. We came to understand how our language and word choices may have been acting as a wedge between ourselves and our community research partners. Patient-centered language can effectively build a bridge between researchers and community partners, as well as enhance cultural competency, and demonstrate being mindful of the social power dynamics between patient and physician.

Integrated Strategies to Address Maternal and Child Health and Survival in Low-Income Settings: Implications for Haiti
Zulfiqar A Bhutta, MD, PhD
An overview of child mortality rates in low-income countries is presented, followed by a discussion of evidence-based interventions that can bridge the equity gaps in global health. Finally, the author comments on the companion article in this issue, “Addressing the Child and Maternal Mortality Crisis in Haiti,” and what is needed for that new project to succeed.

The Jigsaw Puzzle in the Lunchroom
John F Steiner, MD, MPH
Members of our Research Department began to bring jigsaw puzzles into the office. Border pieces were sorted, then assembled. Shapes and colors were aggregated. Some days, nothing changed. Some days, whole images emerged. Each puzzle seemed like a multi-authored scientific paper with unknown contributors—no first author, no senior author, no titles and degrees. If we create the right workspace, we will gravitate to shared puzzles. If our instincts are sharp, we will choose the most promising puzzles to solve. If we are patient and persistent, we will solve them.

Love and the Value of Life in Health Care: A Narrative Medicine Case Study in Medical Education
Jorge Alberto Martins Pentiado, Jr, MD; Helcia Oliveira de Almeida, MsC; Fábio Ferreira Amorim, MD, PhD; Adriano Machado Facioli, PhD; Eliana Mendonça Vilar Trindade, PhD; Karlo Jozefo Quadros de Almeida, MD
This case study is an example of narrative medicine applied to promote self-awareness and develop humanistic content in medical education. The impact and the human appeal of the narrative lie in the maturity and empathy shown by a student when reporting his dramatic experience during the care given to a mother and a newborn with a rare disease. The narrative approach helped the learner to be successful in bringing out the meanings behind the story, and introspection changed a seemingly scary interaction into a positive experience. This narrative shows how the development of narrative competence can help establish a good physician-patient relationship.


The Role of Clinical Records in Narrative Medicine: A Discourse of Message
John W Murphy, PhD; Jung Min Choi, PhD; Martin Cadeiras, MD
This article is designed to unite theory and practice. The focus of attention is the impact of narrative medicine on clinical records. Specifically important is that records are created through dialogue, whereby patients are able to grow the record through their ability to offer critiques and alternative explanations. Merely allowing patients to peruse their records, through advances in technology, is not sufficient to facilitate this aim. Various theoretical and practical considerations are discussed that may facilitate patient involvement and the creation of more accurate and relevant client records.

Melyssa's Story
Lee Jacob, MD
This is a fictionalized account of a potential future scenario, created to dramatize the need for the Bethesda Referral & Teaching Hospital. It is a companion to “Addressing the Child and Maternal Mortality Crisis in Haiti through a Central Referral Hospital Providing Countrywide Care,” page 59, and “Integrated Strategies to Address Maternal and Child Health and Survival in Low-Income Settings: Implications for Haiti,” page 94.

Tears for the Fallen
Akhila Pamula, MD
It wasn’t the fact that he was so young, or even that he had died in front of me; it was the fact that he did it on purpose. I had to excuse myself and take a walk—I had 9 hours left in this shift and I had to pull it together.


The Blue Lagoon
Daniela Alexandru Abrams, MD

The Dead Sea
Paul Rousseau, MD

Flower Merchant
Bridget Bourgon, PA-C

Pigeons in Flight at Boudhanath Buddhist Stupa in Kathmandu, Nepal
Thomas Sun, MD


Lunar Love
Kamran Nikravan, MD



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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.


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