Fall

Fall 2008

The Permanente Journal

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Fall 2008 - Volume 12 Number 4

Original Articles

Associations of Psoriatic Arthritis and Cardiovascular Conditions in a Large Population
Svetlana Kondratiouk, DO; Natalia Udaltsova, PhD; Arthur L Klatsky, MD
Among a multiethnic population of 76,465 men and women, none of the 99 persons with a confirmed outpatient diagnosis of psoriatic arthritis exhibited more atherothrombotic disease (coronary and cerebrovascular) or diabetes mellitus than two control groups, but all 99 persons did have an increased prevalence of systemic hypertension and heart failure, and a higher mean body mass index.

Augmentation of Conventional Medical Management of Moderately Severe or Severe Asthma with Acupuncture and Guided Imagery/Meditation
Lewis Mehl-Madrona, MD, PhD

Patients with moderately severe or severe asthma who, when visiting a complementary and alternative medicine clinic, selectively chose to add a combination of acupuncture and guided imagery/meditation to their maximal medical management, experienced respiratory improvement--decreased symptoms, decreased Emergency Department visits, and decreased number of days of hospitalization, while taking less medications than before--and at a lower cost of care.

TPJ 2007 "Service Quality Awards" Institute for Healthcare Improvement 19th Annual National Forum on Quality Improvement in Health Care

Early Discharge Study for Premature Infants: Singapore General Hospital
Yeo Cheo Lian, MD; Selina Ho Kah Ying, MD; Cheong Chiu Peng, RN; Tay Yih Yann, RN
At Singapore General Hospital, premature infants had a median birth weight of 1210 g. Discharge traditionally occurred when infants were medically fit and weighed 2000 g. The length of hospital stay was reduced 59.8%, primarily by improved discharge planning, revised guidelines (mean discharge at 1915 g), and nurses' active preparation of parents psychologically and mentally for care of their babies at home.

Counseling and Wellness Services Integrated with Primary Care: A Delivery System That Works

Ken Van Beek, LMSW; Steve Duchemin, PA-C; Geniene Gersh, MA, LLP; Susanne Pettigrew, PA-C; Pamela Silva; Barb Luskin

By colocating behavioral health counselors and nutritionists alongside primary care physicians. Grand Valley Health Plan established the national benchmark for patients using ambulatory services for mental health, and ranked first in Michigan on all six HEDIS "effectiveness of care" measures for behavioral health. One result was a 54% decrease in mental health hospitalization. Up to 70% of primary care visits are driven by psychosocial factors, with 25% of patients having a diagnosable mental disorder, and comorbidity occurring in up to 80% of patients.

Are Foot Abnormalities More Common in Adults with Diabetes? A Cross-Sectional Study in Basrah, Iraq
Abbas Ali Mansour, MD; Samir Ghani Dahyak, MD
In a study population of 100 patients with type 2 diabetes and 100 patients without diabetes, researchers found 13 foot abnormalities--prominent metatarsal head, high medial arch, hammertoe, wasting, joint stiffness, amputation, fissures, nail changes, ulcers, blisters, dryness, sclerosis, and dermopathy--statistically more frequent in study participants with diabetes; however only wasting, ulcer, and dryness were strongly associated with diabetes.

Review Articles

The Role of B-Type and Other Natriuretic Peptides in Health and Disease
Ashok Krishnaswami, MD, FACC
B-type natriuretic peptide (BNP) levels are specifically useful in differentiating the etiology of shortness of breath between left ventricular (LV) dysfunction, acute congestive heart failure (CHF), and pulmonary dysfunction without CHF. The primary responsibility of natriuretic peptides (NP) is the maintenance of sodium and water homeostasis and vasomotor tone. Both atrial NP and BNP decrease plasma volume and blood pressure in response to an increased tension of the atrium or ventricle, respectively, but reflect LV function, mass, and load more than volume status.

Prognostic Factors for Long-Term Survival after Glioblastoma

Mohammad Sami Walid, MD, PhD

Long-term survivors of glioblastoma are rare. Several variables besides tumor size and location determine a patient's survival chances: age at diagnosis, where younger patients often receive more aggressive multimodal treatment; functional status, which has a significant negative correlation with age; and histologic and genetic markers.

Case Studies

An Unusual Case of a Cervical Mass Due to Nontuberculous Mycobacterium Fortuitum Infection
Hien Nguyen, MD; Connie Le, MD; Hanh Nguyen, MD
This case of an infected submandibular mass is unique because prompt recognition of the infection and treatment with antimicrobials averted surgery. The varied presentations of nontuberculous mycobacterial disease in immunocompetent patients is a trend important to recognize in a woman, aged 60 years, with stage 1 breast cancer for which she had received radiation and chemotherapy.

Diagnoses are Stereotypes: Go Where They Are
Dustin L Larson
What if clinicians accompanied a homeless person for a day, as the author did? Would they also learn how to inquire about sensitive issues, high-risk behaviors, or lifestyle? Would they learn that individuals don't fit stereotypes?

Clinical Medicine

Image Diagnosis: Pulmonary Embolism

Image Diagnosis: Radial Head Fracture

Image Diagnosis: Abdominal Aortic Aneurysm
Gus M Garmel, MD, FACEP, FAAEM

Three sets of radiographic and computed tomography images depict pulmonary embolism (and popliteal venous source), radial head fracture, and leaking abdominal aortic aneurysm.

Commentary

The Changing Face of HIV Infection
William J Towner, MD, FACP
Since the first report, in 1981, of AIDS in five men who have sex with men (MSM) in Los Angeles, the AIDS epidemic has swept the world. It now increasingly affects women, younger adults, is again increasing in MSM, and disproportionately affects people of color. Older age no longer predicts faster progression.

Information Technology Innovation
Yan Chow, MD, MBA, FAAP

Information technology innovations are assessed for physician and patient use. A large-scale example is Kaiser Permanente's Sidney R Garfield Center for Health Care Innovation--a care delivery simulation laboratory. On a small scale is a trial of the use of a 1-lead electrocardiogram rhythm strip transmitter in the form of a wallet placed against the chest and connected to a cell phone that tracks rhythm disturbances.

Editorials

Relationship of a Physician's Well-Being to Interactions with Patients: Practices of the Highest Performing Physicians on the Art of Medicine Patient Survey
Tom Janisse, MD

In a trusting relationship, physicians who, according to patient surveys, satisfy their patients best described that as doctors they are "part of the medicine" through several empathetic activities: respect, attention and presence, listening, connection, reassurance and support, touch, knowledge, explanation and education. This medicine has a powerful therapeutic treatment effect and is responsible for physicians' sense of feeling valued, making an important contribution, making a difference, and creating personal and professional well-being.

Narrative Medicine

Labyrinths Find Their Way onto Hospital Grounds as Paths to Healing
Jim Gersbach
Walking labyrinths, recently opened at Kaiser Permanente (KP) Sunnyside and Antioch Medical Center hospitals, are intended to let those who enter find their way along a single, clear path. Modeled on the labyrinth of Chartres Cathedral in France, the labyrinths were first tested, through a KP innovation grant, on "finger labyrinths"--boards with the paths grooved into the wood. Surveys of users' stress levels revealed that most felt more relaxed afterward.

Cody
William Lynes, MD
The story of a five-year-old boy named Cody who was cared for by Urology Intern, Dr Cody, after fracturing his kidney in a car crash that killed his parents.

Colic
William Lynes, MD
A stone comes alive and recounts its journey through the renal system to expulsion from a woman's urethra.

Book Reviews

Patient Listening: A Doctor's Guide

The Fibromyalgia Story: Medical Authority & Women's Worlds of Pain

Doctors: The History of Scientific Medicine Revealed Through Biography

Soul of the Healer

Original Visual Art

Sara's Trees
Stephen Weiss, MD

College Avenue

Pamela Fox

449
Sal Iaquinta, MD

Mexican Marionette
Evelyn Zlomke, RN, MPH

Original Literary Art

The Dance
Jonathon W Gietzen, MS, PA-C

True North
Mary Dowd, MD

In the Pod
Mary Dowd, MD

On the Cover

At Angelique

Fred M Freedman, MD